Testicular and Prostate Cancer - Exam 2 Flashcards by Elisabeth Silver

what is the most common solid malignancy in men 15-35 y/o?

testicular malignancy

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right or left side is more common for testicular malignancy?

right side

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what tumors comprise most primary testicular tumors?

Germ cell tumors

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what tumors are germ cell tumors and which one is most common?

nonseminomatous (M/C)

seminomas

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what is the M/C risk factor for testicular cancer?

cryptorchidism

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what is the M/C presenting sx of testicular cancer?

painless nodule/enlargement of testis

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signs and sx’s of metastatic testicular cancer?

back pain, bone pain, gynecomastia

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what does an abnormal teste look like/feel like on PE?

firm, hard, fixed area

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what should put you on high alert for testicular cancer?

cryptorchidism or evidence of orchiopexy (scar from tx for cryptorchidism) -> HIGH RISK FOR TESTICULAR CANCER!!!

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what is the initial dx test ordered for testicular cancer? if it’s abnormal, then follow-up with what?

scrotal U/S

if abnormal, follow up with CT and serum markers

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what do seminomas and non-seminomas look like on scrotal U/S?

Seminomas
-hypoechoic lesion w/o cystic area

Non-seminomas
-not homogenous w/ calcifications, cystic areas, indistinct margins

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what CT do you order if abnormal US for testicular cancer?

abd, pelvis, and chest CT b/c evaluating disease and looking for mets

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what are the serum tumor markers for testicular cancer?

alpha-fetoprotein (AFP)

HCG (elevated in non-semi)

LDH (elevated in both non-semi and semi’s)

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when is alpha-fetoprotein serum tumor marker elevated and not elevated in testicular cancer?

elevated in Non-seminomas

NEVER elevated w/ seminomas

AFP = PATHOGNOMONIC FOR NON-SEMINOMAS

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what is pathognomonic for non-seminomas?

elevated AFP

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what is the initial intervention and the best intervention for testicular cancer? when is it done?

orchiectomy

done after US, serum biomarkers, and CT are done

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is bx of contralateral taste recommended in the US when do orchiectomy?

NO!!!

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what is the gold standard for staging for retroperitoneum mets in non-seminomas testicular cancer?

retroperitoneal LN dissection

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what type of testicular cancer has highest risk of nodal involvement?

non-seminomas

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when is retroperitoneal LN dissection done?

during orchiectomy

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what is offered to pts with testicular cancer before tx?

cryopreservation of sperm

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seminomas are what? (mnemonic from book)

simple (lak tumor markers)

sensitive (to radiation)

slower growing

stepwise spread

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stage 1 seminoma tx?

stage 1 = CA in testes only

ORCHIECTOMY = TX

also do, active surveillance, 1-2 cycles of adjuvant chemo w/ carboplatin, or adjuvant retroperitoneal XRT (if not chemo candidate)

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Stage 2a seminoma tx?

<2 cm involves LN’s

ADJUVANT XRT = TX

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Stage 2b seminoma tx?

stage 2b = 2-5cm LN's or c >5cm LN's BEP (BLEOMYCIN, ETOPOSIDE, CISPLATIN) = TX

post-treatment of seminoma?

CT (Esp if initially had RP) 1-2 months f/u w/ clinician for 2 years and quarterly the 3rd year w/ tumor markers at each check up CXR and CT every 2-4 months

if do CT post-treatment for seminoma and see >3cm residual mass, what do you do?

PET scan and if positive then do RP LN resection

if do CT post-treatment for seminoma and see < 3cm residual mass, what do you do?

surveillance

what do you start with for tx of non-seminoma?

radical orchiectomy - this determines histology and tx plan

stage 1 non-seminoma tx depends on?

tx depends on relapse risk factors: -lymphatic vascular invasion of testicular mass - embryonal carcinoma histologic predominance - T3 (tumor in spermatic cord) or T4 (tumor in scrotum) primary tumor

stage 1 non-seminoma tx if no risk factors?

surveillance

stage 1 non-seminoma tx if 1 or more risk factors?

high risk disease do active surveillance and treat with chemo (1-2 cycles BEP) and RPLND

stage 2 non-seminoma tx?

basically if there are < 2cm LN's and normal tumor markers -> do surveillance and do RPLND if CT found RP LN's 1-2cm if >2cm LN and normal tumor markers do 2 cycles of BEP chemotherapy if CT found >2cm LN and/or elevated tumor markers then do 3 cycles of chemo BEP 3

best surveillance of non-seminoma is with what?

