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Ph RadOnc Residency PBRROE2-3 Review 2021 > Testicular Cancer > Flashcards

Testicular Cancer Flashcards

1
Q

Testicular cancer

Testicular cancer is the most common malignancy among young men in North America and most Western European Countries.

TRUE or FALSE?

A

True.

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2
Q

Testicular cancer

More than 95% of testicular cancers are germcell tumors.

TRUE or FALSE?

A

True.

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3
Q

Testicular cancer

Which is more common? seminoma or nonseminoma?

A

they are almost equally distributed with a slight predominance of seminoma.

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4
Q

Testicular cancer

Which type occurs in younger population?

A

nonseminomas

Seminomas are most commonly diagnosed between the ages of 30 and 34 years, whereas
nonseminomas are usually diagnosed 5 to 10 years earlier

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5
Q

Testicular cancer

Which type is the most common in the elderly? (>60 y)

A

lymphoma

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6
Q

Testicular cancer

Risk factors for developing testicular cancer

A
  • undescended testes (or history of)
  • infertility
  • exogenous hormonal disruptors
  • family history

-cannabis and muscle-building supplements *needs further validation

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7
Q

Testicular cancer

Undescended testicle is a risk factor for developing testicular cancer.

There is also an increased risk in the undescended testicle.

TRUE or FALSE?

A

True

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8
Q

Testicular cancer

Undescended testicle is a risk factor for developing testicular cancer.

Orchidopexy during the
prepubertal phase would be expected to reduce the risk of testicular cancer and is expected to approximate that of the general population.

TRUE or FALSE?

A

False.

orchidopexy during the
prepubertal phase would be expected to reduce the risk of testicular cancer.
However, the relative risk of developing testicular cancer remains higher than in
the general population even after early orchidopexy

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9
Q

Testicular cancer

Undescended testicle is a risk factor for developing testicular cancer.

Differentiate the uterine theory from the position theory.

A

It is hypothesized that a common
etiologic agent predisposes both to testicular maldescent and subsequent
malignancy (uterine theory).

Nevertheless, it is also possible that the
maldescended testicle is subject to a hostile and malignancy-inducing
environment (position theory).

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10
Q

Testicular cancer
Pathology

WHO divides germ cell tumors into two groups.
What are these?

A

GCNIS derived

Unrelated to GCNIS

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11
Q

Testicular cancer
Pathology

Name some GCNIS derived tumors.

A
  • Germ cell neoplasia in situ
  • Seminoma
  • Seminoma with syncytiotrophoblast cells
  • Nonseminomatous germ cell tumors
  • Embryonal carcinoma
  • Yolk sac tumor, postpubertal type
  • Teratoma, postpubertal type
  • Teratoma with somatic-type malignancy
  • Trophoblastic tumors
  • Mixed germ cell tumors
  • Regressed germ cell tumor
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12
Q

Testicular cancer
Pathology

Name some GCNIS unrelated tumors.

A

-Spermatocytic tumor
-Yolk sac tumor, prepubertal type
-Teratoma, prepubertal type
-Mixed teratoma and yolk sac tumor, prepubertal type
-Sex Cord–Stromal Tumors
(Leydig cell tumor
-Sertoli cell tumor
-Granulosa cell tumor
-Tumors in the fibroma–thecoma group
-Mixed sex cord–stromal tumor
-Unclassified sex cord–stromal -group
-Gonadoblastoma)

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13
Q

Testicular cancer
Pathology

What serum marker is NOT elevated in pure seminoma?

A

AFP

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14
Q

Testicular cancer
Pathology

Staining reaction of pure seminoma to PLAP?

A

+ in >90%

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15
Q

Testicular cancer
Pathology

What is the most common component in mixed NSGCTs?

A

Embryonal carcinoma

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16
Q

Testicular cancer
Pathology

What is the least common type of pure NSGCT and is present in about 4% of mixed tumors?

It is particularly
aggressive, almost always metastatic at diagnosis, often to brain, and is
associated with high levels of HCG.

