Testicular Flashcards
What proportion of men with testicular cancer are dx with contralateral testicular ca?
5%
What is the most common type of testicular cancer by far? vs the other type?
Germ cell tumour (95%) vs
non Germ cell tumour (5%)
What are the two types of Germ cell tumour and their approx proportions?
Seminoma 55-60%
Non seminomatous germ cell tumour 40-45%
What serum tumour markers need to be checked before orchiectomy?
bHCG
a Fetoprotein (AFP)
LDH
What type of testicular ca is raised serum markers assoc with?
NSCGT
Does normal serum tumour marker levels exclude GCT?
No, especially for Seminoma
What does persisting or increasing tumour markers after orichectomy usually indicate?
Metastatic disease
What proportion of Germ cell tumour patients have Germ cell neoplasia in situ in the contralat testis?
5%
so physical exam +- USS required on FU
Is there evidence to support PET staging of GCT?
No- ESMO consensus 2022
How is orchiectomy performed?
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.
What is the survival rate of stage I seminoma?
99%
What proportion of seminoma patients present with stage I disease?
80%
Why is minimising treatment toxicity so important for stage I seminoma?
because cure rate is so high 99% regardless of what treatment strategy is chosen
What are adjuvant management options for stage I seminoma?
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
What proportion of higher risk stage I seminoma patients relapse on surveillance?
15-30%
What is the adjuvant chemo regime for stage I seminoma
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
What features make stage I seminoma higher risk?
T size and rete testis invasion
What is the survival rate of stage I NSGCT?
98-100%
How is stage I NSCGT stratified into low or high risk?
Presence of Lymphovascular invasion
(low risk has 12% risk of relapse
high risk has 40-50% risk of relapse)
Stage IIA seminoma with LN <2cm- is adjuvant CHT or RT more effective at reducing recurrence?
Meta analysis shows that Rt and CHT are equally effective at reducing reccurence
For stage IIB seminoma, is CHT or RT more effective at reducing reccurrence?
Meta analysis shows that CHT is more effective
What is the adjuvant paradigm for stage I NSGCT?
Low risk:
Surveillance preferred
1 cycle BEP if can’t do surviellance
High risk:
1 cycle BEP preferred
Surveillance is alternative option
What is the adjuvant management of Stage IIA seminoma?
Chemo
or
RT to PA and ipsilateral iliac lymph nodes (modified dog leg) 20Gy/10# with boost to 30Gy
What is the adjuvant management of stage IIB-III NSGCT?
Good prognostic group:
BEP x 3 cycles
Intermediate/poor prognostic group:
BEP x 4 cycles
What does BEP stand for?
Bleomycin
Etoposide
Cisplatin
Should there be screening for testicular cancer?
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.
Discuss the controversy regarding contralateral testis biopsy (obj 3.3)
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
What is the initial treatment of all stages of seminoma?
Radical inguinal orchiectomy with high ligation of spermatic cord
What is the adjuvant management of stage III seminoma?
EP X 4C or BEP x 3C
RT/surgery for salvage
What is the adjuvant treatment of stage II seminoma?
IIA: modified dog leg RT 20Gy/10# with boost to 30Gy
IIB/C: EP x 4C or BEP x 3C
What is the role of RT in stage IIB seminoma?
RT for select non bulky disease (nodes <3cm))
Modified dogleg RT 20GY/10# with boost to 36Gy
Epi of testicular cancer
- 1% of male cancers
- 10,000 per year in USA, 440 deaths
- most common solid tumour in men 15-34year old
What is the most common testicular cancer in men >60years
Lymphoma
What age range do NSGCT present in?
typically 20-30s
What age range do Seminomas present in?
typically 30-40
What are risk factors for testicular cancer?
(13)
- 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
What is the risk of testicular cancer assoc with abdominal cryptorchid testes?
5% risk of cancer
must be resected
what is the risk of testicular cancer assoc with inguinal cryptorchid testes?
1.3% risk
Should undergo orchiopexy before puberty
risk of ca increases with age at which cryptorchidism is detected/reversed
What is the risk of progression of carcinoma in situ to invasive disease within 5 years?
50%
What is the lymphatic drainage of the testes?
