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Cancer > Testicular cancer > Flashcards

Testicular cancer Flashcards

1
Q

Two main histological subtypes of testicualr cancer

A

Seminomas
Non seminatous germ cell tumours -> embryonal carcinoma, yolk sac tumour, choriocarcinoma, teratoma

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2
Q

Peak incidence of testicular cancer

A

30 to 40 years

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3
Q

Risk factors for testicular cancer

A

Infertility - x 3
Cryptorchidism
FH most significant
Kleinfelters syndrome
Downs syndrome
Atrophic testis
Prev testicular cancer
In utero exposure to oestrogens
Mumps orchitis
Tetsicular maldescent as child and orcidopexy <2 yeras reduce risk
History of testicular torsion

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4
Q

Non germ cell tumours causing testicular cancer

A

Leydig cell tumours
Sarcomas

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5
Q

Clinical features of testicular cancer

A

Painless lump most common presenting symptom unilateral
May have enlargement of testes or swlling
Pain 20%
Back pain
Hydrocele, gynaecomastia
AFP is elevated in 60%
LDH elecated in 40%
Seminomas - hCG elevated 20%

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6
Q

Referral for testicular cancer

A

Non painful enlargement or change in shape or texture of testis
Consider direct access US scan for testicular cancer in men w unexplained or persistent testicular symptoms

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7
Q

First line investigation testicular cancer

A

US

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8
Q

Managemnet of testicular cancer

A

Orchidectomy
Chemotherapy or radiotherapy depending on staging and tumour type

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9
Q

Tumour markers in testicualr cancer

A

AFP, beta hCG, LDH

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10
Q

Prognosis of testicular cacner 5 year survival rate

A

Stage I - 95-99%
Stage II seminoma 90-95%
Stage II non seminoma 80=90%
Stage III seminoma - 70-85%
Stage III non seminoma -60-75%

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11
Q

Risk of recurrence

A

2% cumulative risk of cancer in other testicle in 15 yeras after diagnosis

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12
Q

Long term affects of treatment for testicular cancer

A

Fertility - majority of men still fertile after.
Secondary leaukaemias - platinum and radiotherapy
Short term renal function - platinum
Hearing - cisplatin decreases but not enough for aids
Lung - cisplatin - restrictive lung disease

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13
Q

What can cisplatin therapy cause long term

A

Restrictive lung disease
Hearing - outside conversational tone

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14
Q

Fertility in testicular cancer treatmnet

A

semen may acc impove with treatment - majority still fertile. Wiat 3 months post chemo to conceive. Radiotherapy affects it more - 1-2 yeras

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15
Q

What chemo drug can cause acute pulmonary toxic effects

A

Bleomycin

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16
Q

What secondary cacners has radiation therapy been assocuated with

A

Solid tumours in the radiation portal, often after a dexade
Incl melanoma, stomach, bladder, colon, rectum, pancreas, lung, pleura, prostate, kidney, CT, thryoid

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17
Q

Chronic disease from testicular cacner treatment

A

Metabolic syndrome
CVS events from CHD etc (new regimes less so)
Hypogonadism

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18
Q

Staging of testicualr cancer

A

T1a <3cm
T1b >3cm
T2 limited to testis w lymphovascular invasion or soft tissue invasion
T3 invades spermatic cord soft tissue
T4 - invades scrotum

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19
Q

Lymph node staging in testicular cancer

A

cN1 = Metastases with a lymph node mass ≤2 cm in greatest dimension OR multiple lymph nodes, none >2 cm in greatest dimension.
cN2 = Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension OR multiple lymph nodes, any one mass >2 cm but ≤5 cm in greatest dimension.
cN3 = Metastasis with a lymph node mass >5 cm in greatest dimension.
pN1 = Metastasis with a lymph node mass ≤2 cm in greatest dimension and ≤5 nodes positive, none >2 cm in greatest dimension.
pN2 = Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension; or >5 nodes positive, none >5 cm; or evidence of extranodal extension of tumor.
pN3 = Metastasis with a lymph node mass >5 cm in greatest dimension.