A

trophoblastic tumors (choriocarcinoma)

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17
Q

Testicular cancer
Pathology

What tumor unrelated to GCNIS tends to occur in an older age group, is confined to the testes, and is almost always cured by orchiectomy alone with rare metastasis?

It does not contain glycogen, stains negative for PLAP.

It has a unique amplification on chromosome 9 and is not associated with other germ cell tumors.

A

Spermatocytic tumor.

Previously known as spermatocytic seminoma, the spermatocytic tumor accounts for 2% of testicular tumors.
It tends to occur in an older age group at a mean age of 54 years.
The new nomenclature better differentiates this from seminoma, which reflects its different origin and natural history.
Spermatocytic tumor is confined to the testes, is not associated with elevated HCG levels, and is almost always cured by orchiectomy alone.
Bilaterality occurs in 10%, and metastasis is rare.
The cell of origin of the spermatocytic tumor is probably the postpubertal mature spermatogonia that acquires abnormal proliferative capacity.
Spermatocytic tumor does not contain glycogen, stains negative for PLAP and is not associated with GCNIS.
It has a unique amplification on chromosome 9 and is not associated with other germ cell tumors.

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18
Q

Testicular Cancer
Natural History

What sided tumors usually have a propensity to have contralateral spread?

A

Right-sided

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19
Q

Testicular Cancer
Natural History

Where is the primary lymphatic drainage of testicular tumors?

A

retroperitoneal lymph nodes

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20
Q

Testicular Cancer
Natural History

Left SCF is more commonly involved than right SCF.

TRUE or FALSE?

A

True.

From the retroperitoneal nodes, the lymph drains into the cisterna chyli,
thoracic duct, posterior mediastinum, and left supraclavicular fossa. The thoracic
duct drains into the left subclavian vein in the left supraclavicular region. In 5%
to 10% of patients, drainage into the right supraclavicular area can occur.

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21
Q

Testicular Cancer
Natural History

What anatomic variant/involvement will result in involvement of pelvic/iliac/inguinal nodes?

A

involvement of tunica vaginalis or scrotum

hernia repair (it alters the drainage as well)

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22
Q

Testicular Cancer
Natural History

Most common site of distant metastases in NSGCT?

A

Lungs

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23
Q

Testicular Cancer
Workup and Staging

Brain MRI is done when symptoms are present, except in what histology/subtype where it is part of routine diagnostic procedures?

A

choriocarcioma

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24
Q

Testicular Cancer
Workup and Staging

What are the ultrasound findings suggestive of malignancy?

A

solid intratesticular mass with internal vasculature

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25
Q

Testicular Cancer
Workup and Staging

When to do contralateral testicular biopsy?

A

suspicion of GCNIS

<30 years old and atrophic contralateral testis (30% risk)

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26
Q

Testicular Cancer
Prognostic Factors

What is an adverse prognostic factors for all stages of testicular cancer?

A

increased age

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27
Q

Testicular Cancer
Prognostic Factors

What is the most common predictor of recurrence for stage I seminoma?

A

rete testis invasion

>4 cm (T)

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28
Q

Testicular Cancer
Prognostic Factors

What are the prognostic factors for NSGCTs?

A

extensive embryonal component

LVSI

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29
Q

Testicular Cancer
Staging (AJCC)

T

Tumor limited to the testis and epididymis, + LVSI

A

T2

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30
Q

Testicular Cancer
Staging (AJCC)

T

involvement of the tunica vaginalis

A

T2

“two”nica vaginalis

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31
Q

Testicular Cancer
Staging (AJCC)

T

Tumor limited to the testis and epididymis, no LVSI

A

T1

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32
Q

Testicular Cancer
Staging (AJCC)

T

Intratubular

A

Tis

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33
Q

Testicular Cancer
Staging (AJCC)

T

+scrotum

A

T4

scro4um

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34
Q

Testicular Cancer
Staging (AJCC)

T

+spermatic cord

A

3

Sperma”three”c cord

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35
Q

Testicular Cancer
Staging (AJCC)