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
In what circumstances are inguinal nodes involved with testicular cancer?
If scrotum is disrupted e.g. transcrotal biopsy, hernia repair, vasectomy
not a usual lymphatic drainage site of testis
What are some types of non Germ cell testicular tumours?
Leydig cell tumour
Sertoli cell tumour
rhabdomyosarcoma
lymphoma
What are the subtypes of seminoma?
Classic 85%
Anapaestic 10%
spermatocytic 5%
Are the subtypes of seminoma treated the same or differently?
the same
Does anaplastic seminoma have a worse prognosis than the other types?
no, it has higher mitotic activity but not worse outcomes
what population does spermatocytic seminoma usually occur in?
older men >50years
favourable prognosis
What type of seminomas may have raised bHCG?
pure seminoma with syncytiotrophoblastic cells
elevated in 10-15%
What types of NSGCT are there?
embryonal
Teratoma
choriocarcinoma
yolk sac
mixed tumours
How often is Cis found adjacent to invasive GCT disease?
in nearly 100%, not spermatocytic seminoma or infant tumorus
by what time frame does CIS usually precede invasive GCT?
3-5 years
What is the biological behaviour of seminoma?
Radiosensitive
80% local at presentation
Lymphatic spread
Relapse occurs later
What % of pure seminoma have AFP elevation?
zero 0%
What is the biological behaviour of NSGCT in general?
Radioresistant
70% distant at presentation
often haematogenous spread
relapse occurs earlier
What is the biological features of embryonal tumours?
More aggressive
> 60% DM at presentation (lung, liver)
What is the most common type of pure NSGCT?
Embryonal
What is the second most common type of NSCGT?
Teratoma
What % of embryonal tumours have raised AFP/bHCG?
AFP 70%
bHCG 60%
What is the % of teratomas with raised AFP and bHCG?
AFP 38%
bHCG 25%
What is the biological behaviour of choriocarcinoma?
rare
Very high bHCG (elevated in 100%)
AFP not raised
most aggressive
spread haematogenosuly
may haemorrhage
what is the age predilection for yolk sac tumours?
most common paediatric GCT
80% present in under 2yo
What is the behaviour of yolk sac tumours in adults?
present in mediastinum
chemoresistant
assoc. with pathologic finding of Schiller Duval bodies
How commonly is LDH raised in testicular ca?
in about 50% of GCT
What is the clinical presentation of testicular cancer?
Painless testicular mass or swelling
Less commonly experience a dull ache, heavy sensation in lower abdomen or perianal area, or fullness of scrotum
What features are assoc with higher risk of metastatic dz at time of presentation ?
tumour size and epididymal invasion
What % have gynaecomastia at presentation and why?
5%
due to oestrogen effects of b HCG
What % have infertility at presentation?
50%
What are the diff diagnosis of testicular ca
testicular torsion
epididymitis
hydrocele
varicocele
hernia
haematoma
spermatocele
What % have pain at presentation?
10% will present with acute pain
What is necessary for the physical exam part of workUp?
H&P
Bimanual exam of scrotal contents
Palpation of abdomen ?nodal or visceral dz
examine chest for gynaecomastia
palpation for SCV nodes
What labs are needed for work up of testistular ca?
FBC
CMP
serum tumour markers (AFP, LDH, bHCG)
What are the findings of testicular ca
on USS?
Ca- hypo echoic massW
What are the findings of seminoma on USS?
well defined hypo echoic mass without cystic areas
What are the findings of NSGCT on USS?
hypo echoic mass with calcification, cystic areas and indistinct margins
What type of USS is initially used for imaging of testes?
bilateral scrotal colour doppler USS
Is USS sufficient for staging?
No- surgery is required
USS has 44% accuracy for seminoma nd 8% for NSGCT
What are the imaging modalities needed for testicular work up?
- Bilateral scrotal USS
- CXR
- CT Abdo/pelvis + chest if suspicious
Is PET used routinely for testicular ca workup?
no- alters staging in 10%
may be more useful for seminoma than NSGCT
What patients should get an MRI brain?
if symptomatic
if significant lung mets
high B HCG
Why is trans-scrotal biopsy or orchietomy absolutely contraindicated?
