W2 Testicular Cancer (Joey) Flashcards
Testicular cancer emerges from which cell?
Which age group?
What is the main risk factor?
Testicular Cancer most often emerges from the Germ Cells (up to ~95% of TCas are histologically GC type),
TCa is most commonly diagnosed in males age 18-35 (although more broad common range sometimes considered 15-45)
Usually unilateral
Etiology is unclear
main risk factor is crytorchism
prior testicular cancer
Predominantly thought to be sporadic
Although perhaps a small genetic component
Testicular cancer
Histological changes
When does the “branch off” point occur?
Two tumour types, which is more common?
primordial germ cell
Pre CIS (carcinoma in situ)
While it’s attempting to differential into gonocyte
Pre CIS may lay dormant for a very long time or may undergo disadvantageous genomic changes
seminoma is most common (begins in germ cells)
Non-seminoma: begins in cells that form sperm or eggs
Seminoma: begins in germ cells
Testicular cancer
What is the presentation?
Main met site for testicular cancer?
Three diagnostic labs
non painful testicular mass but it can be painful
Most common distal met site: lungs
Presentation: cough, SOB, hemoptysis
Labs:
⭐️AFP (alpha fetoprotein): normal range <10
—AFP is a plasma protein produced by the embryonic yolk sac and the fetal liver, typically rise in the fetus while progressing in gestation until around 32 weeks where AFP starts to drop off
—May be elevated in certain subsets of testicular cancer
—Also is often elevated in patients with liver cancer, ovarian cancer, cirrhosis
⭐️ beta-hCG ⭐️
—(beta subunit of human choriogonadotropin): normal range <2 mIU/L for men
—In natal males, > 🔸HCG is an extremely abnormal finding and should immediately raise high suspicion for testicular cancer 🔸
—FYI: hCG is sometimes used as a TRT (causes agonism of LH and FSH receptors), but this is even more rarely used than SERMs and A-Is as 2nd line TRT
⭐️ LDH (lactate dehydrogenase):
—normal range approx 150-300 IU/L
—Incredibly non-specific, elevated in many Cas inflammatory processes, hemolysis, but may be early indication of metastatic disease in TCa if significantly elevated)
—CBC, CMP, pre-op labs (PT-INR, PTT)
[know this]
Pure seminoma labs? 2
Non seminoma germ cell tumours — labs
Treatment
Subtypes (in general able to predict the histology of the TCa based on labs):
⭐️Pure seminoma
(~50% of cases):
—AFP negative
—often has elevated beta-hCG and LDH
⭐️Non-seminoma germ cell tumors (aka “NSGCT”, approx the other 50% of cases):
○ Choriocarcinoma: beta-HCG +
○ Yolk sac tumor: AFP +
○ Embryonal carcinoma: AFP + & beta-hCG +
○ Teratoma: no markers positive outside of LDH
○ Teratocarcinoma : AFP + and beta-HCG + (well and poorly differentiated, contain so many cell types, resistant to chemo, this for you need to tear out peritoneal LNs RPLND — retroperitoneal lymph node resection)
Treatment:
radical orchiectomy
Testicular cancer
Pharm treatment
Which agent?
What is this agent highly associated with?
Chemo is not effective against what?
Which surgery is needed?
Chemo: Common initial regimen for most testicular cancer is “BEP” x3-4 cycles (rounds)
⭐️Bleomycin (“Bad-lungs”) - highly associated with pulmonary fibrosis, worsened with high supplemental O2, so if these patients develop associated hypoxia is it often recommended to have these pts not be sating >95% when doing your O2 protocols
● Etoposide
● CisPlatin (cisplatin)
○ Note: ⭐️ Chemo is not effective against teratoma (teratoma is inherently resistant to chemotherapy -
RPLND and radiation are the only real options)
○ Chemo may also be used as post-op adjuvant therapy to help prevent recurrence or metastasis
○ Chemo rarely used as neoadjuvant therapy as pts still need urgent orchiectomy
Testicular cancer
Long term follow up and surveillance
● F/u frequency, restaging scans, & tumor marker surveillance are all highly variable
…
○ Mostly based on specific pathology and stage of the TCa ○ Specific treatment types also change this (specific chemotherapies, radiation, +/- RPLND)
○ Usually it involves serum screening of AFP, beta-hCG, LDH ○ TCa guideline are constantly and recently rapidly evolving… NCCN Guidelines are the “Go-To” for the most-up-to-date recs
AFP and beta-HCG should be zero
LDH will never go to zero but should return to baseline
Testicular cancer take homes
Always get a ______
Common age range ______
Treatment is ______
Chemo is highly a/w ______
Treatment med is ______
● A testicular mass should be considered testicular cancer until proven otherwise, and if you’re not super confident (yet ) in your scrotal exam skills, any scrotal mass can be considered testicular cancer until proven otherwise… so make sure you always get a SCROTAL ULTRASOUND !
● Testicular Cancer is most commonly diagnosed in men ages ~18-35 (and is still somewhat prevalent in
males up to age 45), however do not discount a male with a testicular mass or pain who is outside of this age range
○ TCa essentially does not present itself prior to puberty given the changes in the spermatogenesis process during puberty, however pts younger than pubertal age may have
another intrascrotal pathology occurring (so always get a scrotal ultrasound)
○ Males who are > 45 may still develop TCa (however extremely unlikely), however males of this are group may develop intratesticular / scrotal lymphomas, so still always best to do your workup (scrotal ultrasound)
● The most important roles you can play as a clinician in detection and treatment of testicular cancer:
○ Develop Strong Physical Exam Skills
○ Educate Males on Self-Testicular Exams
○ Have a Low Threshold for Ordering a Scrotal US (cheap, minimally invasive, & give a lot of info!)
○ Any patient with testicular mass, abnormal scrotal ultrasound, and > tumor markers needs an immediate referral to urology / oncology
● Initial treatment is orchiectomy for essentially any testicular mass
● Chemo is highly associated with infertility in this patient population
● Bleomycin is highly associated w/ pulmonary fibrosis (avoid hyper-oxygenating these pts)
