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Metabolic - Urology > Testicular tumours > Flashcards

Testicular tumours Flashcards

1
Q

If a testicular mass is palpated, what not-cancerous pathology could it be?

A
  • Torsion
  • Epididymo-orchitis
  • Scrotal hernia
  • Hydrocele
  • Haematoma
  • Spermatocele
  • Intratesticular benign cyst
  • Syphilitic gumma
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2
Q

Discuss germ cell tumours

A
  • Most common cancers in men aged 15-35

- Much less common in women

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3
Q

Discuss the types of germ cell tumours in men

A

a) Seminomas
b) Non-seminoma (previously teratoma, comprised of both mature and immature cells, teratoma now refers to the mature components

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4
Q

What are the clinical features of testicular cancer?

A
  • Testicular mass +/- pain
  • Metastasis to the para-aortic LNs
  • Back pain
  • Gynaecomastia if the tumour is B-hCG secreting
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5
Q

What are the investigations for testicular cancer?

A
  • Ultrasound or MRI
  • Assay of serum tumour makers: a-fetoprotein, lactase dehydrogenase and b-hCG
  • CT or MRI to look for distant mets
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6
Q

Discuss alpha-fetoprotein

A
  • Normally made by the liver and yolk sac of a fetus
  • Levels should fall by the age of 1
  • Healthy adults should have very low levels
  • High levels occur due to liver cancer and non-seminoma germ cell cancer
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7
Q

Discuss seminomas

A
  • Germ cell tumour of the testicle
  • Malignant
  • Account for 50% of testicular germ cell cancers
  • One of the most treatable and curable cancers with a >95% survival rate
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8
Q

Where can germ cell tumours be found?

A

Gonads mainly, specifically testicles in males

Can also develop in non-gonadal sites such as the pituitary, mediastinum and retroperitoneum

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9
Q

What is the treatment for testicular cancer?

A

Orchidectomy via the inguinal approach to avoid spillage of highly metastatic tumour in the scrotum

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10
Q

Discuss management of semnomas

A
  • Very radio and chemosensitive
  • Associated with raised serum LDH (very rarely b-hCG and never raised a-fetoprotein)
  • Adjuvant therapy with chemotherapy is preferred as it leads to a >95% cure in early stage disease
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11
Q

What is the chemotherapy regimen of choice for seminomas?

A

Carboplatin because it is convenient, it causes reduced acute side effects and doesn’t run the risk of causing secondary malignancy as with xRT

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12
Q

What is BEP?

A

Combination chemotherapy

  1. Cisplatin
  2. Etoposide
  3. Bleomycin
  • Cures 95% of people with metastatic seminoma disease
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13
Q

What is cisplatin?

A

Alkylating agent

1) attachment of alkyl groups to DNA bases, resulting in the DNA being fragmented by repair enzymes in their attempts to replace the alkylated bases
2) DNA damage via the formation of cross-links (bonds between atoms in the DNA) which prevents DNA from being separated for synthesis or transcription
3) the induction of mispairing of the nucleotides leading to mutations

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14
Q

What is etoposide?

A

Topoisomerase II inhibitor

Cell cycle dependent and phase specific, affecting mainly the S and G2 phases of cell division.

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15
Q

What is bleomycin?

A

An antibiotic that has anti-tumour activity

Main mode of action is the inhibition of DNA synthesis with some evidence of lesser inhibition of RNA and protein synthesis

Major effects in G2 and M phases

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16
Q

Discuss management of non-seminomas (teratomas)

A
  • Risk of relapse with stage 1 disease varies from 5-50%
  • Mets commonly involves para-aortic LNs and lung but can spread quickly, especially if b-hCG secreting
  • 80% of seminomas will express either b-hCG or a-fetoprotein
  • Almost all metastatic disease is associated with an elevation in LDH
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17
Q

What is a rapid test for non-seminoma testicular cancer?

A
  • pregnancy test (b-hCG +)

- presence of gynaecomastia

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18
Q

What is the most established treatment for non-seminomas?

