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Testicular Flashcards

1
Q

What proportion of men with testicular cancer are dx with contralateral testicular ca?

A

5%

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2
Q

What is the most common type of testicular cancer by far? vs the other type?

A

Germ cell tumour (95%) vs
non Germ cell tumour (5%)

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3
Q

What are the two types of Germ cell tumour and their approx proportions?

A

Seminoma 55-60%

Non seminomatous germ cell tumour 40-45%

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4
Q

What serum tumour markers need to be checked before orchiectomy?

A

bHCG
a Fetoprotein (AFP)
LDH

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5
Q

What type of testicular ca is raised serum markers assoc with?

A

NSCGT

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6
Q

Does normal serum tumour marker levels exclude GCT?

A

No, especially for Seminoma

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7
Q

What does persisting or increasing tumour markers after orichectomy usually indicate?

A

Metastatic disease

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8
Q

What proportion of Germ cell tumour patients have Germ cell neoplasia in situ in the contralat testis?

A

5%
so physical exam +- USS required on FU

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9
Q

Is there evidence to support PET staging of GCT?

A

No- ESMO consensus 2022

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10
Q

How is orchiectomy performed?

A

Radical orchiectomy is carried out through an inguinal incision.
Any scrotal violation for biopsy or open surgery should be avoided. The tumour-bearing testis is resected with the spermatic cord at the level of the internal inguinal ring.

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11
Q

What is the survival rate of stage I seminoma?

A

99%

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12
Q

What proportion of seminoma patients present with stage I disease?

A

80%

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13
Q

Why is minimising treatment toxicity so important for stage I seminoma?

A

because cure rate is so high 99% regardless of what treatment strategy is chosen

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14
Q

What are adjuvant management options for stage I seminoma?

A

Surveillance- preferred if patient can adhere to follow up

Adjuvant chemotherapy; if patient not willing or able to undergo surveillance or if high risk (one or both of tumour size and rete testis involvement)

Adj RT: but
Adj RT not recommended per ESMO as risk of second malignancy considered too high

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15
Q

What proportion of higher risk stage I seminoma patients relapse on surveillance?

A

15-30%

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16
Q

What is the adjuvant chemo regime for stage I seminoma

A

1-2 cycles of carboplatin with AUC of 7

TE19 trial

two cycles of carboplatin may yield better results than 1 but 1 is recommended by ESMO

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17
Q

What features make stage I seminoma higher risk?

A

T size and rete testis invasion

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18
Q

What is the survival rate of stage I NSGCT?

A

98-100%

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19
Q

How is stage I NSCGT stratified into low or high risk?

A

Presence of Lymphovascular invasion

(low risk has 12% risk of relapse
high risk has 40-50% risk of relapse)

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20
Q

Stage IIA seminoma with LN <2cm- is adjuvant CHT or RT more effective at reducing recurrence?

A

Meta analysis shows that Rt and CHT are equally effective at reducing reccurence

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21
Q

For stage IIB seminoma, is CHT or RT more effective at reducing reccurrence?

A

Meta analysis shows that CHT is more effective

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22
Q

What is the adjuvant paradigm for stage I NSGCT?

A

Low risk:
Surveillance preferred
1 cycle BEP if can’t do surviellance

High risk:
1 cycle BEP preferred
Surveillance is alternative option

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23
Q

What is the adjuvant management of Stage IIA seminoma?

A

Chemo

or

RT to PA and ipsilateral iliac lymph nodes (modified dog leg) 20Gy/10# with boost to 30Gy

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24
Q

What is the adjuvant management of stage IIB-III NSGCT?

A

Good prognostic group:
BEP x 3 cycles

Intermediate/poor prognostic group:
BEP x 4 cycles

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25
Q

What does BEP stand for?

A

Bleomycin
Etoposide
Cisplatin

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26
Q

Should there be screening for testicular cancer?

A

No RCTS on benefits of screening of testicular cancer at population level.

However, data show that it is possible to define men who have a substantially increased risk for the development of a testicular cancer based on family history, genetic predisposition (polygenic risk score), individual history of testicular cancer or cryptorchidism, or a combination of these factors.

ESMO recommends targeted screening of these individuals.