N1

A

≤2 cm

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36
Q

Testicular Cancer
Staging (AJCC)

N2

37
Q

Testicular Cancer
Staging (AJCC)

N3

38
Q

Testicular Cancer
Staging (AJCC)

M1a

A

Non regional node

or

pulmonary metastasis

39
Q

Testicular Cancer
Staging (AJCC)

M1b

A

non pulmonary visceral metastasis

40
Q

Testicular Cancer
Staging (AJCC)

S0

A

normal serum markers

41
Q

Testicular Cancer
Staging (AJCC)

S1

A

LDH <1.5 x N
HCG <5k
AFP <1k

42
Q

Testicular Cancer
Staging (AJCC)

S2

A

LDH 1.5 to 10 x N
HCG <50,000k
AFP <10,000k

and more than S1

43
Q

Testicular Cancer
Staging (AJCC)

S3

A

LDH >10 x N
HCG >50,000
AFP >10,000k

44
Q

Testicular Cancer
Staging (AJCC)

What stage
T1, N0, M0 S0

A

IA

(IB if T2)
(IS if S-1-3)

as long as N0, M0,

45
Q

Testicular Cancer
Staging (AJCC)

What stage
T1, N1, M0 S0/1

A

IIA

all N+, with any T, but M0 and S0/1 are stage II.
N1 = IIA
N2 = IIB
N3 = IIC

46
Q

Testicular Cancer
Staging (AJCC)

What stage
T4, N2, M0 S0/1

A

IIB

all N+, with any T, but M0 and S0/1 are stage II.
N1 = IIA
N2 = IIB
N3 = IIC

47
Q

Testicular Cancer
Staging (AJCC)

What stage
T3, N3, M0 S0/1

A

IIC

all N+, with any T, but M0 and S0/1 are stage II.
N1 = IIA
N2 = IIB
N3 = IIC

48
Q

Testicular Cancer
Staging (AJCC)

What stage
Any T, Any N, M1a?

A

IIIA or B.

A for S0/1
(B for S2)

49
Q

Testicular Cancer
Staging (AJCC)

What stage
Any T, Any N, M1b

50
Q

Testicular Cancer
IGCCCG prognostic grouping

NSGCT good prognosis?

A

*all
Testis/retroperitoneal primary
No non pulmonary visceral metastases
Serum markers - S1

51
Q

Testicular Cancer
IGCCCG prognostic grouping

NSGCT intermediate prognosis?

A

*all
Testis/retroperitoneal primary
No non pulmonary visceral metastases
Serum markers - S2

52
Q

Testicular Cancer
IGCCCG prognostic grouping

NSGCT poor prognosis?

A

*ANY

 Mediastinal primary or
   Nonpulmonary visceral metastases or
   AFP > 10,000 ng/mL
   HCG > 50,000 IU/L or
   LDH > 10x normal
53
Q

Testicular Cancer
IGCCCG prognostic grouping

seminoma poor prognosis?

A 
no such thing.
only good and intermediate.
any primary site
Normal AFP
any HCG, any LDH

difference is pulmonary mets.
intermediate if +
good if –

54
Q

Testicular Cancer

What is the initial surgical procedure that is both diagnostic and therapeutic?

A

radical (inguinal) orchiectomy.

In this procedure, the involved testis is removed en bloc
with the spermatic cord, enclosed by the tunica layers through an inguinal
incision, minimizing the chance of tumor spillage. Historically, it had been
thought that scrotal violation (transscrotal orchiectomy, open testicular biopsy, or
fine needle aspiration) compromised prognosis. Scrotal violation is associated
with a slight increase in local recurrence rate compared with inguinal
orchiectomy (2.9% vs. 0.4%, respectively) but is not associated with any
difference in distant recurrence rates or overall survival

55
Q

Testicular Cancer

What are the options after a diagnosis of stage I seminoma has been made?

A

observation

or

single agent carboplatin (1-2 cycles)

or

RT to paraaortic +/- pelvic nodes

56
Q

Testicular Cancer

What is the schedule if stage I patients will be under surveillance and no adjuvant treatment?