A

BEP (3-4 cycles)

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19
Q

Discuss fertility and testicular cancer

A

20% will be infertile at time of diagnosis but the majority of men who are not infertile, will retain their fertility

20
Q

Discuss testicular cancer

A
  • Most common malignancy in young men (20-34yrs)
  • Highly curable when diagnosed early
  • Most common are seminomas followed by teratomas
21
Q

Discuss the epidemiology of testicular cancer

A

• UK: ~1400 new cases each year with the highest incidence in those aged 25-35
• Relatively rare, accounts for ~1% of all cancers and accounts for <1% of cancer deaths in males
• Most common solid tumours diagnosed in men aged 20-34
White men have, by far, he highest incidence compared to African and Asian men

22
Q

What are the risk factors of testicular cancer?

A

• Cryptorchidism (failed descent of one or both tested) - relative risk of 2-17x for malignancy
- 50-10% of patients with cryptorchidism develop cancer in the contralateral, normally descended testicle
- Seminomas tend to be the predominant tumour type associated with undescended testis
• Family hx
• Testicular atrophy: due to trauma, hormones and viral orchitis (mumps)
• Being white
HIV 5x the risk in men with HIV compared to age matched controls

23
Q

Which side do the majority of testicular masses occur?

A

Right (55%)

24
Q

How do testicular cancers present?

A
  • 85% are painless
  • Found by man or partner
  • Bilateral in 2% of cases
25
Q

Discuss extra-testicular manifestation of testicular cancer

A

• 5-10% of patients have extra-testicular manifestations at the time of presentation with or without evidence of a tumour in the testicles
• Bone pain (skeletal metastasis), lower extremity swelling (venous occlusion), supraclavicular LNs, symptoms of hyperthyroidism and gynaecomastia
Spinal cord and cerebral metastasis may cause neurological symptoms

26
Q

Discuss investigations of testicular tumours

A

• Ultrasound of testis: sensitivity near 100%, if the scan does not confirm a mass but suspicion is high – proceed to CT scan of the pelvis and abdomen
• CT scan (abdo and pelvis): used to assess extra testicular metastasis
• Serum beta-hCG: elevated in all cases of choriocarcinoma (non-seminomatous germ cell tumour – rarest of all testicular cancers). Upper limit reference range for men under 50 is 0.7U/L
• Serum alpha-fetoprotein (AFP): raised in some testicular cancers >25 microgram/L indicates cancer
Serum lactate dehydrogenase (LDH): elevated in 50% of all cases of testicular cancer. Has a high false-positive rate >25 U/L

27
Q

Discuss serum markers of testicular tumours

A

Serum concentrations of a-fetoprotein and/or b-hCG are elevated in most men with teratomas and are used to assess response to treatment

B-hCG is elevated in a minority of men with seminomas and AFP is not elevated in men with pure seminomas

28
Q

Discuss additional tests for testicular masses

A

• CT chest if CT abdo+pelvis is +
Biopsies are not advised in the evaluation of a testicular mass – diagnosis is established by removing and examining the testicle

29
Q

Discuss primary tumour staging of testicular tumours

A 
Tis = germ-cell neoplasm in situ (original place)
T1 = confined to testis without LN invasion
T2 = confined to testis with LN involvement or beyond tunica albuginea
T3 = invades spermatic cord
T4 = invades scrotum
30
Q

Discuss regional LN staging of testicular tumours

A 
NX = LNs can't be assessed
N0 = no LN mets
N1 = regional LN mets <2cm
N2 = regional LN mets 2-5cm
N3 = regional LN mets >5cm
31
Q

Discus staging of testicular cancers

A 
- Stage I = confined to testis	
• Stage II = any pT/TX, N1-3, M0, SX
• Stage IIA = any pT/TX, N1, M0, S0/S1
• Stage IIB = any pT/TX, N2, M0, S0/S1
- Stage IIC = any pT/TX, N3, M0, S0/S1
32
Q

What is a direct access ultrasound?

