Testicular Cancer Flashcards
Risk factors for developing testis cancer including germ cell neoplasia in situ (GCNIS)?
history of UDT/cryptorchidism (4-6x, reduced by 2-3 x if orchidopexy prior to puberty)
family history
personal history of testis cancer
Risk of occult systemic disease for stage one testis cancer is lowest for :
pure seminoma vs. NSGCT
Pure seminomas are more sensitive to chemotherapy and radiation relative to NSGCT?
YES
The most undifferentiated type of NSGCT is?
embryonal carcinoma AND has totipotential capacity (differentiate into other NSGCT - yolk sac, choriocarcinoma, teratoma)
Why is presence of teratoma important for management?
Although histologically benign, may contain genetic anomalies found in malignant GCT → uncontrollable growth and invasion or transformation into somatic-type malignancies
universally resistant to chemo and radiation
ONLY curable by surgical resection
What are the testis cancer tumor markers and their associated histologies?
alpha fetoprotein (AFP) → yolk sac and embryonal (chorio and seminoma do NOT produce) → ½ life 5-7 days
human chorionic gonadotropin (hCG) → chorio and embryonal and syncytiotrophoblastic cells in seminoma → ½ life 24-36 h
lactate dehydrogenase (LDH) → nonspecific, best for estimating disease bulk
Staging for testis cancer is based on:
pathologic stage of tumor
post orchiectomy tumor markers
staging by PE and imaging
Testis TNM
Testis TNM stage:
Testis Risk Categories:
A solid mass on PE or imaging is:
GUIDELINE STATEMENT 1
malignant neoplasm until proven otherwise
When finding solid mass on PE or imaging, what is first step?
GUIDELINE STATEMENT 2
serum tumor. markers (AFP, hCG, and LDH) prior to any treatment
Prior to intervention for testicular mass, patients should be counseled:
GUIDELINE STATMENT 3
risk of hypogonadism and infertility
offered sperm banking (consider prior to orchiectomy if unclear status of contralateral or known subfertility)
What type of scrotal imaging should be used?
GUIDELINE STATEMENT 4
scrotal ultrasound with doppler (for unilateral or bilateral masses)
What workup is required for testicular microlithiasis?
GUIDELINE STATEMENT 5
testicular microlithiasis in absence of solid mass and risk factors doe snot confer and increased risk of malignant neoplasm and doesn’t require further evaluation
Patient with normal tumor markers (hCG and AFP) and indeterminate findings on PE or US, what is next step?
GUIDELINE STATEMENT 6
Repeat imaging 6-8 weeks
(< 2 cm 50-80% are not cancer → benign tumors, infarcts, Leydig cell nodules)
In initial workup of testicular lesion, any other imaging modalities besides US?
GUIDELINE STATEMENT 7
MRI should NOT be used in initial eval and dx of testicular lesion suspicious for neoplasm
Lesion determined by US and PE suspicious for malignancy, next steps after tumor markers?
GUIDELINE STATEMENT 8
with normal contralateral testis
inguinal orchiectomy (testis sparing not recommended, trans-scrotal discouraged)
GUIDELINE STATEMENT 9
testicular prosthesis should be discussed prior to orchiectomy
What is recommended when a patient underwent a scrotal orchiectomy and found to have a testis neoplasm?
GUIDELINE STATEMENT 10
increased risk of recurrence and may be considered for adjunctive tx (excision of scar or RT) for local control
Discuss role of testis sparing surgery, considerations, and surgical considerations?
