Testicular cancer Flashcards
1
Q
testicular cancer is the most common cancer in ____
A
young men
2
Q
ages for testicular cancer
A
non-seminoma- most common in men 17y.o.
seminoma- most common in men 30-34 yo
Rare after 40 y.o.
3
Q
what countries is testicular cancer most common in
A
western countries
4
Q
what causes testicular cancer
A
Undescended Testicles (Cryptorchidism)
6X increased risk and 2X increased risk in contralateral testicle
Infertility: 20X increased risk
Family history/Genetics
5
Q
which testis the longest
A
left testes is longer than the righ
6
Q
the testes are contained in the ____ and are suspended by _____
A
contained in the scrotum
suspended by the spermatic cord
7
Q
what structure transports the sperm from the testes? A. Ejaculatory ducts B.spermatic cords C. Vas deferens D. urethra
A
C
8
Q
the ejaculatory duct opens into the: A.prostatic urethra b. spermatic cord c. penis d. vas deferens
A
A
9
Q
what organ produces sperm? A. testes B.epididymis C.seminal vesicles D. prostate
A
a
10
Q
primary LN drainage of the testes is?
a. paraaortics
b. inguinal
c. common iliac
d. arbitrator LN
A
a
11
Q
the tumour marker used to diagnose testicular cancer is ? A. ca19-9 b.PSA C. AFP D.HER2/neu
A
c
12
Q
\_\_\_\_\_ is a risk factor for testicular cancer A. +age B.hispanic ethnicity C.cryptorchidism D.Trauma to the testicles
A
C
13
Q
primary treatment of testicular cancer is ? A.SX B.CX C.observation D.XRT
A
A
14
Q
Sup border when treating testicular cancer with EBRT is? A.T8 B.T10 C.T12 D.L2
A
B
15
Q
What is not true about XRT of testicular cancer?
A.the orichetomy scar must be included in the TX field
B.late toxicity includes infertility
C.N&V are an acute side effect
D. lower dose/ fx is used to - acute toxicities
A
A
16
Q
function of the testes
A
they house the spermatozoa at different stages of production and they produce testosterone
17
Q
vas deferens
A
transports the sperm to the ejaculatory duct
A close network of anastomosing tubes in a fibrous stroma at the upper end of the testis the tubes converge together into the vas deferent enters the pelvis along the spermatic cord and empties into the seminal vesicles
18
Q
whats the epididymis
A
which is a hard, cord-like structure about 2 feet in length and 5 mm in diameter
19
Q
ejaculatory ducts
A
one on each side, begin at the base of the prostate, run forward and downward between its middle and lateral lobes, and end in the verumontanum after entering the prostate.
20
Q
tumour progression seminoma vs non-seminoma
A
Nonseminoma – Goes to lymph and blood
Seminoma – Goes to lymph
21
Q
cells of origin for testicular cancer
A
germ cell origin
22
Q
sites of distant mets for testicular cancer
A
lung bone and brain
23
Q
clinical presentation of testicular cancer
A
Mass or swelling in next (Lt supraclavicular nodes)
Gynecomastia (enlargement of the breasts, related to production of HCG)
Painless testicular mass (10-20%)
Heaviness (up to 40%)
Discomfort
Swelling
24
Q
presentation testicular cancer indicative of mets
A
back pain (indicative of bone mets) chest symptoms (indicative of lung mets )
25
what type of testicular cancer is most common?