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27
Q

Discuss the controversy regarding contralateral testis biopsy (obj 3.3)

A

Pro:
- allows detection of GCCis before invasive disease occurs, less intense treatment with fewer side effects,
- less intense follow up required
- unlikely to adversely affect fertility as testes with GCCis poor spermatogenesis
- surgical biopsy low risk

Con:
- no survival advantage
- risk of false negative and false reassurance
- procedural risks

ESMO recommendation:
Biopsies of the contralateral testis at the time of orchiectomy should be discussed with, and recom- mended to, high-risk patients (i.e. those aged <40 years with a small atrophic testis and/or microlithiasis).

https://www.annalsofoncology.org/article/S0923-7534(19)34133-X/pdf

good discussion

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28
Q

What is the initial treatment of all stages of seminoma?

A

Radical inguinal orchiectomy with high ligation of spermatic cord

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29
Q

What is the adjuvant management of stage III seminoma?

A

EP X 4C or BEP x 3C
RT/surgery for salvage

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30
Q

What is the adjuvant treatment of stage II seminoma?

A

IIA: modified dog leg RT 20Gy/10# with boost to 30Gy

IIB/C: EP x 4C or BEP x 3C

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31
Q

What is the role of RT in stage IIB seminoma?

A

RT for select non bulky disease (nodes <3cm))
Modified dogleg RT 20GY/10# with boost to 36Gy

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32
Q

Epi of testicular cancer

A
  • 1% of male cancers
  • 10,000 per year in USA, 440 deaths
  • most common solid tumour in men 15-34year old
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33
Q

What is the most common testicular cancer in men >60years

A

Lymphoma

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34
Q

What age range do NSGCT present in?

A

typically 20-30s

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35
Q

What age range do Seminomas present in?

A

typically 30-40

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36
Q

What are risk factors for testicular cancer?
(13)

A
  • Cryptorchidism (abdo >inguinal >high scrotal)
  • Carcinoma in situ of testis/ Intratubular germ cell neoplasia of testes
  • Hypospadia
  • androgen insensitivity syndrome
  • Testicular dysgenesis syndrom
  • previous contralat testicular cancer
  • extragonadal GCT
  • family hx (8-10x RR with brother , 4 x father)
  • white race
  • HIV
  • Marijuana use
  • Peutz Jaegher syndrome
  • Testicular development disorders: Klinefelter syndrome, Down’s syndrome
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37
Q

What is the risk of testicular cancer assoc with abdominal cryptorchid testes?

A

5% risk of cancer
must be resected

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38
Q

what is the risk of testicular cancer assoc with inguinal cryptorchid testes?

A

1.3% risk
Should undergo orchiopexy before puberty
risk of ca increases with age at which cryptorchidism is detected/reversed

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39
Q

What is the risk of progression of carcinoma in situ to invasive disease within 5 years?

A

50%

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40
Q

What is the lymphatic drainage of the testes?

A

along testicular veins to retroperitoneal/para-arotic LN at vertebral levels T11-L4

then via cistern chill and thoracic duct to posterior mediastum, left SVC and axilla

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41
Q

In what circumstances are inguinal nodes involved with testicular cancer?

A

If scrotum is disrupted e.g. transcrotal biopsy, hernia repair, vasectomy

not a usual lymphatic drainage site of testis

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42
Q

What are some types of non Germ cell testicular tumours?

A

Leydig cell tumour
Sertoli cell tumour
rhabdomyosarcoma
lymphoma

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43
Q

What are the subtypes of seminoma?

A

Classic 85%

Anapaestic 10%

spermatocytic 5%

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44
Q

Are the subtypes of seminoma treated the same or differently?

A

the same

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45
Q

Does anaplastic seminoma have a worse prognosis than the other types?

A

no, it has higher mitotic activity but not worse outcomes

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46
Q

what population does spermatocytic seminoma usually occur in?

A

older men >50years
favourable prognosis

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47
Q

What type of seminomas may have raised bHCG?

A

pure seminoma with syncytiotrophoblastic cells

elevated in 10-15%

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48
Q

What types of NSGCT are there?

A

embryonal
Teratoma
choriocarcinoma
yolk sac
mixed tumours

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49
Q

How often is Cis found adjacent to invasive GCT disease?

