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Urology > Testicular tumors > Flashcards

Testicular tumors Flashcards

1
Q

What are the types of testicular tumors?

A

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)

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2
Q

What are the risk factors for testicular tumors?

A

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
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3
Q

What is IGCN?

A

Non invasive precursor of germ cell cancer

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4
Q

What percentage of GCT patients will have IGCN and what percentage of IGCN will progress?

A

5-9% with Germ cell cancer have contralateral IGCN

50% will progress to germ cell cancer in 5 years

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5
Q

Should IGCN be worked up and treated?

A

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

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6
Q

What is the pathology of classic seminoma?

A

Pathology: lobulated and pale, fried egg appearance on histology
20% have lymphocytic infiltrate

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7
Q

What markers are produced by seminoma?

A

10% produce b-HCG, never secretes AFP

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8
Q

What are the important features of spermatocytic seminoma?

A

Spermatocytic seminoma

  • Looks like maturing
  • spermatogonia
  • Presents > 50 years old
  • Rarely metastasizes
  • Treat with radical inguinal orchiectomy and surveillance
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9
Q

What is the pathology of Embryonal Carcinoma?

A

Pathology: grey-white fleshy mass, necrosis, and hemorrhage. Epithelial like cells with papillary projections

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10
Q

What are the markers of Embryonal carcinoma?

A

Markers: Possibly AFP or b-HCG

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11
Q

What is the pathology of yolk sac tumor?

A

Pathology: yellow/pale grey, epithelial cells forming cystic spaces, Schiller-Duval bodies, embryoid bodies, hyaline globules

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12
Q

What are the markers of Yolk sac tumor?

A

Markers: may secrete AFP and b-HCG

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13
Q

What is the pathology of Choriocarcinoma?

A

Pathology: peripheral grey-white mass, central hemorrhage, syncytiotrophoblasts, cytotrophoblasts

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14
Q

What are the markers for Choriocarcinoma?

A

Tumor markers: always b-HCG

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15
Q

What is the pathology of Teratoma?

A

Pathology: Cystic with multiple germ layers

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16
Q

What are the markers for teratoma?

A

Tumor markers: no AFP or b-HCG

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17
Q

What are the usually routes of metastasis for testicular tumors?

A

Usually through lymphatics, except for Choriocarcinoma and yolk sac which spread hematogenously.

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18
Q

What are typical ages of presentation for testicular tumors?

A

Yolk sac:

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19
Q

What are the important features of Leydig cell tumor?

A

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
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20
Q

What are the important features of Granulosa cell tumor?

A

Granulosa cell tumor

  • Benign tumor
  • 75% found within 1 month of birth
  • May produce estrogen
  • Orchiectomy is curative
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21
Q

What are the important features of Sertoli cell tumor?

A

Sertoli cell tumor

  • 10% malignant
  • Produce estrogen and progesterone
  • Presentation: Painless mass, possible virilization and gynecomastia
  • Orchiectomy and surveillance
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22
Q

What is the presentation of a testicular tumor?

A 
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)
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23
Q

What is the workup for a testicular mass/tumor?

A
  1. History
  2. Physical exam
    - Genitals
    - Lymph nodes
    - Abdomen
    - Neurological
    - Breast (gynecomastia)
  3. Ultrasound
    Look for hypoechoic intratesticular mass
  4. Serum tumor markers
    AFP (half-life 7 days)
    Quantitative beta-HCG (half life 3 days) (beware hypogonadism)
    LDH (half life 4 days)
  5. Labs: (LFTs, BMP, CBC)
  6. Imaging
    CXR
    CT abdomen and pelvis: Sn 70%
  7. radical Inguinal Orchiectomy
24
Q

What is the Tumor staging system?

A

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

25
Q

What is the nodal staging system

A

N1: nodal mass 5 cm

26
Q

What is the metastasis staging system?

A

M0: no metastases
M1a: non regional nodal or pulmonary metastases
M1b: Non pulmonary and non nodal distant metastases

27
Q

What is the serum staging system?

A

S1: LDH 10, b-HCG > 50,000, AFP > 10,000

28
Q

What is the overall staging system?