seminoma is slightly more common than non seminoma
| germ cell tumours is most common 95%
26
staging testicular cancer
T1: Tumor limited to testis and epididymis, no vascular/lymphatic invasion
T2: Tumor limited to testis and epididymis, with vascular/lymphatic invasion or involvement with the tunica vaginalis
T3: Tumor invades spermatic cord
T4: Tumor invades scrotum
N1: Mets to single node <2 cm or multiple nodes none more than 2 cm
N2: Mets to single node 2-5 cm or multiple nodes any >2 cm but none >5 cm
N3 Node greater than 5 cm
27
how is testicular cancer detected and diagnosed
Testicular ultrasound
Radical Orchidectomy: Removal of testis and spermatic cord through the groin, avoids scrotal violation
28
serum markers used in staging testicular cancer
Serum α-Fetoprotein (AFP) = Non seminoma component
Serum β-Human Chorionic Gonadatrophin (β-HCG) = present in choriocarcinoma, moderately ↑in seminoma
Serum Lactate Dehydrogenase (LDH) = ↑80% metastatic seminoma, 60% of advanced non seminoma
29
routes of spread for non-seminoma
Non-Seminoma
Can spread to the lymphatics or hematogenously
If they metastasize, it usually involves the lungs and liver
30
distant mets for non seminoma
lungs and liver
31
spread for seminoma
paraaortic retroperitoneal LN- to LN in the mediastinum and supraclavicular fossa
32
distant mets for seminoma
involve the lung parenchyma, bone, liver, or brain
33
which has the worst prognosis seminoma or non seminoma
seminoma is better
34
primary treatment testicular cancer
surgery is primary therapy
35
surgical procedure used for testicular cancer treatent
radical orichetomy
A surgical procedure to remove a testicle and the full spermatic cord through an incision in the lower lateral abdomen (inguinal incision).
36
is the testicle radio sensitive or radio resistant
radio sensitive
37
use of radiation therapy in testicular cancer
its used adjuvantly after surgery in stage 1 and 2 cancer seminomas depending on size of ln
38
DOSES AND ENERGY FOR TESTICULAR CANCER
Dose: 25/20 or 20/10
Energy: 6-18MV
39
Nodes included in treatment volume of testicular cancer
Ipsilateral pelvic nodes (internal and external iliac nodes)
Para-aortic nodes
Ipsilateral renal hilar nodes
40
indications for adjuvant XRT in testicular cancer
Radiation to the nodal regions at risk of having subclinical disease
41
rationale chemotherapy
Used as an ADJUVANT treatment for both seminoma and non-seminoma
42
chemo agents used for testicular cancer
Carboplatin
Has less side effects than cisplatin
Relapse rates are low
BEP (bleyomyacon, etopisode and platinum) – Cisplatin based regimen
Toxicity common in kidney, hearing, neurological, small vessels
43
what chemo agents are used for seminoma vs non seminoma cancer
Seminomas – Carboplatin or BEP
| Non-Seminomas - BEP
44
Treatment of seminoma stage 1 vs non seminoma
seminoma
primary treatment is always radical orichetomy
Surveillance
Adjuvant Radiation 30/20, 25/15, 20/10 XRT of the para-aortic and ipsilateral pelvic LN
Adjuvant Chemo Carboplatin (rare and very unlikely
non seminoma
primary treatment is radical orichetomy
Surveillance
Adjuvant Chemo BEP x 2
45
treatment of stage 2a-b seminoma vs non seminoma
seminoma:radical orichetomy +Depends on size of nodes
<5cm: Adjuvant Radiation 25/20 (Dog Leg) +/- 10/20 (concurrent) (Nodes) XRT of the paraaortic and ipsilateral pelvic LN
>5cm: Adjuvant Chemo BEP x 3 Not usual Chemo can be used but no need to have RT + chemo
nonseminoma:radical orichetomy +
Chemo BEP x 3
Additional Sx – Retroperitoneal node dissection (RPLND)
Difficult to resect due to nerves and vessels required for ejaculation
46
treatment of stage 2c-4 seminoma vs non seminoma
seminoma- radical orichetomy +
Chemo BEP x 3-4
Don’t do radiation because worried about kidney toxicity depending on location of tumour stage 2c
nonseminoma: radical orichetomy +Chemo BEP x 3-4
47
CT scan limits for testicular cancer
Sup Border : T7-8
Inf Border: 5cm inf of ischial tuberosities
48
special immobilization for testicular cancer
requires testicular / scrotal shielding 1cm thick to reduce internal scatter to <1-2%
49
what does NOT need to be included in the treatment volume
NOT surgical scar, scrotum or inguinal nodes because not a lot of recurrence there
50
Dog leg/ hockey stick treatment typical technique
AP/PA is usually treated with extended SSD
51
dog leg/ hockey stick treatment borders
Sup: Top of T10
Inf: Top of obturator foramen
Lat: to include para-aortic, pelvic and renal hilar nodes
