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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
Surveillance afer testicular cancer treatment and when is it done
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
What can use to identify residual non eminoma mass
18-FDG-PET scan
27
Why get gynaecomastia in testicular cancer
High circulating hCG levels
28
What is epidydomy orchtiis
Redness, pain, swelling of testes related to STI or UTI Treat with antibiotics
29
What genetic muataion is seen in >8-% testicular cancers
12 p gain Isochromosome of 12p - i12p - one arm of chromosome lost and replaced with exact replica of other arm
30
What is precursor to testicular cancer
Intratubular neoplasia - carcinoma in situ
31
Whichtesticular cancers are beta hCG positive
Seminoma Choriocarcinoma Embryonal carcinoma Mixed
32
Which testicular cancers are AFP postiive
Mixed Yolk sac tumour Embryonal carcinoma (also b hCG) Non seminomatous tumours 75% have raised either AFP or bHCG or both
33
Which hisotlogy of testicular cancer spreads quicker
Non seminomas - often advanced at presentation Seminomas may take 10 years to cause sympotms due to slow growth
34
Initial investigations other than IS testicular cancer
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
When should serum tumour markers be monitored with orchidectomy
pre-orchidectomy, 24 hours after orchidectomy and weekly thereafter until normal Suggest absence residual if normalise hCG 24 hrs, AFP 4-6 days
36
Differntials testicular cancer
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
What cna cause false postiive hCG levels
Interaction with assay fro LDH Should normalise with IM tesosterone injection
38
How is prognosis of testicular germ cell cancer determined
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
Stage I=IV testes cancer staging general rules
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
A, B and C of staging
A<2cm b2-5cm C >5cm
41
Treatment other than Stage I testicular cancer
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
RPNLD why do
To stage testicular cancer - prevent number of stage IIA patients receiving unneccessray chemo if lymph nodes not involved
43
BEP chemo drugs
Bleomycin Etoposide Cisplatin
44
What secondary cancer risk is increased with platinum based chemo and readiation therapy
Secondary lekaemia, mainly non lymphocytic Etoposide - AML w 11q23 translocation
45
Why are mgerm cell tumours more likely to cause tumour lysis syndrome
Excellent response to chemo means rapid breakdown of tumour and release of lectrolytes
46
Consequences of tumour lysis
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
Prevention of tumour lysis syndrome
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
Predisposing factors tumour lysis syndroem
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
Management tumour lysis syndrome
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
Extragonadal tumours where arise
Midline - (mediastinum, retroperitoneum, or pineal gland).
51
what required for seminoma diagnosis
normal AFP no other germ cells present Radiosensitive

Cancer (22 decks)

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