A

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

29
Q

How are Stage IIC and III risk stratified?

A

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

30
Q

How do you manage Stage IA or IB Pure seminoma?

A

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%)
31
Q

How do you manage Stage IIA or IIB Pure seminoma?

A

Stage IIA or IIB

XRT (30-36 Gy to RPLN and Iliac nodes) (relapse 10%)

32
Q

How do you manage Stage IIC or III pure seminoma?

A

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

33
Q

What is the likely composition of residual mass after treating Pure seminoma?

A

Residual masses
Malignancy 10-20%
Necrosis or fibrosis 80-90%
Teratoma (rare)

34
Q

How do you manage stage IA or IB Non-seminomas?

A

Compliant and T1

  • Surveillance (relapse 15-20%)
  • RPLND (unilateral vs bilateral template)

Non-compliant or T2-4

  • RPLND
  • Chemotherapy (BEP x 2)
35
Q

How do you manage stage IIA or IIB Non-seminoma?

A

S0

  • RPLND
  • Chemotherapy (BEP x 3 or EP x 4)

S1
-Chemotherapy BEP x 3 or EP x 4

36
Q

How do you treat stage IIC or III non-seminoma?

A

Good risk
-BEP x 3 or EP x 4

Intermediate risk, Poor risk
-BEP x 4

37
Q

How are IIC and III non-seminoma patients managed post chemotherapy?

A

Residual mass 1 cm but shrunken with normal markers then resect residual

Tumor grows or markers elevated then salvage therapy

38
Q

What are the possible causes of residual mass after treatment of IIC or III non seminoma?

A

Malignancy 10-20%
Teratoma 30-40%
Necrosis/fibrosis 40-50%

39
Q

How should patients be managed after RPLND for non-seminoma?

A

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

40
Q

What are the benefits of surveillance for seminoma?

A

Occult malignancy in

41
Q

What are the risks associated with surveillance for seminoma?

A

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)

42
Q

What are the risks associated with XRT for seminoma?

A

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

43
Q

What are the benefits of XRT for seminoma?

A

Treats metastases in retroperitoneal nodes

99% Cancer specific survival

44
Q

What are the benefits of Chemotherapy for Seminoma?

A

Treats occult metastases even outside retroperitoneum

Lower mortality than XRT

99% Cancer specific survival

45
Q

What are the risks associated with chemotherapy for seminoma?

A

Myelosuppression, N/V, fatigue, Infertility

4-6% relapse rate at 5 years (1 cycle) 2% for (2 cycles)

Drug specific adverse effects

46
Q

What are the adverse effects associated with Carboplatin, Bleomycin, Etoposide, and Cisplatin?

A

Carboplatin: Myelosuppression, N/V, neuropathy

Bleomycin: Pneumonitis, pulmonary fibrosis

Etoposide: Myelosuppression, mucositis, N/V, alopecia, leukemia

Cisplatin: Nephrotoxicity, Neurotoxicity, Ototoxicity, N/V

47
Q

What are the benefits of surveillance for non seminoma?

A

70% of N0 tumors will have no nodal metastases

48
Q

What are the risks associated with surveillance for non seminoma?

A

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

49
Q

What are the benefits of RPLND for non seminoma?

A

More accurate staging
Nodal mets are treated
Less intense follow up
98% cancer specific survival

50
Q

What are the risks associated with RPLND for non-seminoma?

A

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)

51
Q

What are the benefits of Chemotherapy for non seminoma?

A

BEP x 2
Less intense follow up
Lower relapse
98% cancer specific survival

52
Q

What are the risks associated with chemotherapy for non seminoma?

A

Does not treat teratoma
Infertility, secondary malignancy, Cardiovascular disease
Relapse rate

53
Q

What is the prognosis for stage I seminoma and non seminoma?

A

Seminoma: > 98% 5 year survival

Non-Seminoma: >98% 5 year survival

54
Q

What is the prognosis for Stage IIA and IIB seminoma and non seminoma?

A

Seminoma: > 95% survival

Non-Seminoma: > 95% survival

55
Q

What is the risk for stage IIc and III seminoma and non seminoma?

A

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

Urology (6 decks)

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