Testicular tumors Flashcards
What are the types of testicular tumors?
Germ Cell tumors (90-95%)
- Seminoma (65%)
- Yolk sac tumor
- Embryonal Carcinoma
- Choriocarcinoma
Stromal tumors (5-10%)
- Leydig cell tumor
- Sertoli cell tumor
- Granulosa cell tumor
Gonadoblastoma (Rare)
What are the risk factors for testicular tumors?
Congenital
- Cryptorchidism
- Gonadal dysgenesis
- Testicular feminization
- Kleinfelter’s syndrome
Cancer history
- IGCN
- Personal history of testis cancer
- Family history of testis cancer
General History
- HIV infection
- Infertility
What is IGCN?
Non invasive precursor of germ cell cancer
What percentage of GCT patients will have IGCN and what percentage of IGCN will progress?
5-9% with Germ cell cancer have contralateral IGCN
50% will progress to germ cell cancer in 5 years
Should IGCN be worked up and treated?
Unclear if diagnosis or treatment is necessary
Surveillance: regular scrotal ultrasound with testicular exam
Tx: Orchiectomy or radiation have 100% cure rate, chemotherapy has 66% cure rate
What is the pathology of classic seminoma?
Pathology: lobulated and pale, fried egg appearance on histology
20% have lymphocytic infiltrate
What markers are produced by seminoma?
10% produce b-HCG, never secretes AFP
What are the important features of spermatocytic seminoma?
Spermatocytic seminoma
- Looks like maturing
- spermatogonia
- Presents > 50 years old
- Rarely metastasizes
- Treat with radical inguinal orchiectomy and surveillance
What is the pathology of Embryonal Carcinoma?
Pathology: grey-white fleshy mass, necrosis, and hemorrhage. Epithelial like cells with papillary projections
What are the markers of Embryonal carcinoma?
Markers: Possibly AFP or b-HCG
What is the pathology of yolk sac tumor?
Pathology: yellow/pale grey, epithelial cells forming cystic spaces, Schiller-Duval bodies, embryoid bodies, hyaline globules
What are the markers of Yolk sac tumor?
Markers: may secrete AFP and b-HCG
What is the pathology of Choriocarcinoma?
Pathology: peripheral grey-white mass, central hemorrhage, syncytiotrophoblasts, cytotrophoblasts
What are the markers for Choriocarcinoma?
Tumor markers: always b-HCG
What is the pathology of Teratoma?
Pathology: Cystic with multiple germ layers
What are the markers for teratoma?
Tumor markers: no AFP or b-HCG
What are the usually routes of metastasis for testicular tumors?
Usually through lymphatics, except for Choriocarcinoma and yolk sac which spread hematogenously.
What are typical ages of presentation for testicular tumors?
Yolk sac:
What are the important features of Leydig cell tumor?
Leydig cell tumor
- 10% are malignant
- Pathology: eosinophilic with Reinke crystal
- Produce testosterone and 17-ketosteroid
- Presentation: Precocious puberty in children, impotence, low libido, and gynecomastia in adults
- Treatment: Orchiectomy and surveillance
What are the important features of Granulosa cell tumor?
Granulosa cell tumor
- Benign tumor
- 75% found within 1 month of birth
- May produce estrogen
- Orchiectomy is curative
What are the important features of Sertoli cell tumor?
Sertoli cell tumor
- 10% malignant
- Produce estrogen and progesterone
- Presentation: Painless mass, possible virilization and gynecomastia
- Orchiectomy and surveillance
What is the presentation of a testicular tumor?
Usually a painless testicular mass Pain (10%) Hydrocele (5-10%) Gynecomastia 5% of germ cell tumors 30-50% of sertoli or leydig cell tumors Back pain (retroperitoneal metastases) 1-3% are bilateral (often lymphoma)
What is the workup for a testicular mass/tumor?
- History
- Physical exam
- Genitals
- Lymph nodes
- Abdomen
- Neurological
- Breast (gynecomastia) - Ultrasound
Look for hypoechoic intratesticular mass - Serum tumor markers
AFP (half-life 7 days)
Quantitative beta-HCG (half life 3 days) (beware hypogonadism)
LDH (half life 4 days) - Labs: (LFTs, BMP, CBC)
- Imaging
CXR
CT abdomen and pelvis: Sn 70% - radical Inguinal Orchiectomy
What is the Tumor staging system?
T1: does not extend into the tunica vaginalis or spermatic cord, no LVI
T2: LVI or extension into the tunica vaginalis
T3: extension into spermatic cord
T4: invasion of the scrotum
What is the nodal staging system
N1: nodal mass 5 cm
What is the metastasis staging system?
M0: no metastases
M1a: non regional nodal or pulmonary metastases
M1b: Non pulmonary and non nodal distant metastases
What is the serum staging system?
S1: LDH 10, b-HCG > 50,000, AFP > 10,000
What is the overall staging system?
Stage I: T1-T4, N0, M0
IA: T1
IB: T2-4
IS: T1-4, S1-3
Stage II: T1-4, N1-3, M0
IIA: T1-4, N1, S0-1
IIB: T1-4, N2, S0-1
IIC: T1-4, N3, S0-1
Stage III: T1-4, N0-3, M1, S0-3
Caveat: T1-4, N1-3, M0, S2-3
How are Stage IIC and III risk stratified?
Good risk
Seminoma: normal AFP, no extrapulmonary metastases
Non seminoma: Testicular or RP primary, no extra-pulmonary mets, S0-1
Intermediate risk
Seminoma: Extra-pulmonary mets, normal AFP
Non seminoma: Testicular or RP primary, no extra-pulmonary mets, S2
Poor Risk
Non seminoma: Mediastinal primary, extra-pulmonary mets, or S3
How do you manage Stage IA or IB Pure seminoma?