A

in nearly 100%, not spermatocytic seminoma or infant tumorus

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50
Q

by what time frame does CIS usually precede invasive GCT?

A

3-5 years

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51
Q

What is the biological behaviour of seminoma?

A

Radiosensitive

80% local at presentation

Lymphatic spread

Relapse occurs later

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52
Q

What % of pure seminoma have AFP elevation?

A

zero 0%

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53
Q

What is the biological behaviour of NSGCT in general?

A

Radioresistant

70% distant at presentation

often haematogenous spread

relapse occurs earlier

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54
Q

What is the biological features of embryonal tumours?

A

More aggressive

> 60% DM at presentation (lung, liver)

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54
Q

What is the most common type of pure NSGCT?

A

Embryonal

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55
Q

What is the second most common type of NSCGT?

A

Teratoma

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56
Q

What % of embryonal tumours have raised AFP/bHCG?

A

AFP 70%
bHCG 60%

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57
Q

What is the % of teratomas with raised AFP and bHCG?

A

AFP 38%
bHCG 25%

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58
Q

What is the biological behaviour of choriocarcinoma?

A

rare

Very high bHCG (elevated in 100%)

AFP not raised

most aggressive

spread haematogenosuly

may haemorrhage

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59
Q

what is the age predilection for yolk sac tumours?

A

most common paediatric GCT

80% present in under 2yo

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60
Q

What is the behaviour of yolk sac tumours in adults?

A

present in mediastinum
chemoresistant

assoc. with pathologic finding of Schiller Duval bodies

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61
Q

How commonly is LDH raised in testicular ca?

A

in about 50% of GCT

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62
Q

What is the clinical presentation of testicular cancer?

A

Painless testicular mass or swelling

Less commonly experience a dull ache, heavy sensation in lower abdomen or perianal area, or fullness of scrotum

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63
Q

What features are assoc with higher risk of metastatic dz at time of presentation ?

A

tumour size and epididymal invasion

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64
Q

What % have gynaecomastia at presentation and why?

A

5%
due to oestrogen effects of b HCG

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65
Q

What % have infertility at presentation?

A

50%

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66
Q

What are the diff diagnosis of testicular ca

A

testicular torsion
epididymitis
hydrocele
varicocele
hernia
haematoma
spermatocele

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67
Q

What % have pain at presentation?

A

10% will present with acute pain

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68
Q

What is necessary for the physical exam part of workUp?

A

H&P

Bimanual exam of scrotal contents
Palpation of abdomen ?nodal or visceral dz

examine chest for gynaecomastia
palpation for SCV nodes

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69
Q

What labs are needed for work up of testistular ca?

A

FBC
CMP
serum tumour markers (AFP, LDH, bHCG)

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70
Q

What are the findings of testicular ca
on USS?

A

Ca- hypo echoic massW

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71
Q

What are the findings of seminoma on USS?

A

well defined hypo echoic mass without cystic areas

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72
Q

What are the findings of NSGCT on USS?

A

hypo echoic mass with calcification, cystic areas and indistinct margins

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73
Q

What type of USS is initially used for imaging of testes?

A

bilateral scrotal colour doppler USS

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74
Q

Is USS sufficient for staging?

A

No- surgery is required
USS has 44% accuracy for seminoma nd 8% for NSGCT

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75
Q

What are the imaging modalities needed for testicular work up?

A
  • Bilateral scrotal USS
  • CXR
  • CT Abdo/pelvis + chest if suspicious
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76
Q

Is PET used routinely for testicular ca workup?

A

no- alters staging in 10%
may be more useful for seminoma than NSGCT

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77
Q

What patients should get an MRI brain?

A

if symptomatic
if significant lung mets
high B HCG

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78
Q

Why is trans-scrotal biopsy or orchietomy absolutely contraindicated?

A

Because of risk of tumour seeding into scrotal sac, lymphatic disruption or metastatic spread of tumour into inguinal nodes

79
Q

What fertility measures should be provided prior to treatment?

A

Fertility associates referral

Semen analysis/sperm banking prior to treatment

80
Q

Who gets RPLND?