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20
Q

Stage I testicular cancer

A

Limtied to testis

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21
Q

What anatomical structures in testis determines staging

A

Invasion of the scrotal wall by tumor does not change the stage, increases risk of inguinal lymph node spread,. Invasion of epididymis tunica albuginea and/or the rete testis doesnt change stage Invasion of the tunica vaginalis or lymphovascular invasion -> T2 tumor
invasion of the spermatic cord -> T3 tumor
invasion of the scrotum -> T4.

22
Q

Non seminomatous testicular tumours

A

Embryonal carcinomas.
Yolk sac tumors.
Choriocarcinomas.
Teratomas.
Mixed germ cell tumors.

23
Q

Good prognosis testicular cancer

A

Nonseminoma:

Testis/retroperitoneal primary, and
No nonpulmonary visceral metastases, and
Good markers–all of:
Alpha-fetoprotein (AFP) less than 1,000 ng/mL, and
Beta-human chorionic gonadotropin (beta-hCG) less than 5,000 IU/mL (1,000 ng/mL), and
Lactate dehydrogenase (LDH) less than 1.5 × the upper limit of normal

Seminomatous:
Any primary site, and
No nonpulmonary visceral metastases, and
Normal AFP, any beta-hCG, any LDH

24
Q

Poor prognosis testicular cancer

A

NMediastinal primary, or
Nonpulmonary visceral metastases, or
For markers–any of:
AFP more than 10,000 ng/mL, or
Beta-hCG more than 50,000 IU/mL (10,000 ng/mL), or
LDH more than 10 × the upper limit of normal

No patients with seminomas have a poor prognosis

25
Q

Surveillance afer testicular cancer treatment and when is it done

A

Done after raidcal inguinal orchidetomy with no radiation therapy
CT abdo pelivs
every 4 months for first 3 years
every 6 months for 3 years
annually for next 4 years

Avoids need for chemo or radio
15% relapse
Radiation not recommended in stage I - risk hoigher than benefit
If stage II need to have negative CT and timour markers after surgery

26
Q

What can use to identify residual non eminoma mass

A

18-FDG-PET scan

27
Q

Why get gynaecomastia in testicular cancer

A

High circulating hCG levels

28
Q

What is epidydomy orchtiis

A

Redness, pain, swelling of testes related to STI or UTI
Treat with antibiotics

29
Q

What genetic muataion is seen in >8-% testicular cancers

A

12 p gain
Isochromosome of 12p - i12p - one arm of chromosome lost and replaced with exact replica of other arm

30
Q

What is precursor to testicular cancer

A

Intratubular neoplasia - carcinoma in situ

31
Q

Whichtesticular cancers are beta hCG positive

A

Seminoma
Choriocarcinoma
Embryonal carcinoma
Mixed

32
Q

Which testicular cancers are AFP postiive

A

Mixed
Yolk sac tumour
Embryonal carcinoma (also b hCG)
Non seminomatous tumours 75% have raised either AFP or bHCG or both

33
Q

Which hisotlogy of testicular cancer spreads quicker

A

Non seminomas - often advanced at presentation
Seminomas may take 10 years to cause sympotms due to slow growth

34
Q

Initial investigations other than IS testicular cancer

A

Serum tumour markers (AFP, hCG, LDH)

Scrotal ultrasound
Imaging essential for staging is often performed after orchidectomy (CT of chest/abdomen/pelvis)
CT should be within 3 weeks of surgery and should include CT brain if multiple lung metastases and/or serum hCG >10,000

35
Q

When should serum tumour markers be monitored with orchidectomy

A

pre-orchidectomy, 24 hours after orchidectomy and weekly thereafter until normal
Suggest absence residual if normalise hCG 24 hrs, AFP 4-6 days