Compliant and T1-3
- Surveillance (relapse 15-20%)
- Chemotherapy (1-2 cycles carboplatin) (3% relapse)
- XRT (20 Gy to RPLN/iliac nodes) (relapse 3%)
Non-compliant or T4
- Chemotherapy (1-2 cycles carboplatin) (3% relapse)
- XRT (20 Gy to RPLN/iliac nodes) (relapse 3%)
How do you manage Stage IIA or IIB Pure seminoma?
Stage IIA or IIB
XRT (30-36 Gy to RPLN and Iliac nodes) (relapse 10%)
How do you manage Stage IIC or III pure seminoma?
Chemotherapy: BEP x 3, or EP x 4. Intermediate risk gets BEP x 4
Tumor shrinks 3 cm PET scan
Tumor grows or markers elevate then salvage therapy
What is the likely composition of residual mass after treating Pure seminoma?
Residual masses
Malignancy 10-20%
Necrosis or fibrosis 80-90%
Teratoma (rare)
How do you manage stage IA or IB Non-seminomas?
Compliant and T1
- Surveillance (relapse 15-20%)
- RPLND (unilateral vs bilateral template)
Non-compliant or T2-4
- RPLND
- Chemotherapy (BEP x 2)
How do you manage stage IIA or IIB Non-seminoma?
S0
- RPLND
- Chemotherapy (BEP x 3 or EP x 4)
S1
-Chemotherapy BEP x 3 or EP x 4
How do you treat stage IIC or III non-seminoma?
Good risk
-BEP x 3 or EP x 4
Intermediate risk, Poor risk
-BEP x 4
How are IIC and III non-seminoma patients managed post chemotherapy?
Residual mass 1 cm but shrunken with normal markers then resect residual
Tumor grows or markers elevated then salvage therapy
What are the possible causes of residual mass after treatment of IIC or III non seminoma?
Malignancy 10-20%
Teratoma 30-40%
Necrosis/fibrosis 40-50%
How should patients be managed after RPLND for non-seminoma?
If N0 then surveillance
If N1-2
And Compliant then surveillance or (EP x 2 or BEP x 2)
If N1-2 and Non-compliant then EP x 2 or BEP x 2
If N3 then EP x 4 or BEP x 3
What are the benefits of surveillance for seminoma?
Occult malignancy in
What are the risks associated with surveillance for seminoma?
15-20% relapse rate over 5 years
32% relapse rate if tumor > 4 cm and rete testis invasion
Increased psychological stress
Relapse most common in first 2 years (mean time to relapse 7 months)
What are the risks associated with XRT for seminoma?
Doubles risk of death from cardiac disease
Doubles risk of non germ cell cancer
3-5% relapse rate
Acute: N/V, fatigue, bone marrow suppression
Late: Peptic ulcer, gastritis, secondary malignancy, CV disease
What are the benefits of XRT for seminoma?
Treats metastases in retroperitoneal nodes
99% Cancer specific survival
What are the benefits of Chemotherapy for Seminoma?
Treats occult metastases even outside retroperitoneum
Lower mortality than XRT
99% Cancer specific survival
What are the risks associated with chemotherapy for seminoma?
Myelosuppression, N/V, fatigue, Infertility
4-6% relapse rate at 5 years (1 cycle) 2% for (2 cycles)
Drug specific adverse effects
What are the adverse effects associated with Carboplatin, Bleomycin, Etoposide, and Cisplatin?
Carboplatin: Myelosuppression, N/V, neuropathy
Bleomycin: Pneumonitis, pulmonary fibrosis
Etoposide: Myelosuppression, mucositis, N/V, alopecia, leukemia
Cisplatin: Nephrotoxicity, Neurotoxicity, Ototoxicity, N/V
What are the benefits of surveillance for non seminoma?
70% of N0 tumors will have no nodal metastases
What are the risks associated with surveillance for non seminoma?
Higher recurrence rate 25%
Psychological stress
LVI, >T1, 50% embryonal cell, 70% proliferation rate, absence of yolk sac tumor, all increase risk of recurrence
Relapse 15-20% when LVI absent, 50% when LVI present
What are the benefits of RPLND for non seminoma?
More accurate staging
Nodal mets are treated
Less intense follow up
98% cancer specific survival
What are the risks associated with RPLND for non-seminoma?
0.3% mortality rate
Ejaculatory dysfunction 1-30% (use nerve sparing),
Bowel obstruction (1-3%),
Chylous ascites (2%),
renal vascular injury (3%),
10% relapse (usually outside retroperitoneum)
What are the benefits of Chemotherapy for non seminoma?
BEP x 2
Less intense follow up
Lower relapse
98% cancer specific survival
What are the risks associated with chemotherapy for non seminoma?
Does not treat teratoma
Infertility, secondary malignancy, Cardiovascular disease
Relapse rate
What is the prognosis for stage I seminoma and non seminoma?
Seminoma: > 98% 5 year survival
Non-Seminoma: >98% 5 year survival
What is the prognosis for Stage IIA and IIB seminoma and non seminoma?
Seminoma: > 95% survival
Non-Seminoma: > 95% survival
What is the risk for stage IIc and III seminoma and non seminoma?
Good risk Seminoma: 86% survival
Good risk Non-seminoma: 94% survival
Intermediate risk Seminoma: 72% survival
Intermediate risk Non-seminoma: 83% survival
High risk Non-seminoma: 71% survival