A

select patients with NSGCT

81
Q

What comprises the S stage?

A

post-orchiectomy serum tumour marker levels (LDH, AFP and B HCG)

82
Q

What is the T 1/2 of BHCG and AFP

A

bHCG 24-36 hours
AFP 5-7 days

83
Q

What are prognostic factors in seminoma?

A

Stage
Non pulmonary visceral mets

84
Q

What are prognostic factors in NSCGT?

A

LVI
non pull visceral mets
S3
mediastinal primary
embryonal predominant

85
Q

What is stage IIA based on AJCC 8th edition

A

Any T stage N1 (regional LN less than or equal to 2cm, single or multiple nodes)

86
Q

What does the AJCC 8th edition use to stage testicular cancer?

A

T, N, M per usual plus S staging which is post op serum tumour marker levels

87
Q

What stages are there in testicular cancer?

A

1-III, not IV

88
Q

What is the risk of relapse after orchiectomy for seminoma?

A

12% for stage I seminoma with size <3cm (T1a)

20% for those with size > or equal to 3cm (T1b)

89
Q

If a patient with seminoma stage I T1a does not relapse in the first 2 Years after orchiectomy, what is their risk of relapse in the next 5 years?

A

3.9%

90
Q

If a patient with stage I seminoma, T1b, does not relapse in their first two years after orchiectomy, what is their risk of relapse in the next 5 years

A

5.6%

91
Q

Where is the most common place for nodal relapse to occur?

A

90% of nodal relapses occur in the para-aortic lymph nodes (“landing zone”

92
Q

What proportion develop pelvic nodal relapse?

A

10%

93
Q

what direction does nodal crossover occur in?

A

right to left, (15%)
rarely from left to right

94
Q

What defines stage III?

A

Metastatic disease
(non retroperitoneal LN, visceral mets)

95
Q

What is stage IIB ?

A

Any T
Regional LN >2cm and less than or equal to 5cm

96
Q

If there is a mixed seminoma/NSGCT, what paradigm are they treated on?

A

NSGCT

97
Q

What is the role of RT in NSGCT?

A

salvage/palliation

98
Q

Is RPLND indicated in seminoma or NSGCT?

A

NSGCT

99
Q

What is the NCCN recommended follow up paradigm for stage I seminoma patients on active surveillance?

A

H&P q3mo for year 1
q 6mo for year 2 and 3,
then annually

serum tumour markers and USS for equivocal exam

CT abdo/pelvis q3monthly year 1, q6monthly years 2-3, q12-24mo years 4-5
CXR if clinically indicated
CT chest if symptomatic

100
Q

What stages is CHT the preferred adjuvant option for?

A

IIB, IIC and III

101
Q

What is the adj chemotherapy used for stage I seminoma

A

carboplatin (AUC 7) x 1-2 cycles

102
Q

What are the chemo options for stage IIb, IIC and III seminoma patients?

A

BEP x 3
EP x 4

103
Q

What is the adj RT approach for stage I if indicated?

A

PAs to 20GY/10#

104
Q

what is the adj RT approach to stage IIa seminoma?

A

modified dog leg covering PA and ipsilateral internal iliac nodes 20Gy/10# with boost to 30Gy for gross disease

105
Q

What is the adj RT approach for IIb seminoma?

A

modified DL field (PA and ipsilat internal iliac) to 20 Gy/10 fx is followed by boost to 36
Gy to the gross disease

106
Q

Should the L renal hilum be covered when treating with adj RT?

A

Yes- per TE10

107
Q

What are CI to adj RT?

A

horshoe kidney,
inflammatory bowel disease
prior RT
genetic syndrome which would increase risk of future malignancies

108
Q

What evidence supports active surveillance in men with stage I seminoma?

A
  • no prospective trials support directly
  • systematic review of literature (2060 men): showed relapse occurred in 17% and mortality was 0.3% due to effective salvage treatment
  • another trial showed risk of relapsed 6% if tumour size <4cm and no rete testis invasion
  • danish retrospective cohort study showed majority of relapses occurred within 5 years (only 4.3% after 5 years) and 15year DSS 99.3% and OS 91.6% supporting that risk of relapse and death in stage I is low
109
Q

What is the evidence of treatment of Para-aortics alone in Stage I seminoma rather than dog leg?