GUDIELINE STATMENT 11A
tss through inguinal incision in pts wishing to preserve gonadal fx with masses < 2 cm and (1) equivocal US/PE and negative hCG and AFP (2) congenital, acquired or functionally solitary testis, or (3) b/l synchronous tumors
GUIDELINE STATMENT 11B
counseled regarding (1) high risk of local recurrence (2) need for monitoring with PE/US (3) role of adjuvant RT to testis to reduce local recurrence (4) impact of RT ons perm and testosterone (5) risk of testicular atrophy and need for tRT and/or subfertility/infertility
GUIDELINE STATMENT 11C
in addition to suspicious mass, multiple bx of ipsi testis normal parenchyma (GCNIS) should be obtained and evaluated by GU pathologist
In patients with hx of GCT or GCNIS the risk of second primary tumor in contralateral testis is:
GUIDELINE STATEMENT 12
Rare but significant increase risk
(2%overall, 70% metachronous, 30% synchronous)
In patient with GCNIS on testis biopsy or malignant neoplasm after TSS, what are recommendations and options:
GUIDELINE STATEMENT 13A
with GCNIS or s/p TSS → inform patients of r/b of surveillance, radiation, or orchiectomy
GUIDELINE STATEMENT 13B
recommend surveillance in pts who prioritize preservation of fertility and testicular androgen production
GUIDELINE STATEMENT 13C
recommend RT (18-20 Gy) or orchiectomy in patients who prioritize reduction of cancer risk taking into account the less risk of hypogonadism with RT
Discuss utility of serum tumor markers in treatment planning:
GUIDELINE STATEMENT 14
Nadir makers should be repeated at appropriate T ½ time interval after orchiectomy for staging and risk stratification
GUIDELINE STATEMENT 15
for pts with elevated AFP or hCG post orchiectomy, clinicians should monitor tumor markers to establish nadir levels before treatment only if nadir would influence treatment
In metastatic GCT (Stage IIC or III) planning for chemo what is the regimen based on?
GUIDELINE STATEMENT 16
IGCCCG risk stratification based on serum tumor markers (hCG, AFP, LDH) prior to chemo, staging imaging studies, and tumor histology from orchiectomy. Any post-pubertal male, should be treated as an adult
Describe Good Prognosis risk category for Seminoma and Non-Seminoma GCT:
Non-Seminoma
Testis/retroperitoneal primary, no non-pulmonary visceral mets, good markers
(AFP < 1000, hCG < 5000, LDH < 1.5 x norm)
56% of non-seminomas
5 yr PFS 89%
5 yr OS 92%
Seminoma
any primary site, no non-pulmonary visceral mets, normal AFP, any hCG, any LDH
90% seminomas
5 y PFS 82%
5 y OS 86%
Describe Intermediate Prognosis for Seminoma and Non-Seminoma GCT:
Non-Seminoma
testis/retroperitoneal primary, no non-pulmonary visceral mets, intermediate markers
(AFP > ,1000 < 10,000, hCG > 5,000 and < 50,000, and LDH > 1.5 x N and < 10 x N)
28% non-seminomas
5 y PFS 75%
5 yr OS 80%
Seminoma
any primary site, non-pulmonary visceral mets, normal AFP, any hCG, any LDH
10% seminomas
5 y PFS 67%
5 y OS 72%
Describe Poor Prognosis for Seminoma and Non-Seminoma GCT:
Non-Seminoma
mediastinal primary, non-pulmonary visceral mets, poor markers
(AFP > 10,000, hCG > 50,000, LDH >10 x N)
16% of non-seminomas
5 y PFS 41%
5 y Survival 48%
Seminoma
No patients classified as poor
Post orchiectomy elevated (AFP and hCG - 3 x normal), what should be done before treatments?
GUIDELINE STATEMENT 17
A rising trend should be confirmed before management decisions are made as false positive elevations may occur
Patients with newly diagnosed GCT, what imaging should be done?
GUIDELINE STATEMENT 18
CT scan A/P with IV contrast or MRI (if CT contra)
GUIDELINE STATEMENT 19A
Chest imaging
GUIDELINE STATMENT 19B
In setting rising of post-orchiectomy markers, mets on CT A/P, CXR or PE, A CHEST CT
GUIDELINE STATMENT 19C
Stage 1 seminoma, CXR (superior specificity) over Chest CT
GUIDELINE STATEMENT 19D
NSGCT Chest CT over CXR (especially if recommended adjuvant tx)
GUIDELINE STATEMENT 20
Newly dx GCT, do NOT obtain PET for staging
In newly dx GCT, how do you guide management decisions?
GUIDELINE STATEMENT 21
assign of TNM category
(image chest, A/P, post orchiectomy nadir AFP, hCG, and LDH)
GUIDELINE STATEMENT 22
Imaging w/in 4 weeks
Markers w/in 10days
Management decisions for newly dx GCT should be made with whom and based on which histology?
GUIDELINE STATEMENT 23
Multidisciplinary team (urology, med onc, rad onc, pathology, radiology)
GUIDELINE STATEMENT 24
Expert review of pathology in clinical scenarios where treatment decisions impacted
(review of expert alters subtype in 4-6%, 27% pathology reports revised)
In newly dx patients post orchiectomy with normal STM and equivocal findings on imaging for mets, how do you decide on tx?