36
Q

Differntials testicular cancer

A

Benign epididymal masses are relatively common
Epididymo-orchitis or orchitis (if not resolving within 3 weeks should be referred for urological assessment)
Lymphoma/leukaemic infiltrate

37
Q

What cna cause false postiive hCG levels

A

Interaction with assay fro LDH
Should normalise with IM tesosterone injection

38
Q

How is prognosis of testicular germ cell cancer determined

A

Histology (seminoma vs. non-seminoma)
The extent to which the tumour has spread (testis only vs. retroperitoneal lymph node involvement vs. pulmonary or distant nodal metastasis vs. non-pulmonary visceral metastasis)
For nonseminomas, the degree to which serum tumour markers are elevated

39
Q

Stage I=IV testes cancer staging general rules

A

I - no evience mets. 1M = no rpimary tumour but elevated tumour makrers
2 - INfradiaphragmatic nodal involvement
3 - supradiaphragmatic nodal involvement
4 - extralymphatic mets eg lung mets, H+ =liver, Br+ = brain, Bo+ = bone

40
Q

A, B and C of staging

A

A<2cm
b2-5cm
C >5cm

41
Q

Treatment other than Stage I testicular cancer

A

In stage 2A and B seminoma, radiotherapy to the para-aortic and iliac lymph nodes is indicated. For all other stages of all forms of GCT, orchidectomy is delayed, as chemotherapy is the mainstay of treatment. In good prognosis disease, 3 cycles of bleomycin, etopiside and cisplatin (BEP) chemotherapy are used, with weekly monitoring of tumour markers, and post treatment CT imaging for response assessment. Orchidectomy is performed after chemotherapy.

42
Q

RPNLD why do

A

To stage testicular cancer - prevent number of stage IIA patients receiving unneccessray chemo if lymph nodes not involved

43
Q

BEP chemo drugs

A

Bleomycin
Etoposide
Cisplatin

44
Q

What secondary cancer risk is increased with platinum based chemo and readiation therapy

A

Secondary lekaemia, mainly non lymphocytic
Etoposide - AML w 11q23 translocation

45
Q

Why are mgerm cell tumours more likely to cause tumour lysis syndrome

A

Excellent response to chemo means rapid breakdown of tumour and release of lectrolytes

46
Q

Consequences of tumour lysis

A

Cardiac arrest, arrhythmias
hypocalcaemia, hyperkalaemia, hyperphosphataemia
Acute renal failure
urate nephropathy
hyperuricaemia
Disseminated intravascular coagulation
cell death
activation of coagulation cascades
intravascular haemolysis (high LDH)

47
Q

Prevention of tumour lysis syndrome

A

Adequate hydration and urine output (alkalinisation)
Allopurinol or rasburicase as inhibitors of urate oxidase
Beware of drug interactions
ACE inhibitors, spironolactone, NSAIDs
Beware diet
Bananas, chocolate etc.

48
Q

Predisposing factors tumour lysis syndroem

A

Large volume, chemo-sensitive tumour
Burkitt’s lymphoma, other non-Hodgkin lymphoma, leukaemia, small cell lung cancer, germ cell tumours, neuroblastoma, sarcomas
High serum LDH is a clue that the patient is at risk
Renal impairment
Lymphomatous involvement of the kidney
Male, <25 years

49
Q

Management tumour lysis syndrome

A

Requires adequate hydration and strict management of electrolytes but using a low K+ diet, oral and rectal resonium, IV calcium gluconate, IV bicarbonate, insulin/glucose, furosemide, forced hydration and in some cases haemodialysis.

50
Q

Extragonadal tumours where arise

A

Midline - (mediastinum, retroperitoneum, or pineal gland).

51
Q

what required for seminoma diagnosis

A

normal AFP
no other germ cells present
Radiosensitive

Cancer (22 decks)

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