A

MRC TE10 study
- established PA only as standard in stage I seminoma
- no diff in 3 year PFS or OS between PA only and dog leg
- 4 pelvic relapses in PA group vs 0 in DL group
- 9 relapses in each group
- less acute toxicity and higher sperm counts in PA field

110
Q

In the MRC TE10 trial, what were the treatment arms?

A

PA field treated T11-L5

Dog leg treated PAs plus ipsilat internal iliac nodes

111
Q

What is the evidence for RT dose of 20GY/10# in stage I seminoma?

A

Based on MRC TE18

Noninferiority trial of 625 patients with stage I seminoma (pT1–3N0) randomized to 20 Gy/10 fx vs. 30 Gy/15 fx, all to PAS (T11–L5). Designed to assess noninferiority and powered to exclude a 4% difference in 2-year relapse rates.

No diff in OS or PFS

20Gy arm had less acute side effects at 4 weeks but no diff at 12 weeks

6 new primary cancers dx in 30Gy arm

112
Q

What is the evidence for CHT over RT in stage 1 seminoma?

A

MRC TE19 trial

Carboplatin is noninferior to RT in terms of Relapse free survival, and has reduced side effects.

Single-agent carboplatin is given for 1 to 2cycles

113
Q

What does the pooled analysis of TE10, TE18, TE19 trials show?
(Stage I seminoma non inferiority trials)

Mead, UK TE Pooled Analysis

A

Pattern of relapse depends on adjuvant treatment received
- patients treated with carboplatin more likely to fail in retroperitoneum
- patients treated with PAs failed in neck/mediastinum and pelvis
- patients treated with DL failed in mediastinum or neck

99.8% CSS overall

114
Q

What are the NCCN 2020 recommendations for management of stage II seminoma?

A

RT
- dog leg (PA plus ipsilat internal iliac)
- IIa 30Gy
- IIb 36Gy

CHT:
- BEP x 3 or EP x 4

Chemo preferred for stage IIb and higher

Radiation not considered preferred for bulky nodal disease due to higher failure rates

115
Q

Why is BEP/EP used in stage II seminoma rather than single agent carboplatin?

A

Krege, German testicular cancer study group 2006

Single-agent carboplatin was not effective in eradicating RP metastasis in stage IIA/B seminoma.

overall failure rate was 18% in stage IIA/B seminoma

116
Q

What is the risk of developing a second malignancy after adjuvant treatment for testicular cancer?

What evidence supports this?

A

Travis 2005

Population-based registries of >40,000 testicular cancer survivors used to calculate relative and absolute risks of second solid cancers.

If dx age 35:

RR 2 for second solid tumour for RT alone

RR 1.9 for CHT alone

RR 2.9 for RT and CHT

Risk remains elevated for at least 35 years

117
Q

What did the MRC TE19 trial show?

A

Adjuvant carboplatin non-inferior to RT for stage 1 seminoma, with less side effects

118
Q

Describe the field for a PA strip

A

Sup: T10/T11 junction
Inf: L5/S1
Lateral: tip of transverse process
Including L renal hilum if L testicular primary

width is 9-11cm

119
Q

Describe the volume for PA strip

A

CTV20 = 1.2 cm radial expansion of IVC
1.9cm radial expansion of aorta, clipped at anatomical boundaries from 2cm below top of kidney to to aortic bifurcation

PTV20 = CTV + 5mm expansion

120
Q

Describe the difference between dog leg and modified dog leg?

A

Modified dog leg covers the PA strip and ipsilateral internal iliac

Dog leg is a vertical expansion of modified DL inferiorly to the ipsilateral mid obturator Foramen

121
Q

Describe the field of modified dog leg/hockey stick

A

Continuation of PA strip to cover ipsilat internal iliac

Lateral: straight ling from tip of ipsilat L5 transverse process to super-lateral border of acetabulum

Medial: tip of contralateral L5 transverse process to medial border of ipsilateral obturator foramen

Inf: sup border of ipsilat acetabulum

122
Q

Treatment paradigm for seminoma
(diagram)

A
123
Q

Treatment paradigm for non seminoma

A
124
Q

What is the micro appearance of germ cell neoplasia in situ?

