Testis cancer Flashcards
Nonguideline directed care of patients with testicular cancer is common, most frequently in the form om inappropriate imaging and overtreatment. What does it lead to?
Delayed definitive therapy
Unnecessary morbidity
Higher rates of relaps
How common is testicular cancer in western society?
3-10 cases per 100,000 males/year
Hur stor andel av urologisk cancer utgörs av testikelcancer?
5%
What is the most common type of testicular cancer and what are the two subgroups?
Germ cell tumours (90-95%)
Non-seminoma
Pure seminoma
Utredning för misstänkt testikeltumör?
Kliniskt examination -skrotum - palpabel resistens i buken -gynekomasti -palp supraklavikulärt Ultraljud Tumörmarkörer
What are the Serum Tumour markers (STMs) for testicular cancer?
AFP: produced by yolk sac cells
hCG expression of trophoblasts
LDH (lactate dehydrogenase)
When is hCG elevated with testicular cancer?
- all choriocarcinomas
- 50% embryonal carcinomas
What information can you gain from LDH (lactase dehydrogenase)-levels with testicular cancer?
- less specific
- proportional to tumour volume
- elevated in 80% of advanced testicular cancer
What is the proper course of action with life threatening disseminated testicular cancer?
Lifesaving chemotherapy with delayed orchiectomy after completion of induction chemotherapy
When should you perform and orchiectomy after diagnosing testicular cancer?
Preferably within 24-48 hours and no later than 10 days
When should you consider performing organ-sparing surgery with testicular cancer?
Synchronous bilateral testicular tumours
Metachronous contralateral tumours
A tumour in a solitary testis with normal pre-operative testosterone levels
What are the riskfactors for contralateral testicular tumours?
testicular volume <12 mL
a history of cryptorchidism or poor spermatogenesis
When is a contralateral biopsy not necessary (when performing surgery for testicular cancer)?
In patients older than 40 years without risk factors
What information do you need for a complete staging and grading of testicular cancer?
Histopathology
Postoperative tumour markers
CT
What are the histopathological criteria for testicular cancer?
- pT category
- histological type
- peri-tumoural venous and/or lymphatic invasion
- presence of GCNIS
Mention a few Non-seminomal cancers of the testicle:
Embryonal carcinoma Yolk sac tumour Trophoblastic tumours Teratoma, post-pubertal type Teratoma with somatic-type malignancies Mixed germ cell tumours
Mention two Benign tumours of the testicle:
Spermatocytic tumour
Teratoma, prepubertal type
Hur stor andel av testikelcancer utgörs av icke “Germ cell tumours”?
2-4% hos vuxna män
When should you perform a FDG PET CT with testicular cancer?
Only if you have a residual mass at least 6 week after chemotherapy when treating a seminoma
What are teh progsnostic risk factors for stage 1 testicular cancer?
(answer for both seminoma and non-seminoma)
Seminoma:
tumour size >4 cm
invasion of rete testis
Non-seminoma:
vascular invation in blood or lymphatic vessels
percentage of embryonal carcinoma >50%
proliferation rate >70%
What Germ Cell tumours doesn’t need any other therapy than orchiectomy?
Spermatocytic tumour
Prepubertal teratoma
What is the relapse risk with stage 1 seminoma?
15-20% in 5 years
How do you treat a relapse of testicular seminoma?
Chemotherapy
What is the overall cancer-specific survival rate of testicular seminomas?
97-100%
-even postponed therapy is efficient
What is the main drawback with surveillance instead of chemotherapy with testicular seminomas?
The need for more intesive follow-up
How should you treat stage 1 testicular seminoma?
Either:
Surveilance- at very low risk
-tumour size <4 cm without rete testis invasion
or
One-course carboplatin-based chemotherapy
How should you NOT treat stage one testicular seminoma?
Radiotherapy
Retroperitoneal lymph node dissection (RPLD)
Vad är uppföljningsprogrammet för stadium 1 testikel seminom?
DToch tumörmarkörer var 6:e månad i 2 år
DT och tumörmarkörer på slutet av år 3 och 5
When does a relaps in stadium 1 NSGCT (non seminoma germ cell tumour) most often occur?
