TC Flashcards
Testis mass approach
See in my rapid access clinic with pt partner if prefers , appreciate he is anxious /worried
Hx :
duration of mass , painful/painless, urinary symptoms , sexual hx , trauma, previous surgeries , back pain , weight loss
UDT , family hx
O/E offer chaperone , left supraclavicular node , abdo for masses signifying mets, genitalia exam
I will arrange same day urgent US testes with doppler , send tumor markers
Testis tumor investigations
Afp, hcg,LDH , also regular blds as will be going for surgery
US : homogenous vs heterogenous hypoechoic mass , would like to see the doppler and the contralateral testis
CT CAP
Sperm banking ( viral screening)
Points to discuss with testis ca pt
Clinical diagnosis
Radical orchidectomy
Sperm banking
Prothesis
Seminoma
20% risk of recurrence in 5 yrs ( mostly in first 2 yrs )
Increase risk (prgnosticators for relapse ): > 4 cm, rete testes invasion
Ecah alone 16% risk , presence of both is 32% risk
Stages : AJCC TNM staging
1 A ( N0M0 , T1)
1B ( N0M0 , T2-T4)
2 A : N1 ( <2cm)
2B : N2 ( 2-5 cm)
2 C : N3 ( > 5 cm)
Stage 3 Mets
2 C and above are advanced seminoma
Stage 1 management post op
Surviellance ( 3 monthly clinically and markers, 6 monthly CXR , annual CT for 4 yrs)
Single cycle Carboplatin
Radiation ( 20 Gy , hockey stick fashion : para aortic nodes and ipsilateral iliac nodes )
Both chemo and rads treatment modalities are equally effective
TNM
Tis
T1 confined testis and epidydimis with no LVI , can involve albugenia but not vaginalis
T2 : confined to T and E with LVI , or no LVi but involving vaginalis
T3 sperdmatic cord
T4 scrotum
ITGCN ( TIN )
Malignant pre invasive lesion ( CIS)
Precursor of all testicular malignancies except spermatocystic seminoma
Has 50% chance of progression to germ cell tumors in 5 yrs
Present in contralateral testis in 5-9% of pts
If pt had ITGCN on bx from contralateral testis what to do?
Options are surviellance or treatment ( radiotherapy ( 20 Gy) or surgery and testosterone replacement )
Chemotherapy is not routinely recommended
When to do contralateral testis bx and how to do it?
EAU recommends:
Pt younger than 40
Testis volume <12 mls
Also other indicators:
Infertility
Hx of UDT
Trans scrotal incision double polar bx , bouin’s solution
Testicular microlithiasis
Def: more than 5 on one field of US each less than 2 mm , normal testis shape and volume
No clinical significance, not indication for bx
How do you follow them?
I reassure pts , tell them do self examine
I risk stratify them , if has no risk factors for testis ca then will discharge and advise re referral urgently if feels any lump.
If has risk factors then I keep them under my follow up once a year for US .
Testicular microlithiasis
Def: more than 5 on one field of US each less than 2 mm , normal testis shape and volume
No clinical significance, not indication for bx
How do you follow them?
I reassure pts , tell them do self examine
I risk stratify them , if has no risk factors for testis ca then will discharge and advise re referral urgently if feels any lump.
If has risk factors then I keep them under my follow up once a year for US .
Stage II seminoma
Chemo
3 cycles of BEP or
4 cycles of EP if pt high risk for bleomycin ( age >40 , smoker , wide spread pulmonary mets )
If persistent retroperitoneal mass post op , repeat tumor markers , do PET for activity of tumor then consider bx and proceed to RPLND
NSGCT
LVI is prognosticator for relapse
30% risk of relapse with surgery only - usually in first year
Stage 1 : options are surviellance , chemotherapy ( BEP 3 or 4 cycles according to risk stratification IGCCCG ) ,
Or RPLND if pt non compliant to first 2 or persistence of retroperitoneal disease post chemo > 1 cm ie stage 2
Stage II : BEP , or RPLND if persistent
Have to repeat markers and staging scans before making a plan for persistent disease or new retroperitoneal disease
Stage 2 c or 3 ( advanced seninoma)
Referral to specialised centre for platinum and isophosphamide based chemo and enrolment to clinical trials
RPLND
Open tra abdominal or trans thoracic abdominal dissection and removal of all great vessels LNS to get rid of the disease and prevent recurrence . Despite that ~ 10% might recur on extra abdominal sites ( chest)
Death 1-3%
Morbidity 5-10%
Spinal ischemia 1%
Renal pedicle injury - nephrectomy 2-3% esp if previous chemo
Chylous ascites ( treatment for this is somatostatin and low fat diet / dietician involvement etc)
Lymphocele
Retrograde ejaculation
Infection , wound dehiscence
Bleeding, blood transfusions
Ileus , bowel obstruction
To minimise morbidity can perform template ( one side ) RPLND as tumor rarely cross sides.
Prothesis same session
Ramani et al No significant difference in term of LOS or re admission to hospital
The only thing is the risk of delay of chemo should the prothesis is infected
Complications:
Infection- need for removal
Hematoma
Chronic pain
Migration
Extrusion through scrotal skin
How to do it :
I do same session after orchidectomy, sterile no touch technique , prevent infection preop with hair removal on table , Abx cover , meticulous hemostasis, minimise staff , cover the prosthetic in Abx , absorbable stitch at the anchor thread it through then stitch it to scrotum and cover pt with Abx post op for 5 days.
