- embryonal cell carcinomas - teratomas - mixed cell type- most common - choriocarcinoma

testicular and prostate cancer Flashcards by Amy Fraser

types of testicular cancer

germ cell make up 95% of cases

- germ cell subdivided into seminomas vs non-seminomatous germ cell tumors (NSGCT)

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types of NSGCT

embryonal cell carcinomas
teratomas
mixed cell type- most common
choriocarcinoma

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risk factor for testicular cancer

hx of cryptorchidism, even if surgically repaired

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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

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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)

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what do seminomas look like on US

hypoechoic lesions

- no cystic areas

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what to NSGCT look like on US

nonhomogenous
calcificatinos
cystic areas
indistinct margins

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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

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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

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what should all testicular cancer pts be offered before any treatment

cyropreservation of sperm

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stage 0 testicular cancer

tumor in situ

- abnormal cells but cannot feel mass

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stage I testicular cancer

cancer just in testis

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stage II testicular cancer

cancer in LN

- retroperitoneal or para-aortic LN usually

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stage III testicular cancer

distant mets

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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

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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

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NSGCT risk factors for relapse

lymphatic vascular invasion of testicular mass
embryonal carcinoma
T3 or T4 primary tumor

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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

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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

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management for advanced testicular cancer

same for seminomas vs NSGCT

- based on good, intermed, or poor risk status

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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