Testicular Cancer & Penile Cancer

Stage I of testicular cancer

lesion confirmed inside the testes

What is penile cancer?

malignant growth on the skin or tissues of the penis

What are the sx of testicular cancer?

most common sx is painless enlargement of the testes - 10% are asymptomatic with painless mass or enlargement of the testis; secondary hydrocele (basically lump noticed randomly on exam or by someone else etc) - 10% are symptomatic with heaviness in testicle; hemorrhage - delay seeking treatment - 10% present with metastatic disease with back pain (spinal mets); cough (pulmonary mets); lower extremity swelling/edema (vena cava obstruction); supraclavicular nodes - Other symptoms are gynecomastia, precocious puberty

Testicular Ca Q: What will tumor markers show for Teratoma?

no elevation in any tumor markers so negative AFP, B-hCG, and LDH

What is the most common germ cell tumor?

non-seminomas (65%)

What labs to order for penile cancer?

not indicated unless suspect metastatic disease (CBC, CMP, UA, Ca)

Penile Ca: what is the tx for primary lesion?

Penectomy - partial (Grade 1B) or complete amputation (Grade 2B) (partial means scooping it out rather than cutting out penis) Organ-sparing procedures include topical chemotherapy (Fluorouracil 5% cream aka 5-FU most commonly used or Imiquimod 5%), Mohs microsurgery, wide local excision, laser surgery, radiation therapy (EBRT or brachytherapy)

What is the most common sx of penile cancer?

a painless lump, mass, or ulcer

When should pt w/ testicular cancer be referred to oncology?

suspect metastasis

When should pt w/ testicular cancer be referred to urology?

those w/ solid testicular mass

What are the tx options for penile cancer?

tx based on staging Primary lesion: - Penectomy - partial (Grade 1B) or complete amputation (Grade 2B) - Organ-sparing procedures include topical chemotherapy (Fluorouracil 5% cream aka 5-FU most commonly used or Imiquimod 5%), Mohs microsurgery, wide local excision, laser surgery, radiation therapy (EBRT or brachytherapy) Regional nodes: FNA/biopsy - Surveillance, dissection, adjuvant chemotherapy or radiation therapy Metastasis: individualized treatment

Which race is penile cancer typically seen in?

hispanic males *whites and blacks equally affected, asian/pacific islanders men have lower risk

Stage II (a, b, c) of testicular cancer

if in testes and retroperitoneal lymph nodes

Stage III of testicular cancer

if in testes, lymph nodes, and distant metastasis

Penile Ca: what is the tx for metastasis?

individualized tx

Testicular Ca Q: What will tumor markers show for Seminomas?

AFP is always normal at 0 but B-hCG and LDH are positive

What labs to order for testicular ca?

CBC, CMP (liver mets), UA (blood, semen) STI, base-line sperm count Tumor markers: - AFP: never elev w/ pure seminomas or teratomas - Beta human chorionic gonadotropin (B-hCG): sometimes w/ seminomas - Lactate dehydrogenase (LDH): elevated w/ both

What to check for on PEx for testicular cancer?

Check for gynecomastia, cough (if mets goes to lungs so need to check for cough) Abdomen/Back (masses, back pain, supraclavicular lymph nodes) Genitalia - hydrocele/hematocele Lower extremity edema (IVC obstruction) - if due to inferior vena cava or lymph node involvement so need to check

What are the risk factors of testicular cancer?

Cryptorchidism Ectopic testicle (testicle descends but goes somewhere else abnormal and not to the scrotum) FHx Testicular trauma Down's/Klinefelter's Syndromes Mumps orchitis Prior testicular cancer

Penile Ca Q: How to we assess for regional nodes?

FNA of nodes & biopsy or dissection

Penile Ca: what is the tx for regional nodes?