Lateral border based on external iliacs + 2 cm margin
Medial border based on para-aortics + 2 cm margin
52
what do we concentrate on treating lt vs rt dog leg technique
rt sided we concentrate on treating LN by the right testicular vein
lt sided we notch fields by the lt kidney the renal hilum nodes are at risk
53
when is testicular shielding used/ not used
used in patients who are young and still want to father children, not used in older men or men who have a vasectomy
54
what is the modified dog leg
we can use par aortic fields the ind border is moved up to the acetabulum, wheres the inf border in the dog leg is the arbitrator foramen
55
paraaortic fields borders and what method is it treated with
AP/PA fields
Sup:top of T10
inf:L5
the width is 10-12 cm to include the paraaortic LN
56
acute side effects of XRT to the testicle
nausea and diahrrea
57
chronic side effects of XRT to the testicle
infertility and low sperm count
| more toxicity comes from chemotherapy therefore chemo and radiation should NOT be given concurrently
58
crossover of lymph channels left and right in the testis commonality
crossover from right to left is constant but crossover from left to right happens rarely and only occurs after the primary nodes are filled
59
seminoma is most often diagnosed at what stage
stage 1 ( confined to the testes)
60
seminoma drainage
spreads in an orderly fashion to retroperitoneal LN first, then to the lymphatics in the mediastinum and supraclavicular fossa
61
most common presentation of testicular cancer
painless swelling in the scrotum
62
occult testicular cancer is usually diagnosed by
US
63
Staging systems used for testicular cancer
Royal Marsden Hospital system , UICC and AJCC
64
SA, S2 and S3 levels
serum levels that can be used to diagnose testicular cancer
S1- LDH <1.5XN AND hCG <5000 and AFP<1000
S2-LDH 1.5-10, or hCG 5000-50,000 or AFP1000-10,000
S3-LDH >10 or hCG >50,000 OR AFP >10,000
65
SURVEILANCE IN TESTICULAR CANCER
used in stage 1 seminoma (better prognosis) patient is followed for 10 years, most common site of relapse is retroperitoneum
66
stage 2c seminoma treatment depending on location
Disease is confined to the retroperitoneum and is 5-10cm in diameter
if the mass is centrally located the patient will get XRT after SX
If the mass is is located so that the volume covers most of one kidney or liver cispltinum chemotherapy should be used
67
what dose is spermatogenesis compromised at
the production of sperm
| this is compromised at doses as little as .5Gy and 2 Gy can lead to permanent damage
68
side effects of cisplatinum chemo
nausea vomiting and alopecia
69
acute chemo side effects
myelosupression, pulmonary fibrosis, cisplatinum nephrotoxicity
70
late chemo side effects
secondary cancer when chemo is given in germ cell tumours, high tone hearing loss, renal dysfunction, hypertension, raynauds phenomenon
71
surgical side effects
most common is infertility, infection, pulmonary embolus and ascites
72
is XRT more important in semnoma or non seminoma
seminoma
73
weight of testes
15-19g
74
how long are the seminiferous tubules
35-70 cm
75
function of sertoli cells
nutritional, regulatory and supportive of the germ cells
76
function of leydig cells
produces testosterone
77
what dose causes - sperm count? azoospermia?
- sperm count can occur between .15-.35 Gy and azoospermia occurs in almost all men after 1Gy
78
after XRT can men produce sperm again? how long does it take for sperm production to resume?
sperm production occurs after 7 months if they receive 1Gy, or after 24 months with 6 Gy
79
what single dose fraction causes complete sterilization
6.5-9 Gy however if this dose is fractionated the sperm production will usually recover eventually
80
how long his it recommended that the patient try not to have kids after treatment
6 months after finishing all treatments
81
what subtype of testicukar carcinoma is diagnosed with mets
choriocarcinoma (non seminoma)
82
1st site f distant mets
lungs
83
what could elevated serum markers indicate post-oricheyomy ?
could indicate metastatic cancer
84
is prognosis better for seminoma or non seminoma
seminoma is better
85
what is a normal sperm count
>20 ,million
86
what LN are treated in stage 1 and how what are the treatment field borders
AP/PA fields which include PA and retroperiineal LN
| S: T11 i:L5 L: 10 cm wide to include transverse processes
87
CT scan limits
t7-8 to 5 cm below ischial tuberosities