AFP and HCG serum markers

if pt has relapse of testicular cancer and are chemo naive, how do you treat?

give BEP chemo

if pt has relapse of testicular cancer and aren't chemo naive, how do you treat?

use different chemotherapy -> VIP (vincristine, ifosfamide, cisplatin)

incidence of prostate cancer cancer increases with?

age b/c it is a hormonally dependent cancer

risk factors for prostate cancer?

AA race, high fat diet, family hx

most prostate cancers are what type of cells and originate where in the prostate?

most are adenocarcinomas and originate in the peripheral zone of the gland

sx's of prostate cancer?

MOST HAVE NO SX'S do DRE starting at 50 y/o and detect mass in posterior/lateral aspect of the gland BONEY PAIN!!! -> BACK PAIN!!! WEIGHT LOSS

where is the most common place for mets for prostate cancer?

mets most commonly occur in axial skeleton in prostate cancer -> GET BACK PAIN AS SX!!!

what does the new recommendation for screening for prostate cancer say?

don't do screening in asymptomatic men

screening tests for prostate cancer?

DRE PSA (prostate specific antigen) - can be misleading b/c not specific to prostate cancer (can be elevated in BPH, prostatitis, etc.)

dx of prostate cancer?

elevated PSA (≥ 2.6) or abnormal DRE TRUS (transrectal U/S guided) bx of the prostate

what is TRUS for prostate cancer dx?

transrectal U/S guided bx of the prostate done for dx of prostate cancer GET AT LEAST 10 BX VARIOUS PARTS OF THE PROSTATE (apex, mid-portion, base)

if persistently elevated PSA level but neg TRUS bx for prostate cancer, then do what?

repeat bx 1-2x and include transition zone this time

dx imaging for prostate cancer?

MRI of abdomen and pelvis 99-Technetium bone scan

MRI for dx of prostate cancer better to stage cancer than what?

MRI of abdomen and pelvis are better for staging for prostate cancer than TRUS

what is 99-Technetium bone scan for dx of prostate cancer detect? when is it indicated?

looks for mets to the axial skeleton b/c that is that main place for mets in prostate cancer indicated when PSA >10-20

what factors warrant imaging for prostate cancer (since you don't image everyone)?

presence of PSA levels >10, high grade histology (Gleason score ≥7, or physical findings that suggest stage T3

imaging for stage 2A and below for prostate cancer?

NO!!!

Gleason staging for prostate cancer based off of what?

bx samples (histology)

scale range for Gleason staging? score range?

scale range: 1-5 -1 is the least worrisome histology and 5 is the most aggressive histology score range: 2-10 score

score of 2-6 in Gleason staging indicates?

low-grade or well differentiated tumor

score of 7 in Gleason staging indicates?

moderate-grade or moderately differentiated tumor

score of 8-10 in Gleason staging indicates?

high-grade or poorly differentiated tumor

why are the scores of Gleason so important?

b/c correlates tumor volume, pathologic stage, and prognosis

localized disease tx for prostate cancer (low risk disease)

active surveillance: - PSA no more often than every 6 months - DRE no more often than every 12 months - repeat prostate bx no more often than every 12 months radiation therapy prostatectomy

localized disease tx for prostate cancer (intermediate risk disease)

radiation therapy - ERBT (+/- androgen deprivation therapy 4-6 months) - Brachytherapy - Combo of ERBT and Brachytherapy Prostatectomy w/ pelvic LN dissection

localized disease tx for prostate cancer (high risk disease)

- ERBT + ADT (2-3yrs) - ERBT + Brachytherapy + ADT 1 yr - Prostatectomy w/ pelvic LN dissection -> Consider radiatiotherapy

what are the C/I's to brachytherapy for prostate cancer tx?

large volume gland, chronic diarrhea or active inflammatory disease of rectum, marked voiding symptoms

what is the preferred initial tx for metastatic prostate cancer?

Hormone Therapy -GnRH agonist -> Leuproide -this med can cause temporary testosterone flare for 3wks-3months -> if worried about flare use Degarelix (LHRH antagonist)

when do you use bisphosphonates for prostate cancer tx?

in metastatic disease -use with androgen deprivation to prevent osteoporosis

when do you use complete androgen blockade for metastatic stage prostate cancer?

if there is bony pain, BOO, flare add CAB to tx for these reasons