Testicular cancer
is a testicular biopsy or an inguinal orchiectomy done to diagnose testicular ca
inguinal orchiectomy
what is the primary treatment for testicular cancer
inguinal orchiectomy
much many testicular ca pts have history of crypto
10-15%
cryptochidism increases testicular ca risk by how much
10-50 fold
risk of replase with survelliance in Stage I Seminoma
15-20%
risk for developing a contralateral tumor in testicular ca
2.7%- requires continued follow up of contralateral testicle
risk increase of family history of testicular ca
3-10 fold brother; 8-10 fold father/son; 3-4 fold
what percent of testicular cancer are stage 1
90%
CS1 Non-seminoma: RPLND
A standard option in stage I and minimal stage II non-seminoma Complication: Retrograde ejaculation as low as 5-10% with a modified "nerve-sparing" approach
what are the lab tests to order for testicular tumor
AFP, LDH, HCG
when is inguninal orchiectomy done
ALL patients with suspected testicular cancer must undergo orchiectomy even if they are metastatic at the time of diagnosis
how to treat a post chemo mass
ANSWER: Surgical Resection if possible Additional chemotherapy (2 cycles) if mass has viable cancer
when is adjuvant therapy considered in stage 1 seminoma
Adjuvant therapy may be considered for selected patients (with adverse features) Radiotherapy to Retroperitoneal lymph nodes Chemotherapy (Carboplatin)- this is preferred LONG-TERM Toxicity is unknown
what are extragondal GCTs associated with
Associated with Klinefelter's (XXY) (20%)
Adjuvant BEP vs RPLND in CS I non-seminoma
BEP chemo seems to be better than surgery
agressiveness of extragonadal GCTs
Biologically more aggressive Genetically / histologically identical to testis primary
what are the chemo toxicity risks
Bleomycin lung toxicity (<5%) Monitor DLCO Secondary leukemia (<1%) Etoposide, Cisplatin Nephrotoxicity (cisplatin) (20%, elevated Cr) Neuropathy / ototoxicity (cisplatin) (20-30%) Infertility (25-50%) 25% infertile at baseline, dose related Sperm Banking is essential Raynaud's (25-40%) May persist for years Cardiovascular (6%) CAD increased upto 7-fold compared to age-match controls Increased rates of hypercholesterolemia, HTN
Stage I Seminoma Adjuvant Chemotherapy
Carboplatin 400mg/m2 x 2 cycles Follow up: 20 to 120 months 1.8% relapse rate Low toxicity (<5% grade 3 or 4 hematologic toxicity)
radiation v chemo for stage 1 seminoma
Carboplatin caused less fatigue and time off work Relapse rate 3.5% (RT) vs 4.7% (carbo) Second GCT 1.96% (RT) vs 0.54% (carbo) at 5 years because RT had the greater risk for a 2nd cancer, it is the less preferred option
why are serum tumor markers important
Critical in making diagnosing GCTs Prognostic and assessing treatment outcomes
what is beta-HCG found in
Elevated in either seminomatous and nonseminomatous tumors Half-life is approximately 1 to 3 days
Types of non seminoma GCT
Embryonal carcinoma- if this is pure it is more chemosensitive but aggressive with a high recurrance rate Choriocarcinoma Yolk sac tumor Teratoma: mature or immature
what is the most common histology in testicular cancer
GCT
how is GCT managed in extragonadal primary sites
GCT can also occasionally occur in extragonadal primary sites, but managed the same as testicular GCTs
what is the tumor assumption when a testicular mass is found
GCT unless proven otherwise
what is most common type of testicular cancer
Germ cell tumor is the most common type of testicular cancer (95%)
what are the cycles of chemo for the different risk GCT (in advanced diseases)
Good risk (= 3 cycles of BEP) Intermediate risk (= 4 cycles of BEP) Poor risk (=4 cycles of BEP)
treatment of different advanced types of non-seminoma
IIA (marker NEGATIVE): RPLND >> Chemotherapy IIA (marker POSITIVE): Chemotherapy IIB:/IIC Chemotherapy stage 3 is chemo
what can residual masses post chemo be in non seminoma
In non-seminoma, residual masses may represent cancer, teratoma, or fibrosis Up to 50% contain either cancer or teratoma
what does management of GCT depend on
Management depends on the Stage and Risk stratification
CS I Non-Seminoma: Surveillance
Not Passive: Requires compliant patient, intensive monitoring to avoid late detection of relapse (most occur in first 2 years) Avoid surgery or chemotherapy for 70% of CS I patients without residual disease Equivalent high cure rate when salvage chemotherapy given at relapse
what are adverse prognostic features of stage 1 non seminoma
Predominant embryonal carcinoma lymphovascular invasion
