UTP5 - Testiculo e Pénis - Cancro (2) Flashcards
Algorithms?
◆ In metastatic NSGCT (stage >IIC) with a good prognosis, three courses of BEP is the primary treatment of choice
◆ In metastatic NSGCT with an intermediate prognosis, the primary treatment of choice is four courses of standard BEP
◆ In metastatic NSGCT with poor prognosis, the primary treatment of choice is on cycle of BEP, followed by tumor marker assessment after 3w; in the case of an unfavorable decline, chemotherapy intensification can be initiated
◆ Stage >IIC seminoma should be treated with primary chemotherapy according to the same principles used for NSGCT
BEP?
◆ Etoposide 100mg/m2 IV D1-D5
◆ Cisplatin 20mg/m2 IV D1-D5
◆ Bleomycin 30000 IU IV D1, D8, D15
◆ Bleomycin - Lung fibrosis (life-threatening pulmonary toxicity)
– Age (>40 years)
– Drug dose
– Poor renal function
– Advanced disease
– Smoking history
– Concomitant use of oxygen or radiation therapy
◆ If < 60 years – 360000 IU max
◆ VIP if bleomycin contra-indicated
RPLND?
◆ CT scan 4-6 weeks after chemotherapy
– largest axial dimension
◆ Seminoma
– > 3cm and active PETFDG/CT
– Biopsy (?)
◆ Non-Seminoma
– > 1cm
– < 1cm if mature teratoma in primary orchiectomy
Monitoring disease: serum markers + CT?
◆ T1/2 serum markers → less than expected rate of decline:
– Tumour persistence (pN2/3)
– Chemotherapy resistance (Is)
– Tumour relapse (pN1)
– Incomplete resection
Extra-gonadal germinative testicular tumours?
◆ Mediastinum
– Worst prognosis
◆ Retroperitoneal
– Same prognosis and staging
– Possible tumour regression
◆ Orquidectomy?
– Dominant retroperitoneal side
– Testicular atrophy
– Testicular ultra-sound (50%):
. Scars, calcifications, hypo or hyperechoic areas
Non germinative testicular tumours?
◆ Higher incidence – paediatric age
◆ Palpable mass + Estrogenic/Testosterone-related changes
– Virilisation, GYNECOMASTIA, decrease of libido
◆ Leydig cell tumour (intracytoplasmatic crystals of Reinke)
– 1-3 %
– Malignant - 10-15 %:
. > 5 cm
. Lymphovascular invasion
. High mitotic index
. Necrosis
. Spermatic chord invasion
. R1
◆ Sertoli cell tumour
– 1 %, < 20 years
– Gynecomastia - 30 %
– Malignant/metastatic - 10 %
. ≈ Leydig cell tumour
Penile Tumors?
◆ Common SCC == 48-65% == Depends on location, stage, and grade
– Basaloid carcinoma == 4-10 == Poor prognosis, frequently early inguinal nodal metastasis
– Warty carcinoma == 7-10% == Good prognosis, metastasis rare
– Verrucous carcinoma == 3-8% == Good prognosis, no metastasis
– Papillary carcinoma == 5-15% == Good prognosis, metastasis rare
Risk factors and relevance?
◆ Phimosis == OR 11-16
◆ BXO/lichen sclerosis
◆ Sporalene and UVA treatment == OR 9 (>250 Tx)
◆ Smoking == OR 5-10
◆ HPV 22% Verrucous SCC; 36-66% Basaloid/warty
◆ Low socioeconomic status
◆ Multiple sexual partners == OR 3-5
Squamous Cell Carcinoma? IMPORTANT
◆ Lesser aggressive: Verrucous, Papillary, Warty, Pseudohyperplastic, Cuniculatum
◆ More aggressive: Basaloid, Sarcomatoid, Adenosquamous, Poorly differentiated
Pathological Prognostic Factors (pTNM and tumour grade)? IMPORTANT
◆ Good prognosis
– Foreskin
◆ Worst prognosis
– Perineural invasion and higher histological grading
– Lymphatic invasion
◆ T2=T3; N1=N2
HPV and Penile tumours?
◆ Basaloid, Mixed Warty-Basaloid, Warty - HPV9,16,18 (up to 36-66%)
◆ Verrucous, papillary – HPV up to 22%
Staging and imaging?
◆ Exame Físico
◆ TAC
Penile Biopsy - indications?
◆ Doubt (e.g. CIS, Metastasis, Melanoma)
◆ Treatment with topical agents, radiotherapy, LASER surgery
Penile Tumors - Treatment?
◆ Glans resurfacing
◆ LASER ablation
◆ Brachytherapy
◆ Partial amputation
Management of regional lymph nodes?
◆ Radiotherapy == Not recommended for nodal disease except as a palliative option.
◆ Palpable inguinal nodes (cN1/cN2) == Radical inguinal lymphadenectomy
◆ Fixed inguinal lymph nodes (cN3) == Neoadjuvant chemotherapy followed by radical inguinal lymphadenectomy in responders.