A

assessments every 4 to 6 months in the first 2 years,

six monthly assessments in years 3 to 5,

and annual assessments until year 10.

57
Q

Testicular Cancer

What is included in the “dog-leg” or “hockey-stick” traditional field for adjuvant RT in stage I seminoma?

A

the paraaortic and ipsilateral
pelvic lymph nodes.

lower border of dog leg is midpelvis.

58
Q

Testicular Cancer
Stage I Seminoma

Where is the most common site of relapse in patients treated with adjuvant paraaortic RT?

A

ipsilateral pelvic
(GTCSG and MRC trials)

lower common iliac or upper external iliac nodes

59
Q

Testicular Cancer
Stage I Seminoma

Where is the most common site of relapse in patients treated with adjuvant carboplatin?

A

retroperitoneum/paraaortic area

60
Q

Testicular Cancer
Stage II Seminoma

What is the treatment of choice for non-bulky IIA/B disease?

A

RT to the paraaortic and ipsilateral pelvic nodes

61
Q

Testicular Cancer
Stage II Seminoma

Is there a benefit in doing prphylactic SCF RT in stage IIA/B patients as it is the most common site of relapse after infradiaphragmatic RT?

A

None.

In the past, some authors recommended prophylactic
supraclavicular irradiation. However, the proportion of patients destined to
relapse exclusively in the supraclavicular fossa is <5%, and results with
infradiaphragmatic irradiation alone with chemotherapy as salvage are
excellent.

62
Q

Testicular Cancer
Stage II Seminoma

Is single agent carboplatin still an option for stage IIA/B disease?

A

No.
High failure rate (18%) -GTSG.

It can be used as neoadjuvant but the results are not definitive.

63
Q

Testicular Cancer
Stage II Seminoma

What is the treatment of choice for IIC disease?

A

systemic treatment.

RT remains an option but relapse >30% is considered high. -Chung et al.

64
Q

Testicular Cancer
Stage II Seminoma

If RT is an option for stage IIC (>5 cm nodes) disease, when can you do it and when do you consider systemic treatment?

A

The choice of modality
is also influenced by the size and location of the retroperitoneal nodal mass. If
the mass is centrally located and does not overlie most of one kidney or
significantly overlap the liver, primary radiation therapy remains an option. If
the location of the mass is such that the irradiation volume covers most of one
kidney or significant volumes of the liver, then the potential morbidity of
radiation therapy can be avoided by chemotherapy

65
Q

Testicular Cancer
Stage III Seminoma

What is the standard treatment?

A

3 courses of BEP (bleomycin, etoposide and cisplatin)

or 4 courses of EP.

66
Q

Testicular Cancer
Stage II Seminoma

What is the standard RT dose for stage IIA/B non bulky disease?

67
Q

Testicular Cancer

What size of residual mass is suspicious (and proven by most centers) to harbor microscopic / viable cancer cells?

68
Q

Testicular Cancer

Upon completion of chemotherapy, there is a residual mass >3 cm that is well-defined and with discrete borders merging into surrounding structures and
resembling a fibrous plaque.

What is the next step?

A

Resect!

positive histology can be found in 50%

69
Q

Testicular Cancer

Upon completion of chemotherapy, there is a poorly defined residual mass >3 cm.

What is the next step?

A

Resecting is hazardous as it may risk great vessel, ureteric, or small bowel injury.

It may be observed.

However, in the best set-up, a FDG-PET may be requested as its sensitivity in >3 cm masses is 100%.

70
Q

Testicular Cancer

Upon completion of chemotherapy, there is a poorly defined residual mass >3 cm.
This was avid on FDG-PET

What is the next step?

A

RT

Resecting is hazardous as it may risk great vessel, ureteric, or small bowel injury.

71
Q

Testicular Cancer

When do you perform FDG-PET after systemic treatment?

A

FDG-PET should
be performed 6 weeks after day 21 of the last chemotherapy cycle, as earlier
imaging has a higher risk of false-positive results.

72
Q

Testicular Cancer

What is the treatment for progressive disease after primary and salvage treatment?