A

Malignant cells within seminiferous tubules: large cells with abundant cytoplasm, fried
egg appearance, frequent mitosis,
atypical primordial cells with large nuclei

PALP (placental-like alkaline phosphatase) +ve

125
Q

What is the macro appearance of seminoma?

A

homogenous, grey-white, entire testis replaced ‘cut potato’

126
Q

What serum marker pattern is seen in seminoma?

A

AFP not elevated in seminoma (if AFP elevated, consider diagnosis of
NSGCT);

BHCG may be elevated due to syncytiotrophoblast (15% of seminoma)

127
Q

What is the micro appearance of seminoma?

A

‘fried egg appearance’ (abundant clear cytoplasm glycogen),
lobular
configuration of tumour with fibrous septa,
lymphocytic infiltrate

128
Q

What is the IHC of seminoma?

A

SALL4+ve (=germ cell),

PLAP+, OCT3/4+, CD117(i.e. cKIT)+, D2-40+ve,
SOX2+ve

129
Q

Molecular/cytogenetics of seminoma?

A

Isochromosome from the short arm of chromosome 12, i(12p) present

KIT mutations

130
Q

What testicular germ cell tumours do not arise from GCNIS

A

teratoma
yolk sac
spermatohytic seminoma

131
Q

What are the extratesticular manifestations of seminoma?

A

Where the primary is not located in the testes but a different site e.g. mediastinum, retroperitoneum, pineal gland (= germinoma)

132
Q

What is the age predilection for spermatohytic seminoma vs testicular DLBCL?

A

ss- >50
DLBCL- elderly

133
Q

Are serum markers elevated in spermatocytic seminoma?

A

no

134
Q

what is the macro appearance of spermatocytic seminoma

A

homogenous pale grey appearance, soft friable cut surface, 10% bilateral,

135
Q

What does spermatocytic seminoma arise from?

A

Differentiated spermatogonia

136
Q

What are the micro features of spermatocytic seminoma?

A

Composed of 3 CELL TYPE of variables sizes – SMALL lymphocyte-like cells,
INTERMEDIATE cells, GIANT cells) (diagnosis based on morphology)

  • no stroma/ glycogen/ lymphocyte (cf classical seminoma)
  • 6% with sarcomatoid features (=poor prognostic factor)
137
Q

How does spermatocytic seminoma and classical seminoma differ on their microscopic appearance?

A

classical has abundant clear cytoplasm glycogen and lymphocytes

Spermatocytic does not

138
Q

What is the IHC of spermatocytic seminoma?

A

Positive: CAM 5.2+,

Negative: PLAP-, OCT3/4-, CD30-, B-HCG-, AFP-

cf classical seminoma which is positive for PLAP and OCT3/4

139
Q

What is the age predilection for embryonal carcinoma?

A

15-35y/o (rare after 50y/o, never in <15y/o)

140
Q

What serum markers are elevated in embryonal carcinoma?

A

elevated LDH, 70% elevated AFP, 60% elevated B-HCG,
(other: also elevated PLAP, CA19-9)

141
Q

What are the macro features of embryonal carcinoma?

A

Gray-tan mass with hemorrhage and necrosis.

does not replace testis,

poorly circumscribed.

142
Q

Micro appearance of embryonal carcinoma

A

anaplastic epithelioid cells, with huge nucleoli, overlapping nuclei,
large primitive cells, in alveolar/ papillary pattern

143
Q

What is the IHC of embryonal carcinoma?

A

Positive:
SALL4+, PLAP+, OCT3/4+,

CD30+ (highly sensitive/ specific marker for
embryonal carcinoma; not in other testicular germ cell tumour), SOX2+,

Negative:
B-HCG-, CD117-

144
Q

Most common growth patterns for embryonal carcinoma?

A

Solid, glandular, papillary

145
Q

What is the diff between mature and immature teratoma?

A

Mature teratoma contains differentiated cells or organdie structures.

Immature teratoma contains undifferentiated elements resembling tissues in embryonic stages of development

146
Q

What % of teratoma have elevated AFP?

A

40%

147
Q

What % of teratoma have elevated B HCG?