80% in the first year
How often does stadium 1 NSGCT (non seminoma germ cell tumour) relapse?
30%
Where does stadium 1 NSGCT (non seminoma germ cell tumour) most often relapse?
60% in the retroperitoneum
How common is subclinical metastases in clinical stadium 1 NSGCT (non seminoma germ cell tumour)?
up to 30%
What is the result of surveillance vs Adjuvant chemotherapy in stadium 1 NSGCT (non seminoma germ cell tumour)?
Surveillance –> 30% recurrence/relapse
Adjuvant chemotherapy –> <2% recurrence/relapse
What is risk-adapted treatment in stadium 1 NSGCT (non seminoma germ cell tumours)?
Low risk (stage 1A- pT1, no vascular invasion) --> surveillance (if not willing one course of BEP)
High risk (stage 1B, pT2-4) –> one(two) courses of BEP
What does BEP stand for in the treatment for testicular cancer?
Cisplatin
Etoposide
Bleomycine
When should you perform a nerve-sparing retroperitoneal lymph node dissection on patients with stage 1 NSGC (non seminoma germ cell tumours)?
to highly selected aptients only:
those with contraindication to adjuvant chemotherapy and unwilling to accept surveillance
When should you perform a Brain scan (CT/MRI) on a patient with metastatic testicular cancer?
I case of symptoms
and patients with metastatic disease with multiple lung metastases
and/or high beta-hCG values.
Vilken utredning är obligat vid misstänkt metastaserad testikelcancer?
UL testiklar Tumörmarkörer DT-thorax+buk MRI kotpelare OM patienten har symptom DT-hjärna/MR OM patienten har symptom eller multipla lungmetastaser och/eller högt beta-hCG
Vad är skillnaden mellan stadium M1a och M1b vid metastaserad testikelcancer?
M1a: metastaser i regionala lymfkörtlar och/eller i lungorna
M1b: andra metastaser
Vad innebär stadium 1 testikelcancer?
Sjukdom begränsad till testikeln
Vad innebär stadium II testikelcancer?
Retroperitoneala lymfkörtelmetastaser
IIA <2 cm
IIB 2-5 cm eller fler än 5st
IIC >5 cm
Vad innebär stadium III testikelcancer?
IIIA lymfkörtelmetastaser som inte är regionala
IIIB lungmetastaser
IIIC metastaser till andra organ
Which patients with metastatic testicular cancer have a poor prognosis?
Not any patients with seminoma
Patients with non-seminoma and: mediastinal primary non-pulmoary visceral metastases AFP >10,000 ng/mL or hCG >50,000 IU/L (10,000 ng/mL9 or LD > 10 x ULN
What is the standard treatment for stage IIA/B seminoma
Radiotherapy
2:hands alternativ är BEPx3
What is the standard treatment for stage IIA/B NSGCT (non seminoma germ cell tumour)?
Chemotherapy
and RPLND of residual disease
What is the one exception to chemotherapy for stage IIA/B NSGCT (non seminoma germ cell tumour)?
Stage IIA NSGCT & pure teratoma without elevated markers
–> nerve sparing RPLND or surveillance
What is the cure rate of non-seminoma stage IIA testicular cancer?
98%
Which factors correlate with preserved fertility after chemotherapy for testicular cancer?
cisplatin-dose
FSH
age
What can you expect when it comes to fertility after chemotherapy for testicular cancer?
Most men with normal pre-treatment sperm analysis will return to normal by 3 years after chemo
When is the spermatogenesis at its lowest after chemotherapy for testicular cancer?
10-14 months after chemotherapy
How common it late realapse (>2 years) in
seminoma?
non-seminoma?
seminoma 1,4%
non-seminoma 3,2%
What are the differential diagnosises when a patient has a late relapse of testicular cancer?
Metastases from a new contralateral primary A new primary EGGCT Metastases from a new non - GCT primary Transformed teratoma Growing teratoma
How do you treat late relapse (>2 years) NSGCT?
Surgery
if incomplete result of surgery –>salvage chemotherapy
rapidly rising hCG –> induction salvage chemotherapy before surgery