A

When a test is performed and primary care retain clinical responsibility throughout, including acting on the result

33
Q

What is a hydrocele?

A

Fluid within the tunica vaginalis

Primary or secondary

Primary: associated with a patent processus vaginalis which typically resolves during first year of life, more common in younger men, larger and can resolve spontaneously

Secondary: testes trauma, tumour or infection

34
Q

What is epididymoorchitis?

A

Inflammation of epididymis

Caused by chlamydia, E.coli, mumps, gonorrhoea, TB

Sudden onset, tender, swelling, dysuria

35
Q

What is a varicocele?

A
  • Dilated veins of pampiniform plexus
  • Left side more commonly affected
  • Can be visible bag of worms
  • Patient may complain of dull ache
36
Q

What is a haematocele?

A

Blood in tunica vaginalis, usually occurs due to trauma, needs draining

37
Q

Differentials for testicular cancer

A
  • Testicular torsion
  • Epididymo-orchitis
  • Scrotal hernia
  • Hydrocele
  • Epididymal cyst
  • Haematoma
  • Spermatocele
  • Intratesticular benign cyst
  • Syphilitic gumma (A gumma  is a soft, non-cancerous growth resulting from the tertiary stage of syphilis. It is a form of granuloma)
38
Q

Types of testicular tumours

A
  • Seminoma (55%)
  • Non-seminomatous germ cell tumour (33%)
  • Mixed germ cell tumour (12%)
39
Q

What is a germ cell tumour?

A

Neoplasm derived from germ cells

Can be benign or malignant

Mainly occur inside gonads

40
Q

Clinical features of testicular cancer

A
  • Testicular mass +/- pain
  • Metastases to the para-aortic LNs
  • Back pain
  • Gynaecomastia if the tumour is hCG secreting
41
Q

Investigation of testicular tumours

A
  • Ultrasound or MRI
  • Assay of serum tumour markers: a-fetoprotein, lactase dehydrogenase (LDH) and B-hCG
  • Pregnancy tests on men in A&E have saved the lives of men with metastatic germ cell cancer
  • CT or MRI to look for distant mets
42
Q

Treatment of testicular cancer

A

Orchidectomy via the inguinal approach to avoid spillage of highly metastatic tumour in the scrotum

43
Q

Epidemiology of testicular cancer

A
  • UK: ~1400 new cases each year with the highest incidence in those aged 25-35
  • Relatively rare, accounts for ~1% of all cancers and accounts for <1% of cancer deaths in males
  • Most common solid tumours diagnosed in men aged 20-34
  • White men have, by far, he highest incidence compared to African and Asian men
44
Q

Risk factors for testicular cancer

A
  • Cryptorchidism (failed descent of one or both tested) - relative risk of 2-17x for malignancy
  • 50-10% of patients with cryptorchidism develop cancer in the contralateral, normally descended testicle
  • Seminomas tend to be the predominant tumour type associated with undescended testis
  • Family hx

Testicular atrophy: due to trauma, hormones and viral orchitis (mumps)

Being white

HIV 5x the risk in men with HIV compared to age matched controls

45
Q

1st order investigations for testicular cancer

A
  • Ultrasound of testis: sensitivity near 100%, if the scan does not confirm a mass but suspicion is high – proceed to CT scan of the pelvis and abdomen
  • CT scan (abdo and pelvis): used to assess extra testicular metastasis
  • Serum beta-hCG: elevated in all cases of choriocarcinoma (non-seminomatous germ cell tumour – rarest of all testicular cancers). Upper limit reference range for men under 50 is 0.7U/L
  • Serum alpha-fetoprotein (AFP): raised in some testicular cancers >25 microgram/L indicates cancer
  • Serum lactate dehydrogenase (LDH): elevated in 50% of all cases of testicular cancer. Has a high false-positive rate >25 U/L

Metabolic - Urology (10 decks)

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