Because of risk of tumour seeding into scrotal sac, lymphatic disruption or metastatic spread of tumour into inguinal nodes
What fertility measures should be provided prior to treatment?
Fertility associates referral
Semen analysis/sperm banking prior to treatment
Who gets RPLND?
select patients with NSGCT
What comprises the S stage?
post-orchiectomy serum tumour marker levels (LDH, AFP and B HCG)
What is the T 1/2 of BHCG and AFP
bHCG 24-36 hours
AFP 5-7 days
What are prognostic factors in seminoma?
Stage
Non pulmonary visceral mets
What are prognostic factors in NSCGT?
LVI
non pull visceral mets
S3
mediastinal primary
embryonal predominant
What is stage IIA based on AJCC 8th edition
Any T stage N1 (regional LN less than or equal to 2cm, single or multiple nodes)
What does the AJCC 8th edition use to stage testicular cancer?
T, N, M per usual plus S staging which is post op serum tumour marker levels
What stages are there in testicular cancer?
1-III, not IV
What is the risk of relapse after orchiectomy for seminoma?
12% for stage I seminoma with size <3cm (T1a)
20% for those with size > or equal to 3cm (T1b)
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?
3.9%
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
5.6%
Where is the most common place for nodal relapse to occur?
90% of nodal relapses occur in the para-aortic lymph nodes (“landing zone”
What proportion develop pelvic nodal relapse?
10%
what direction does nodal crossover occur in?
right to left, (15%)
rarely from left to right
What defines stage III?
Metastatic disease
(non retroperitoneal LN, visceral mets)
What is stage IIB ?
Any T
Regional LN >2cm and less than or equal to 5cm
If there is a mixed seminoma/NSGCT, what paradigm are they treated on?
NSGCT
What is the role of RT in NSGCT?
salvage/palliation
Is RPLND indicated in seminoma or NSGCT?
NSGCT
What is the NCCN recommended follow up paradigm for stage I seminoma patients on active surveillance?
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
What stages is CHT the preferred adjuvant option for?
IIB, IIC and III
What is the adj chemotherapy used for stage I seminoma
carboplatin (AUC 7) x 1-2 cycles
What are the chemo options for stage IIb, IIC and III seminoma patients?
BEP x 3
EP x 4
What is the adj RT approach for stage I if indicated?
PAs to 20GY/10#
what is the adj RT approach to stage IIa seminoma?
modified dog leg covering PA and ipsilateral internal iliac nodes 20Gy/10# with boost to 30Gy for gross disease
What is the adj RT approach for IIb seminoma?
modified DL field (PA and ipsilat internal iliac) to 20 Gy/10 fx is followed by boost to 36
Gy to the gross disease
Should the L renal hilum be covered when treating with adj RT?
Yes- per TE10
What are CI to adj RT?
horshoe kidney,
inflammatory bowel disease
prior RT
genetic syndrome which would increase risk of future malignancies
What evidence supports active surveillance in men with stage I seminoma?
- 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
What is the evidence of treatment of Para-aortics alone in Stage I seminoma rather than dog leg?
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
In the MRC TE10 trial, what were the treatment arms?
PA field treated T11-L5
Dog leg treated PAs plus ipsilat internal iliac nodes
What is the evidence for RT dose of 20GY/10# in stage I seminoma?
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
What is the evidence for CHT over RT in stage 1 seminoma?
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
What does the pooled analysis of TE10, TE18, TE19 trials show?
(Stage I seminoma non inferiority trials)
Mead, UK TE Pooled Analysis
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
What are the NCCN 2020 recommendations for management of stage II seminoma?
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
Why is BEP/EP used in stage II seminoma rather than single agent carboplatin?
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
What is the risk of developing a second malignancy after adjuvant treatment for testicular cancer?
What evidence supports this?
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
What did the MRC TE19 trial show?
Adjuvant carboplatin non-inferior to RT for stage 1 seminoma, with less side effects
Describe the field for a PA strip
Sup: T10/T11 junction
Inf: L5/S1
Lateral: tip of transverse process
Including L renal hilum if L testicular primary
width is 9-11cm
Describe the volume for PA strip
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
Describe the difference between dog leg and modified dog leg?
