Testicular Flashcards
How are testicular tumours classified
95% Germ cell (50% seminoma & 50% non-seminomatous)
5% Sex cord stromal cancers (Leydig & Sertoli)
What types of non-germ cell tumour are there
And where do they arise from
Yolk sac, teratoma, chorocarcinoma
Sertoli/Leydig cell
Embryonal
What is the risk of future contralateral testicular cancer, if previous testicular cancer
5% increased risk of contralateral disease
What risk factors are there for testicular cancer
Previous testicular cancer - 5% increased risk
FHx - brother = x10, father = x4
Subnormal testicular development - maldescent, Down’s, Klinefelters
Unilateral maldescent = 5-10x increased risk; bilateral maldescent = 1 in 44)
Intra-tubular germ cell neoplasia (Like CIS: 50% risk at 5yrs)
Testicular atrophy or small volume (<12mls)
What is the typical age range for development of testicular cancer
25-35yrs
>60yrs - more likely to be lymphoma
What tumour marker is raised in seminoma
bHCG (in 10-20%)
What tumour marker is not elevated in seminoma
AFP
What tumour markers are raised in non-seminomatous germ cell tumours
bHCG (in 35%) & AFP
What is raised in choriocarcinoma
bHCG - very high
Where is the lymphatic spread for testicular tumours
R - interaortocaval nodes
L - para-aortic nodes
How should a new testicular tumour be investigated
Examination of testes and breast tissue
Bloods - bHCG, AFP, LDH
USS testes
CTCAP, MRI brain
Biopsy (orchidectomy) - note mediastinal primary alone is a poor prognostic marker
consider biopsy of contralateral testis if risk factors (volume <15ml) to exclude ITGCN
Treatment related
Fertility - sperm banking
EDTA (renal function), lung function (bleomycin), audiometry (cisplatin)
What is the first step in management of a testicular cancer, assuming no visceral mets
Orchiectomy and recheck serum markers
How does the presence of visceral mets / decompensation at presentation influence initial management of a testicular cancer
Start with chemo and delay orchiectomy
What is the management of residual retroperitoneal disease post chemo
Residual retroperitoneal lesions >1cm -> resect by RPLND to establish if necrotic tissue or viable tumour is present, and to remove any mature teratoma
What is the management of ITGCN if found at biopsy of the contralateral testis (present in 5%)
What proportion progress to malignancy
What are the risks
what is the follow up
RT: 20Gy in 10#
50-100% will progress
Risks of RT: Infertility & need for testosterone replacement
Follow up - annual ultrasound
What is the management of a stage 1 seminoma
How are the risks stratified for stage 1
80% are found at stage one (node negative)
Orchidectomy has 95% cure rate, so priority is to minimise toxicity
High risk - >4cm or Rete testis invasion
Low risk - <4cm & no Rete testis invasion
Low risk - surveillance only
Tumour markers 3/12 for first year
Year 1 -> 3-6 monthly CT, then annual scanning
High risk - adjuvant treatment
What is the adjuvant treatment for a high risk stage 1 seminoma (or pt unwilling to undergo surveillance)
Single cycle carboplatin at AUC7
reduces risk of relapse to approx 1%, which tends to be para-aortic
Radiotherapy if carboplatin not suitable:
20Gy/10#
Either para-aortic strip (T11- L5 inclusive, laterally to transverse processes of vertebrae (4-4.5cm)
Include left renal hilum in L testicular tumour
Or dog-leg field (T11 - mid-obturator foramen) if previous inguinal surgery, orchidopexy, herniorrhaphy, RP trauma
What adjuvant treatment is needed for a spermatocytic seminoma
None - low risk
What is the treatment for a relapsed stage one seminoma
If prev surveillance - give one cycle carboplatin + PA RT, or 4 cycles BEP
If prev carboplatin & good prognosis: 3x BEP
If prev carboplatin and int prognosis: 4x BEP / VIP
How is a stage 2A seminoma defined
What is the treatment
stage 2A = node positive below diaphragm, <2cm
Treatment options:
Orchiectomy then
Adjuvant chemo - 3x BEP or 4x EP (regardless of prognosis/risk)
OR dog leg RT - 30Gy/15# (para-aortic and ipsilateral iliac LNs) +/- single cycle carboplatin
How is a stage 2B seminoma defined
What is the treatment
stage 2A = node positive below diaphragm, 2-5cm
Treatment options:
BEP x3 or EP x4
OR dogleg RT 36Gy/18# OR 30Gy/15# with single cycle carboplatin ahead of RT
How is a stage 2C seminoma defined
What is the treatment
stage 2C = node positive below diaphragm, >5cm
Treatment options:
BEP x3 or EP x4
RT not recommended
What is the management of a stage 3 seminoma
How is it stratified
Stage 3 - LNs above diaphragm
Split according to prognosis (good and intermediate)
If good prognosis: 3x BEP or 4xEP
If intermediate prognosis: 4x BEP, or 4x VIP
When is scrotal irradiation indicated
Extensive tumour in spermatic cord or had scrotal violation during surgery
What is the management of a stage 1 NSGCT
How is it stratified
Orchiectomy
LVI- - surveillance (or 1x BEP if not suitable)
LVI+ - 1-2x BEP
What is the management of a stage 2 NSGCT
Node positive below diaphragm
Split by marker positive or negative
If S0 (marker negative) - Orchiectomy then surveillance
If S1 (marker positive) - 3x BEP if good prognosis, and 4x BEP if int/poor prognosis
What is the management of a stage 3 NSGCT
Node positive above diaphragm
Good prognosis - 3x BEP
Int/poor prognosis - 4x BEP
When is radiotherapy indicated for testicular tumours
Seminoma:
Adjuvant for high risk stage 1 & carboplatin not suitable - 20Gy/10# - para-aortic strip or dog-leg field
Option for a relapsed stage 1 seminoma
Stage 2A-B seminoma if not receiving BEP - dog leg RT - 30Gy/15# (para-aortic and ipsilateral iliac LNs) +/- single cycle carboplatin
NSGCT - not indicated
What investigation is not useful after relapse of a NSGCT
PET CT
What is the management of a primary mediastinal seminoma
And primary mediastinal NSGCT
Seminoma - normal risk - 3x BEP
NSGCT - poor risk - BEP then excise regardless of whether markers have normalised.