GUIDELINE STATEMENT 25
Consider repeating imaging 6-8 weeks to clarify extent of dz before tx
Recommended tx for Seminoma GCT stage 1:
GUIDELINE STATEMENT 26
Surveillance after orchiectomy (<20% recurrence)
adjuvant RT and carboplatin-based chemo are less preferred (3-9% recurrence)
Recommended tx for pts w/Seminoma GCT and Stage IIa/b with LN < 3 cm? For IIB w/LN > 3 cm?
GUIDELINE STATEMENT 27
IIA/B LN < 3 cm: recommend RT(dog leg up to 30 Gy) or multi-agent cisplatin-based chemo (4 cycles EP or 3 cycles BEP) based on SDM
IIB LN >3 cm: chemotherapy recommended
Long term chemotherapy for GCT a/e:
cardiovascular, gastrointestinal, hematologic, infertility, secondary malignancy, neurologic, renal, pulmonary
Recommended tx for patients with NSGCT with elevated or rising post orchiectomy serum AFP and hCG:
GUIDELINE STATEMENT 28
risk appropriate multi-agent chemotherapy
Recommended treatment for Stage 1A NSGCT:
Reminder: IA pT1N0M0S0(beyond seminiferous tubules, still in testicle)
GUIDELINE STATEMENT 29
Surveillance preferred
RPLND or BEP x 1 (decline surveillance or non-compliance)
What are independent risk factors for relapse in NSGCT?
LVI and embryonal carcinoma
Recommended treatment for Stage 1B NSGCT:
Reminder IB: pT2-T4N0M0S0
GUIDELINE STATEMENT 30
surveillance, RPLND, or 1-2 BEP based on SDM
Patients with stage 1 NSGCT and any secondary somatic malignancy (teratoma with malignant transformation) in primary tumor, what is recommended tx:
GUIDELINE STATEMENT 31
RPLND
(teratoma has capacity to de-differentiate into somatic malignancy including sarcomas and carcinomas)
Patient with stage IIA NSGCT and S0, recommended tx:
Reminder IIA: any pTN1 (<5 nodes, < 2 cm) M0 S0 or S1 (in this question S0)
GUIDELINE STATEMENT 32
RPLND (benefit avoid chemo/remove teratoma) or chemotherapy
Patient with stage IIB NSGCT and S0, recommended tx:
Reminder: Stage IIB: Any pT, N2 (1 but <5 nodes with >2cm <5 cm, OR grown outside LN, OR > 5 nodes), M0S0 (this case) or S1
GUIDELINE STATEMENT 33
Risk-appropriate BEP vs. possible RPLND (select patients, S0)
Who should perform RPLND and how?
GUIDELINE STATMENT 34
referral to experience surgery at high volume center
GUIDELINE STATEMENT 35
experience and expertise with MIS can consider, acknowledge lack of long-term oncologic data
Describe an RPLND with curative intent:
GUIDELINE STATEMENT 36
*full b/l template with pts with suspicious LN on CT or intra-op or teratoma
*full b/l or modified template may be performed in clinically neg nodes
*right modified template may omit para-aortic LN below IMA (omission para-aortic LN above IMA controversial)
*left modified template may omit paracaval, precaval, and retrocaval LN (omission of interaortocaval LN controversial)
*nerve-sparing should be offered to preserve ejaculatory function
*nerve-sparing should NOT compromise quality of dissection
*complete retroaortic and/or retrocaval LND w/dissection and division of lumbar vessels should be performed within planned template
*ipsilateral gonadal vessels removed in ALL patients
*cephalad extent is crus of diaphragm to level of RA, caudad extent crossing of ureter over ipsilateral common iliac
After primary RPLND, what is recommended mgmt based on staging features:
GUIDELINE STATEMENT 37
Surveillance or chemo with stage II (not pure teratoma)
pN1 and/or pN1-3 pure teratoma → surveillance
pN2-3 → multi-agent chemotherapy (BEP)
What is surveillance protocol for Stage I seminoma:
GUIDELINE STATEMENT 38
H&P, cross-sectional imaging of abd +/- pelvis q 4-6 mo x 2 y, q6-12 mo yrs 3-5
routine chest and STM as indicated clinically