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
Describe the field of modified dog leg/hockey stick
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
Treatment paradigm for seminoma
(diagram)
Treatment paradigm for non seminoma
What is the micro appearance of germ cell neoplasia in situ?
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
What is the macro appearance of seminoma?
homogenous, grey-white, entire testis replaced ‘cut potato’
What serum marker pattern is seen in seminoma?
AFP not elevated in seminoma (if AFP elevated, consider diagnosis of
NSGCT);
BHCG may be elevated due to syncytiotrophoblast (15% of seminoma)
What is the micro appearance of seminoma?
‘fried egg appearance’ (abundant clear cytoplasm glycogen),
lobular
configuration of tumour with fibrous septa,
lymphocytic infiltrate
What is the IHC of seminoma?
SALL4+ve (=germ cell),
PLAP+, OCT3/4+, CD117(i.e. cKIT)+, D2-40+ve,
SOX2+ve
Molecular/cytogenetics of seminoma?
Isochromosome from the short arm of chromosome 12, i(12p) present
KIT mutations
What testicular germ cell tumours do not arise from GCNIS
teratoma
yolk sac
spermatohytic seminoma
What are the extratesticular manifestations of seminoma?
Where the primary is not located in the testes but a different site e.g. mediastinum, retroperitoneum, pineal gland (= germinoma)
What is the age predilection for spermatohytic seminoma vs testicular DLBCL?
ss- >50
DLBCL- elderly
Are serum markers elevated in spermatocytic seminoma?
no
what is the macro appearance of spermatocytic seminoma
homogenous pale grey appearance, soft friable cut surface, 10% bilateral,
What does spermatocytic seminoma arise from?
Differentiated spermatogonia
What are the micro features of spermatocytic seminoma?
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)
How does spermatocytic seminoma and classical seminoma differ on their microscopic appearance?
classical has abundant clear cytoplasm glycogen and lymphocytes
Spermatocytic does not
What is the IHC of spermatocytic seminoma?
Positive: CAM 5.2+,
Negative: PLAP-, OCT3/4-, CD30-, B-HCG-, AFP-
cf classical seminoma which is positive for PLAP and OCT3/4
What is the age predilection for embryonal carcinoma?
15-35y/o (rare after 50y/o, never in <15y/o)
What serum markers are elevated in embryonal carcinoma?
elevated LDH, 70% elevated AFP, 60% elevated B-HCG,
(other: also elevated PLAP, CA19-9)
What are the macro features of embryonal carcinoma?
Gray-tan mass with hemorrhage and necrosis.
does not replace testis,
poorly circumscribed.
Micro appearance of embryonal carcinoma
anaplastic epithelioid cells, with huge nucleoli, overlapping nuclei,
large primitive cells, in alveolar/ papillary pattern
What is the IHC of embryonal carcinoma?
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-
Most common growth patterns for embryonal carcinoma?
Solid, glandular, papillary
What is the diff between mature and immature teratoma?
Mature teratoma contains differentiated cells or organdie structures.
Immature teratoma contains undifferentiated elements resembling tissues in embryonic stages of development
What % of teratoma have elevated AFP?
40%
What % of teratoma have elevated B HCG?
25%
Macro appearance of teratoma
lobulated with cysts of mutinous, gelatinous or serous material
What are the micro features of teratoma?
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)
What is the most aggressive kind of NSGCT?
Choriocarcinoma
What is the natural hx of choriocarcinoma?
Haematogenous spread,
may haemorrhage (present with bleeding assoc with mets e.g. haemoptysis, hemorrhagic brain mets, GI bleeding)
Aggressive
What endocrine abnormalities are choriocarcinoma assoc with?
gynaecomastia in 10%
Hyperthyroidism
What tumour marker abnormalities are seen with choriocarcinoma
very high bHCG (thousands, in all cases)
AFP always normal
What does bHCG correlate with in choriocarcinoma
prognosis and tumour burden
What is the macro appearance of choriocarcinoma
usually does not cause testicular enlargement, only small palpable testicular
nodule; friable, haemorrhagic, necrotic
What is the micro appearance of choriocarcinoma
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)
What is the IHC of choriocarcinoma?
