testicular and prostate cancer Flashcards
types of testicular cancer
- germ cell make up 95% of cases
- germ cell subdivided into seminomas vs non-seminomatous germ cell tumors (NSGCT)
types of NSGCT
- embryonal cell carcinomas
- teratomas
- mixed cell type- most common
- choriocarcinoma
risk factor for testicular cancer
- hx of cryptorchidism, even if surgically repaired
clinical presentation of testicular cancer
- greatly varied but usu pts wait 3-6 months to seek care
- painless nodule/ enlargement of testis*
- heavy sensation
- acute testicular pain
- asymptomatic
- rarely present with gynecomastia
dx of testicular cancer
- scrotal US best initial test
- if US is suspicious move on to CT (abd-pelvis and chest)
- serum tumor markers- good for NSGCT
- radical inguinal orchiectomy +/- retroperitoneal LN dissection (RPLND)
what do seminomas look like on US
- hypoechoic lesions
- no cystic areas
what to NSGCT look like on US
- nonhomogenous
- calcificatinos
- cystic areas
- indistinct margins
serum tumor markers for testicular cancer
- best for NSGCT
- AFP
- HCG
- LDH- good for both types
- best for f/u of disease or s/p primary treatment
why do pts often get RPLND with testicular cancer
- 44% of time the scan is falsely negative due to micromets
- if pts dont have RPLND have up to 25% relapse in first year
what should all testicular cancer pts be offered before any treatment
- cyropreservation of sperm
stage 0 testicular cancer
- tumor in situ
- abnormal cells but cannot feel mass
stage I testicular cancer
- cancer just in testis
stage II testicular cancer
- cancer in LN
- retroperitoneal or para-aortic LN usually
stage III testicular cancer
- distant mets
treatment for seminomas
- majority present in stage 1 and very rarely metastasize
- orchiectomy usu curative
- close f/u
- if LN involvement add adjuvant XRT or monitor
- if more extensive LN involvement pts get adjuvant chemo
follow up for seminomas
- get CT esp if initially had RPLN
- if > 3 cm residual mass -> PET scan -> if pos then resection
- if < 3 cm mass - surveillance
- 1-2 mo f/u X 2 years
- quarterly f/u in 3rd year
- CXR and CT q 3-4 mo
NSGCT risk factors for relapse
- lymphatic vascular invasion of testicular mass
- embryonal carcinoma
- T3 or T4 primary tumor
treatment for NSGCT stage 1
- radical orchiectomy
- if no RF for relapse then can do close surveillance
- if 1 or more RF- chemo 1-2 cycles, RPLND
treatment for NSGCT stage 2
- orchiectomy
- following surgical RPLND + bx or CT findings:
- < 2 cm= surveillance
- < 2 cm with 1+ RF= chemo 1-2 cycles
- > 2 cm and/or elevated tumor markers= chemo 2-3 cycles
management for advanced testicular cancer
- same for seminomas vs NSGCT
- based on good, intermed, or poor risk status
good risk for advanced testicular cancer
- seminomas with just lung mets
- NSGCT with just lung mets or low tumor markers
- treatment= chemo X 3 cycles
intermed or poor risk for advanced testicular cancer
- seminomas- spread beyond lungs
- NSGCT- spread beyond lungs, tumor markers either intermed or high
- treatment= chemo X 4 cycles
when does relapse usually occur for testicular cancer
- within first 1-2 years
treatment for relapse of testicular cancer in chemo naive
- BEP chemo
treatment for relapse of testicular cancer with chemo and orchiectomy
- VIP chemo instead of BEP
treatment for relapse of testicular cancer within first 4 weeks
- considered chemo/ platinum refractory
- requires high does chemo
treatment for relapse of testicular cancer after 2 years
- uncommon
- require aggressive surgical approach and systemic chemo
prostate cancer
- 2nd most common male cancer
- increased incidence with age
- most are adenocarcinomas
where do most prostate cancers occur
- peripheral zone
risk factors for prostate cancer
- AA race
- high dietary fat
- family hx
clinical presentation of prostate cancer
- most are asymptomatic*
- may have lower UT sx
- hematuria/ hematospermia
- DRE- nodular, asymmetric, indurated
- boney pain
- LE lymphedema
- BOO
- adenopathy
- weight loss
screening for prostate cancer
- PSA
- DRE
PSA
- correlates with volume of prostate, benign or malignant
- useful for detecting and staging ca, monitoring response to tx, detecting recurrence
- not specific
- increases with age
- monitor fractioned PSA
- consider PSA velocity- how fast it is changing
what is an elevated PSA
- > 4
what is fractioned PSA
- % free PSA relative to total PSA
- more free PSA the better
- if > 30% ratio low likelihood ca
- if < 10% ratio higher risk ca
diagnosis of prostate ca
- elevated PSA or abnormal DRE -> TRUS bx
- MRI good for staging
- bone scan if PSA > 10- 20
transrectal US (TRUS) guided biopsy
- get at least 10 biopsies, sometimes up to 18
- assoc with improved detection of prostate Ca and risk stratification
- if persistently elevated PSA but neg bx may . need to repeat bx 1-2 X
gleason staging
- used for staging, treatment and prognosis of prostate ca
- 2 samples from largest areas of abnormalities (primary and secondary grades)
- each rated on a scale of 1-5, total of 2-10
stage I prostate cancer
- cant palpate tumor
- found only on bx
stage II prostate cancer
- tumor just in prostate
stage III prostate cancer
- tumor goes into seminal vesicles or penetrates capsule
- doesnt go into any other adjacent structures
stage IV prostate cancer
- penetrates through capsule and spreads elsewhere
standard treatment for prostate cancer
- based on pts life expectancy and risk stratification
- active surveillance/ watchful waiting
- radical prostatectomy +/- pelvic LN dissection
- XRT- very effective
- hormone therapy- palliative care
types of XRT for prostate cancer
- external beam radiation therapy (EBRT)
- brachytherapy- direct implant of radioactive source in prostate
what is the treatment for most pts with metastatic prostate cancer
- androgen deprivation therapy (ADT)
- used as palliative measure, not curative
- may also receive XRT, TURP for BOO, or chemo
where are most prostate cancer mets found
- axial skeleton
drug classes for ADT
- GnRH agonists
- LHRH antagonists
- complete androgen blockade
- non-steroidal anti-androgens
- bisphosphonates
GnRH agonists
- preferred initial ADT medication
- initially testosterone increases in first 3 weeks (flare) -> feedback sys shuts down and no more testosterone made
- leuprolide
- goserelin
- histarelin
- triptorelin
LHRH antagonists
- directly inhibits testosterone production
- no flare effect
- degarelix
complete androgen blockade
- combined GnRH + anti-androgen therapy
why give bisphosphonates for prostate ca
- prevents osteoporosis
- helps with bone pain due to mets
what are the nomograms used for prognosis of prostate ca
- kattan nomogram
- CAPRA nomogram
