Testicular Cancer Flashcards
How many cases occur every year, and how many deaths?
9,500 cases
400 deaths
Risk factors for testicular cancer
-GCNIS
-Hx UDT (RR 6x, but falls to 3x if pexied before puberty)
-FMHx
-Personal Hx
Most undifferentiated type of testicular cancer
embryonal - can become any other type of testicular cancer
Which conditions elevate AFP?
Yolk sac or Embryonal testis cancer
Cancers - stomach, panc, biliary, liver, lung
Liver disease, ataxia telangectasia
Half life of AFP
5 days (A-five-P)
Management of AFP (general rules)
Stable levels <25 can be monitored
Causes for elevated HCG
Choriocarcinoma, embryonal testis cancers
Some seminomas
Cancers - liver, biliary, panc, stomach, lung, breast, kidney, bladder
Pituitary masses
HCG half life
24 hrs
Testicular cancer Staging
0 - pTIS N0 M0 S0
1- pT1-4 N0 M0 SX
1A - pT1 N0 M0 S0
1B - pT2-T4 N0 M0 S0
IS - any pT N0 M0 S1-3
II - N1-3
IIA - any pT N1 M0 S0/1
IIB - any pT N2 M0 S0/1
IIC - any pT N3 M0 S0/1
III - M1
IIIA - M1a S0/1
IIIB - M0/1a with S2
IIIC - M0/1a with S3 OR M1B any S
S staging
S0 - normal
S1 - LDH <1.x5 ULN or bHCG <5000 or AFP <1000
S2 - LDH 1.5-10x or bHCG 5k-50k or AGP 1k-10k
S3 - LDH >10x or HCG >50k or AFP >10k
Early management of testis mass
Assume cancer until proven otherwise
Draw tumor markers
Scrotal US - repeat in 6 weeks if equivocal
Counsel about hypogonadism and infertility and offer banking
Unilateral orch
Offer prosthesis
How many patients will recover sperm production after cisplatin?
50% at 2 years, 80% at 5 years
Management of microlithiasis
Nothing unless risk factors or mass
When should testis sparing surgery be offered?
mass <2cm, equivocal US, neg markers, solitary testis, bilateral masses
Counsel VERY carefully
Be sure to take multiple biopsies of ipsilateral testicle
What is the risk of contralateral testicular cancer or GCNIS?
2%
Management of GCNIS after TSS
Observation
Testicular radiation (18-20Gy)
NOT chemo
Management after orch
Expert path review
Repeat markers, trend if <3x ULN
Only wait for nadir if it would change treatment
CT with IV contrast
Chest imaging (CT if high risk or NSGCT, CXR if CS1 sem)
Manage only with markers within 10 days and imaging within 4 weeks
Non-sem IGCC risk stratification
good prognosis (92% 5 year survival)
-Testis/RP primary
-No non-pulm visceral mets
-Good markers (S1)
intermediate prognosis (80% 5 year survival)
-Testis/RP primary
-No non-pulm visceral mets
-S2 markers
Poor prognosis (48% 5 year survival)
-mediastinal primary OR
-non-pulmonary visceral mets OR
-S3 markers
Sem IGCCC classification
Good (86% 5 year survival)
-Any primary
-No non-pulm visceral mets
-Normal AFP
Intermediate (72% 5 year survival)
-Non-pulm visceral mets
Management of CS1 sem
Surveillance
(Radiotherapy)
(Carboplatin)
CSIIA/IIB sem
LN <3cm - BEPx3 or EPx4, RT (30Gy dogleg), (RPLND)
LN >3cm - chemotherapy
Management of IA NSGCT
Surveillance
(BEPx1)
(RPLND)
Management of IB NSGCT
Surveillance
RPLND
BEPx1-2
Management of CSI NSGCT and secondary somatic malignancy (teratoma) in the primary specimen
RPLND
Management of CSIIA NSGCT
Normal markers - RPLND or BEPx3 or EPx4
Management of IIB NSGCT
Normal markers - BEPx3 or EPx4 or (RPLND)
RLPND nuances
Send to expert
MIS RPLND is ok
Bilateral if suspicious imaging
Nerve sparing should be offered but should not compromise LND
Complete retroaortic and/or retrocaval with lumbar division is important
Remove ipsilateral gonadal veins
Go to the crus of the diaphragm
Go down to crossing of ureter to common iliac
Post RPLND management
N1-3 teratoma or N1 - surveillance
N2-3 - BEPx2
Relapse rate for CSI seminoma with observation
13-19%
CSI seminoma surveillance regimen
H&P q6months for 5 years
Imaging every 5 months for 5 years
Can forego routine surveillance after 5 years
HCG only if preop HCG elevated
No chest imaging necessary
CSI NSGCT surveillance
Exam and markers and imaging q3mo for a year
Exam and makers and imaging q4mo for a year
Exam and markers q6months for a year
Exam and markers q12 months for 2 years
Imaging annually after second year
Risk of late relapse after 5 years for CSI nSGCT
1%
Survivorship for testicular cancer
Hypogonadism
Fertility
CV risk
Secondary malignancy
Management of post-chemo RP masses for sem
<3cm - surveillance
>3cm - PET, resect or chemo
How does testicular cancer spread?
Chorio - blood
Others lymphatic through RP –> cisterna chyli –> thoracic duct
Side effects of BEP
Bleo - pulm toxicity
Etoposide - myelosuppression
Cisplatin - renal toxicity
Causes for elevated AFP
hepatitis, cirrhosis
Yolk sac, embryonal, teratoma
Causes for elevated HCG