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)
What is the most common type of paediatric germ cell tumour?
yolk sac/endodermal sinus tumour
Is yolk sac tumour assoc with cryptorchidism or GCNIS?
No
What serum marker is assoc with yolk sac?
elevated AFP (95-98% of cases)
~ 25% have elevated B-HCG
What is the macro appearance of yolk sac tumour?
soft solid tumour with mucinous/
gelatinous appearance
What is the micro appearance of yolk sac tumour?
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)
What is the IHC of yolk sac tumour
AFP + (highly characteristic),
glypican3 +
What is the macro of leydig cell tumours?
yellow, golden homogenous tumour
What is the natural hx of sex cord stromal tumours (Leydig cell or Sertoli cell)
90% benign
10% may metastasize
What is the micro appearance of Leydig cell tumours?
Reinke crystals pathognomic but only present in 30-40%
What is the IHC of Leydig cell tumour?
Inhibit +
Chromogranin +
What is the micro appearance of Sertoli cell tumour?
tubular architecture, abundant eosinophilic cytoplasm, dense fibrous stroma
What is the function of the leydig cells in the testes?
secretes testosterone
What is the function of the Sertoli cell
from sex cord, supports spermatogenesis
What does T1a vs T1b denote
T1a tumour size less than or equal to 3cm,
T1b> 3cm
What does T2 mean
LVI , or tunica vaginalis involvement
What does T3 mean
Spermatic cord involvement
What does T4 mean
scrotal invasion
What does N1 mean
less than 5 positive nodes and all less/equal to 2cm
What does N2 and N3 mean
N2 2-5cm
N3 >5cm
What are the regional LN in testicular cancer
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
Brief summary of stages
Stage 1 =
N0
Brief summary of stages
Stage 2a =
Stage 2b =
Stage 2c =
2a = nodes <2cm (N1)
2b = does 2-5cm (N2)
2c = nodes >5cm (N3)
Brief summary of stages
Stage III =
M1
What is the management of residual disease after chemotherapy in NSGCT?
any residual disease >1cm needs to be resected even if normal serum markers
What is the management of post chemo residual disease in seminoma? (give 3 diff situations only, not their management)
- Residual mass <3cm and normal AFP/B-HCG
- Residual mass >3cm
normal AFP and B-HCG - Progressive disease (increasing mass/rising serum markers)
What is the management of Residual mass <3cm and normal AFP/B-HCG after chemotherapy?
Surveillance
What is the management of Progressive disease (increasing mass/rising serum markers) after chemotherapy?
- 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)
What is the management of post chemo Residual mass >3cm normal AFP and B-HCG?
— Surveillance OR
— Staging PET 6 weeks post chemo
– continue surveillance if neg
– resection/biopsy if positive –> further chemo if viable tumour
What is the effect of different RT doses to the testis?
0.5Gy=transient azoospermia; 2Gy=azoospermia for several years;
6-8Gy=permanent sterility;
30% patients fertile after RT)
What is the drainage of the L and R testicular veins?
L into L renal vein
R into IVC
What are some of the risk of trans-scrotal bx or orchiectomy of testes?
- risk of seeding of tumour into scrotum
- disruption to lymphatic drainage
- risk of spread to inguinal nodes (non regional)
What is a classification system which stratifies germ cell testicualr cancer into different prognosis groups?
IGCCCG criteria
Seminoma divided into good and intermediate prognosis groups
NSGCT divided into good, intermediate and poor prognosis groups
as per IGCCCG criteria what is a good prognosis seminoma?
Any primary site
AND
No non-pulmonary visceral mets
AND
normal serum markes
as per IGCCCG criteria, what is an intermediate prognosis seminoma?
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)
as per IGCCCG criteria, what is a good prognosis NSGCT?
Testis/retroperitoneal primary
AND
No NPVM
AND all of AFP <1000
HCG <5000
LDH <1.5 ULN
What is an intermediate prognosis seminoma as per IGCCCG
testis/retroperitoneal primary
AND
No NPVM
AND ANY OF
AFP >1000
BHCG >5000
LDH >1.5x ULN
What is a poor prognosis NSGCT? per IGCCCCG
Mediastinal primary
OR
NPVM
OR any of
AFP >10,000
HCG >50, 000
LDH >10 x ULN