A

25%

148
Q

Macro appearance of teratoma

A

lobulated with cysts of mutinous, gelatinous or serous material

149
Q

What are the micro features of teratoma?

A

Pre-pubertal
– more likely to have tissues arrangement mimicking organs, but any tissue type may be present,
- hair follicles may be seen (not in post-pubertal type)

Post-pubertal
– any type of tissue may be present (e.g. gastrointestinal glands, respiratory epithelium, cartilage, squamous epithelium with keratinization),
- will have GCNIS, a/w atrophic testis with sclerosis and microlith

Teratoma with somatic type malignancy
– sarcoma is more prevalent somatic type malignancy but other tumour types can occur e.g. adenocarcinoma, squamous cell carcinoma and primitive neuroectodermal tumour (PNET)

150
Q

What is the most aggressive kind of NSGCT?

A

Choriocarcinoma

151
Q

What is the natural hx of choriocarcinoma?

A

Haematogenous spread,
may haemorrhage (present with bleeding assoc with mets e.g. haemoptysis, hemorrhagic brain mets, GI bleeding)

Aggressive

152
Q

What endocrine abnormalities are choriocarcinoma assoc with?

A

gynaecomastia in 10%
Hyperthyroidism

153
Q

What tumour marker abnormalities are seen with choriocarcinoma

A

very high bHCG (thousands, in all cases)
AFP always normal

154
Q

What does bHCG correlate with in choriocarcinoma

A

prognosis and tumour burden

155
Q

What is the macro appearance of choriocarcinoma

A

usually does not cause testicular enlargement, only small palpable testicular
nodule; friable, haemorrhagic, necrotic

156
Q

What is the micro appearance of choriocarcinoma

A

composed of three main cell types:

o SYNCYTIOTROPHOBLASTIC cells (large, multinucleated cells with smudgy chromatin)

o CYTOTROPHOBLASTIC cells (round/ polygonal cells, sharp cell borders, clear
cytoplasm, single nucleus)

o INTERMEDIATE TROPHOBLASTIC cells (clear cytoplasm, large than cytotrophoblast
with single nuclei)

157
Q

What is the IHC of choriocarcinoma?

A

B-HCG+ve (from syncytiotrophoblast), SALL4+, EMA+ve, cytokeratin +ve

Negative:
OCT3/4- (+ in classic seminoma/ embryonal ca),
CD117- (+ in classic
seminoma),
CD30- (+ in embryonal)

158
Q

What is the most common type of paediatric germ cell tumour?

A

yolk sac/endodermal sinus tumour

159
Q

Is yolk sac tumour assoc with cryptorchidism or GCNIS?

A

No

160
Q

What serum marker is assoc with yolk sac?

A

elevated AFP (95-98% of cases)

~ 25% have elevated B-HCG

161
Q

What is the macro appearance of yolk sac tumour?

A

soft solid tumour with mucinous/
gelatinous appearance

162
Q

What is the micro appearance of yolk sac tumour?

A

microcystic and reticular pattern,
sieve-like/ lace-like appearance (due to intracytoplasmic vacuoles and merging of cells),

Schiller-Duval bodies pathognomic (glomeruli-like endodermal sinuses, where central papillary lined by tumour cells; but not always present)

163
Q

What is the IHC of yolk sac tumour

A

AFP + (highly characteristic),

glypican3 +

164
Q

What is the macro of leydig cell tumours?

A

yellow, golden homogenous tumour

165
Q

What is the natural hx of sex cord stromal tumours (Leydig cell or Sertoli cell)

A

90% benign
10% may metastasize

166
Q

What is the micro appearance of Leydig cell tumours?

A

Reinke crystals pathognomic but only present in 30-40%

167
Q

What is the IHC of Leydig cell tumour?

A

Inhibit +
Chromogranin +

168
Q

What is the micro appearance of Sertoli cell tumour?

A

tubular architecture, abundant eosinophilic cytoplasm, dense fibrous stroma

169
Q

What is the function of the leydig cells in the testes?