A

second-line chemotherapy

73
Q

Testicular Cancer

In some cases, disease may be bilateral and bilateral orchiectomy is effective.

However, testis-sparing approach is an emerging alternative.

When can you do it?

A

tumors <2 cm in size

negative margins

74
Q

Testicular Cancer

What is the PORT dose for testis-sparing procedures?1

A

18-20 Gy to the residual testicle to eradicate GCNIS (which is found in >80% of cases).

75
Q

Testicular Cancer

Patients with GCNIS almost invariably progress to invasive cancer.

TRUE or FALSE?

A

true.

it’s a precursor lesion

76
Q

Testicular Cancer
Anatomy

left sided tumors involve the preaortic and paraaortic nodes and nodes at renal hilum first before the interaortocaval…

right sided involve the interaortocaval/precaval first before the preaortic…

TRUE or FALSE?

77
Q

Testicular Cancer

What nodes are included in the CTV for stage I?

A

interaortocaval
preaortic and paraaortic.
+/- ipsilateral common and external iliac.

left renal hilar (for left-sided tumors)

Remember, the left involves the preaortic first.
The right goes to the interaortocaval first.

78
Q

Testicular Cancer

What nodes are included in the CTV for stage II?

A

all included in stage I
)interaortocaval
preaortic and paraaortic)
+ ipsilateral common and external iliac.

left renal hilar (for left-sided tumors)

79
Q

Testicular Cancer

What are the borders of the traditional dog-leg (assuming that pelvic nodes are to be treated)?

A

Superior - T9-T10
Inferior - above the obturator foramen
lateral - covers the transverse process at the paraaortic area and the renal hilum for left sided tumors.

80
Q

Testicular Cancer

What are the borders of the traditional dog-leg (assuming that pelvic nodes are NOT to be treated)?

A

Superior - T9-T10
“Inferior - L5-S1 disc space”
lateral - covers the transverse process at the paraaortic area and the renal hilum for left sided tumors.

81
Q

Testicular Cancer

What are the borders of the “modified” and modified dog-leg?

A

superior - T10-T11

inferior - superior aspect of the acetabulum or bottom of L4 if pelvic nodes are not to be treated

82
Q

Testicular Cancer

Authors found, after analyzing 90 patients, that almost all
detected nodes in stages I and II were contained within a ___cm posterior and lateral margin and a
___cm anterior margin from the arterial vasculature.

A

2.5

and

2.1-

83
Q

Testicular Cancer

What are the commonly used RT dose for stage I?

A

North America 25/1.25/20

UK 20/2/10 or 30/2/15

84
Q

Testicular Cancer

What are the commonly used RT dose for stage II?

A

25/1.25/20 +10/5-8 boost to residual >2-3 cm.

Alternative:
30/2/15 for IIA
36/2/18 for IIB

85
Q

Testicular Cancer

What is the threshold dose for transient aspermia after RT as reported by Hahn et al?

A

> 65 Gy
no aspermia below 50 Gy.

Recovery of sperm in the semen occurred in most within 30 to 80
weeks of radiation therapy

86
Q

Testicular Cancer

What hormone is elevated in men after dog leg RT, highest within 6 months and return to normal within 3 years?

87
Q

Testicular Cancer

Radiation therapy (mean dose _____Gy to bone marrow) without chemotherapy was associated with a threefold elevated risk of leukemia.

A

Radiation therapy (mean dose 12.6 Gy to bone marrow) without chemotherapy was associated with a threefold elevated risk of leukemia

88
Q

Testicular Cancer

There is a risk for secondary leukemia even for patients just observed.

TRUE or FALSE?

A

TRUE

Although treatment
factors are strongly implicated in the development of second primary
malignancies following treatment, an excess risk of second cancers is seen even
among testicular cancer patients who have just been observed. An increased rate
of spontaneous chromosomal translocations is seen in lymphocytes of patients
with early-stage seminoma compared to healthy controls

Ph RadOnc Residency PBRROE2-3 Review 2021 (57 decks)

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