FNA/biopsy - surveillance, dissection, adjuvant chemotherapy or radiation therapy

Classification of testicular tumors

Germ cell tumors composed of diff tumor types derived from primitive germ cells of the embryonic gonad picture shows: - starts as germ cells --> two main types: seminomas aka gets to certain stage and stops changing & nonseminomas which can differentiate into diff types of testicular cancers

What images to order for penile cancer?

MRI of penis to assess depth of cancer invasion - other imaging not indicated unless suspect metastatic disease

What are the risk factors of penile cancer?

Medical conditions (phimosis, paraphimosis, late circumcision, urethral strictures, penile tears) Poor hygiene (balanitis, smegma) HIV HPV 16 and 18 Recurrent UTIs Age Smoking

What are the sxs of penile cancer?

Most common presentation is: - a painless lump, mass, or ulcer - but lesion can be painful, majority appear on the glans, corona, or prepuce Appearance varies (red rash-like, foul-smelling discharge, or bleeding) 30-60% have inguinal adenopathy at presentation 1-10% of cases present with distant metastasis

What is the first-line of tx, establishes dx, and staging of testicular cancer?

Radical orchiectomy

What is the epidemiology for penile cancer?

Rare in the US <1% Disease of older men usually dx > 60 y/o White and Black men equally affected Increase prevalence w/ Hispanic males Asian/Pacific islanders men have lower risk 95% are epithelial squamous cell carcinomas (SCC)

What is the pathophysiology for penile cancer?

Reticular/Standard infiltration - small blocks of tumor cells infiltrate the stroma, or pushing type infiltration - blocks of tumor cells invade tissue but keep well-defined borders Most penile cancers originate in the coronal sulcus of the glans or under the foreskin

What is the staging of testicular cancer based on and what are the stages?

Staging based on TNM and tumor markers: • Stage I: lesion confined inside testes • Stage II (a, b, c): if in testes and retroperitoneal Lymph nodes • Stage III: if in testes, lymph nodes, and distant metastasis

How to we stage penile ca?

TNM

What is the most common solid malignant tumor in young men between ages 20-35yo?

Testicular Cancer

What imaging can be ordered for testicular ca?

Testicular US - determines if intra- or extratesticular

What are the tx options for testicular ca?

active surveillance - pt must be reliable - annual f/u w/ serial tumor markers, CXR, contrast CT or MRI (abd/pelvic) for 5-10 yrs radiotherapy (radiosensitive) or chemo

USPSTF recommends against routine screening for testicular cancer in who?

adolescent and adult males (since rare and good prognosis overall)

We can't stage and tx testicular cancer until when?

after initial surgery

What is the prognosis for testicular ca?

best prognosis out of the 4 cancers we talked about in lecture - prof Seminomas: • Stage I - 98% and Stage II - 92-94%, 5-year disease free with effective treatment Non-seminomas: • Stage I & II- 96-100%, 5-year disease free with all treatments Both types: • Stage III - 95% complete response with treatment • Bulky and disseminated - with treatment have a 5-year disease-free survival rate of 55-80%

95% of penile cancers are...?

epithelial squamous cell carcinomas

90-95% of testicular cancers are ....?

germ cell tumors - 65% nonseminomas and 35% seminomas

What is the main differentiating sign/sx of testicular cancer that is also the most common sx these pts present w/?

painless enlargement of the testes

What are the complications of penile cancer?

penile amputation if left untreated (it will fall off) metastasis to inguinal & femoral lymph node, and then organs

What is the pathophysiology of testicular cancer?

poorly understood (multifactorial)

Testicular Ca Q: AFP is never elevated w/ what?

pure seminomas or teratomas

Testicular cancer is slightly more common on what side?

right side which correlates w/ right-sided cryptorchidism

Germ cell tumor classification

seminomas (35%): well differentiated non-seminomas (65%) - yolk sac tumors - choriocarcinoma - teratomas - embryonal carcinomas - mixed germ cell tumor (30%): 2nd most common germ-cell tumor after seminomas

In what race is testicular cancer more common?

whites > blacks