A

secretes testosterone

170
Q

What is the function of the Sertoli cell

A

from sex cord, supports spermatogenesis

171
Q

What does T1a vs T1b denote

A

T1a tumour size less than or equal to 3cm,

T1b> 3cm

172
Q

What does T2 mean

A

LVI , or tunica vaginalis involvement

173
Q

What does T3 mean

A

Spermatic cord involvement

174
Q

What does T4 mean

A

scrotal invasion

175
Q

What does N1 mean

A

less than 5 positive nodes and all less/equal to 2cm

176
Q

What does N2 and N3 mean

A

N2 2-5cm
N3 >5cm

177
Q

What are the regional LN in testicular cancer

A

Regional LN are abdominal para-aortic, pre-aortic, inter-aorto-caval, pre-caval, para-caval, retro-caval, retro-aortic nodes (nodes along spermatic vein is considered regional LN); laterality does not affect N classification

178
Q

Brief summary of stages
Stage 1 =

A

N0

179
Q

Brief summary of stages
Stage 2a =
Stage 2b =
Stage 2c =

A

2a = nodes <2cm (N1)

2b = does 2-5cm (N2)

2c = nodes >5cm (N3)

180
Q

Brief summary of stages
Stage III =

A

M1

181
Q

What is the management of residual disease after chemotherapy in NSGCT?

A

any residual disease >1cm needs to be resected even if normal serum markers

182
Q

What is the management of post chemo residual disease in seminoma? (give 3 diff situations only, not their management)

A
  1. Residual mass <3cm and normal AFP/B-HCG
  2. Residual mass >3cm
    normal AFP and B-HCG
  3. Progressive disease (increasing mass/rising serum markers)
183
Q

What is the management of Residual mass <3cm and normal AFP/B-HCG after chemotherapy?

A

Surveillance

183
Q

What is the management of Progressive disease (increasing mass/rising serum markers) after chemotherapy?

A
  • Clinical trial (preferred) OR
  • Chemotherapy
    —- conventional dose vinblastine/ ifosfamide/ cisplatin (VeIP), or paclitaxel/ ifosfamide/ cisplatin (TIP)
    —– High dose chemotherapy (with peripheral blood stem cell support)
    — Consider salvage surgery (if solitary site)
184
Q

What is the management of post chemo Residual mass >3cm normal AFP and B-HCG?

A

— Surveillance OR
— Staging PET 6 weeks post chemo
– continue surveillance if neg
– resection/biopsy if positive –> further chemo if viable tumour

185
Q

What is the effect of different RT doses to the testis?

A

0.5Gy=transient azoospermia; 2Gy=azoospermia for several years;
6-8Gy=permanent sterility;
30% patients fertile after RT)

186
Q

What is the drainage of the L and R testicular veins?

A

L into L renal vein
R into IVC

187
Q

What are some of the risk of trans-scrotal bx or orchiectomy of testes?

A
  • risk of seeding of tumour into scrotum
  • disruption to lymphatic drainage
  • risk of spread to inguinal nodes (non regional)
188
Q

What is a classification system which stratifies germ cell testicualr cancer into different prognosis groups?

A

IGCCCG criteria

Seminoma divided into good and intermediate prognosis groups

NSGCT divided into good, intermediate and poor prognosis groups

189
Q

as per IGCCCG criteria what is a good prognosis seminoma?

A

Any primary site

AND

No non-pulmonary visceral mets

AND

normal serum markes

190
Q

as per IGCCCG criteria, what is an intermediate prognosis seminoma?

A

Any primary site

AND

NON-pulmonary visceral mets

AND

normal serum markers

(so the diff between good and intermediate is that there are non pull visceral mets in intermediate)

191
Q

as per IGCCCG criteria, what is a good prognosis NSGCT?

A

Testis/retroperitoneal primary

AND

No NPVM

AND all of AFP <1000
HCG <5000
LDH <1.5 ULN

192
Q

What is an intermediate prognosis seminoma as per IGCCCG

A

testis/retroperitoneal primary

AND

No NPVM

AND ANY OF

AFP >1000
BHCG >5000
LDH >1.5x ULN

193
Q

What is a poor prognosis NSGCT? per IGCCCCG

A

Mediastinal primary

OR

NPVM

OR any of
AFP >10,000
HCG >50, 000
LDH >10 x ULN

194
Q
A

GU (5 decks)

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