testicular tumors Flashcards
What are the different tumors classified as GCT?
Seminomatous:
-seminoma (M) / dysgerminoma (F)
Non-seminomatous
- Choriocharcinoma (b-HCG)
- Yolk sac tumor (AFP)
- Teratoma (mature/immature/malignant)
- Embryonal carcinoma (AFP + BHCG)
- Mixed (Embryonal Carcinoma often predominates)
In peds: most are non-seminomatous
In adult: seminomatous predominates.
What is the age distribution of testicular tumor?
divided into prepubertal (<5 yo) and pubertal
What is the general histological expectation in prepubertal lesion?
Prepubertal: benign. consider testicular sparing.
If Malignant (AFP increased), overwhelmingly Yolk sac tumor. Orchiectomy + observation
What is the general histological expectation in pubertal testicular lesion?
Most are malignant, with mixed histology.
Orchiectomy + chemo.
RPLND only if residual nodes post chemo
What are the risk factors for testicular tumor?
- T21
- testicular dysgenesis (disorder of sexual dev)
- familial hx
- Undescended testis: inguinal 1%, abdominal 5%. bilateral testicle are at risk.
Risk increases with prolonged delay before orchidopexie.
What is the histological differential of benign testicular lesion?
Teratoma
Epidermoid
dermoid
Leydid cell hyperplasia
Leydig cells: dispersed in seminiferous tubules, potent androgen secreting cell.
What investigation are needed when assessing a testicular tumor?
Prepubertal:
Testicular US
AFP + bHCG + LDH
Pubertal: Testicular US AFP + bHCG + LDH CT-abdo pelvis Ct-Chest
in post pubertal, improved progrosis if AFP < 1000, bhcg< 5000, LDH < 1.5X N
What are the metastasis site of testicular cancer?
Lung
mediastinum
retroperitoneum
brain
What is COG’s testicular cancer staging?
1) tumor limited to testicle, R0 resection, normalization of tumor marker
2) R1 (ex transscrotal bx), markers fails to return to normal level, close margin on cord
3) N+ ( if 1-2 cm , may consider bx)
4) Metastatic, abdominal visceral tumor
What are the factor influencing prognosis?
Stage
histology
lymphovascular invasion
Age: nearly all prepubertal have a stage 1
Who gets chemo?
Stage 1: no. f/u serial AFP
Stage 2, 3, 4 yes.
PEB:
cis-platinum (ototoxicity + infertility, consider sperm bank before initiation)
Etoposide
bleomycine
Is there an indication for neoadjuvant chemotherapy in testicular cancer?
No.
What are the critical surgical steps of a radical orchiectomy?
generous inguinal incision with scrotal hockey stick extension if necessary.
Early proximal vascular control of the cord at internal ring.
avoid rupture of testicle.
send fresh to pathology
what is the clinical implication of an increased AFP level but an abscence of YST on the pathology specimen?
YSK is notoriously difficult to identify in testicular cancer. treat as malignant.
as per protocol, 1 cm slices are done on the tumor. you can ask finer sections to your pathologist.
Post PEB adjuvant chemo, persistent Retroperitoneal lymph nodes are identify. what is the next step?
RPLND.
on histology, an extensive teratomatous infiltration is often seen, with no residual viable tumor.