treatment for stage 1S non seminoma
Primary Chemotherapy (BEP x 3 cycles or EP x 4 cycles) depends on age- Blemomycin have bad lung symptoms, this is more common in older pts, so older pts get EP
what does risk stratification for advanced disease depend on
Primary Tumor Histology Seminoma or non-seminoma Site of primary tumor: Testicular/RP primary or Mediastinal primary Lung mass doesnt increase recurrance, but other organs does Non-pulmonary visceral metastasis (e.g., liver, bone, or brain) Presence or absence Levels of Post-orchiectomy Serum Tumor Markers
what are the risk factors for GCT
Prior history of a GCT Positive family history Cyroptochidism Testicular dysgenesis Klinefelter syndrome
what is AFP found in
Produced exclusively by nonseminomatous cells (embryonal or yolk-sac tumors); NEVER by seminoma. Elevated AFP with a histological "pure" seminoma to undetected focus of nonseminoma and treated as non-seminoma. Half-life 5 to 7 days
prognosis for extragonadal GCTs
Prognosis is poor, unless pure teratoma
what are the salvage therapies if the cancer replases quickly
Salvage Chemotherapies TIP VIP or VeIP High Dose chemotherapy followed by Autologous Stem Cell Transplant
what are the serum markers for GCT
Serologic tumor markers (AFP, b-HCG, and LDH) are prognostic and their serologic staging guides treatment
what are the other testicular ca beside GCT
Sex cord-stromal tumors, paratesticular cancer, mesothelioma, and metastasis
what is stage 1S GCT
Stage 1S is the patients with persistent tumor markers after orchiectomy.
treatment of different sadvanced types of seminoma
Stage II IIA ("Non-bulky"): XRT > Chemotherapy IIB ("Bulky" disease: Chemotherapy >> XRT Stage IIC or Stage III: Chemotherapy Good risk Intermediate risk
what are the types of non-GCT
Stromal tumors (Leydig, Sertoli) Extratestciular intrascrotal tumors Metastatic tumors (lymphoma, leukemia, prostate cancer)
Stage I Seminoma Treatment Options
Surveillance Adjuvant Therapy: Radiation Therapy (note that surgery is not discussed here) Chemotherapy (Carboplatin)
Stage I Non-Seminoma Treatment Options
Surveillance Nerve-Sparing Retroperitoneal Lymph Node dissection Chemotherapy (BEP: bleomycin, etoposide, cisplatin) x 1 cycle
what initial test is done to evaluate a testicular mass
ultrasound
what are extragonadal GCTs tumors treated with
Treat with standard poor-risk regimens
Any adverse features for high risk of relapse in seminoma
Tumor >4cm Rete testis involvement
what does relapse risk and management stragety depend on
Type of histology: Seminoma or Non-seminoma TNM-S Stage and Risk Stratification
stage 3 tumor
abnormal lymph nodes above diaphragm or other organs; elevated markers (S1, S2, S3) IIIa IIIb IIIc
what is stage 2
abnormal retroperitoneal lymph nodes, w or w/o S1 IIa: <2cm or elevated markers only IIb: 2-5 cm IIc: >5cm (LN mass)
what is the risk of relapse in non-seminoma
about 30%
how is the 5 year survival rates of testicular cancer
above 95% in localized and regional 72% in distant
is staging based on tumor marker elevation before or after orchiectomy
after
right orichetomy LN landing zone
aorta cava LN
Stage I Seminoma Radiation Therapy
can still do even if no disease is on the scan Prophylactic/Adjuvant retroperitoneal radiation with low doses (25-30Gy) decreases the rate of relapse to 3-6% at 5 years Toxicity: GI, infertility(small added risk)- recommend sperm banking Relative risk of secondary cancer: 1.3 to 7.5 fold (GI, renal, bladder, leukemia)
how do you treat a stage 1 non seminoma that has relpased in the lungs
chemotherapy- BEP x 3
what is stage 1
confined to the testies without N or M 1a is T1 1b is T2-5 1s is serum marker elevation
what classifies nonseminoma pts into the different risk categories
different serum marker levels, location of primary tumor, and metastases (mediastinal primary tumor or nonpulmonary visceral metastasis are poor risk)
standard of care for CS1 non seminoma
discuss the 3 options and the preferred option is survelliance Chemotherapy may be considered in selected patients with adverse features (embryonal predominance and LVI)
what are the types of nonseminatous germ cell tumors
embryonal choriocarcinoma yolk sac tumor teratoma teratoma with malignant/somatic transformation mixed germ cell tumor
what is the most common solid testicular mass in a men aged 20 and 34 yrs
germ cell tumor
what tumors does Peutz-Jeghers syndrome give
increased incidence of sex cord tumor (Sertoli cell testicular tumors), breast, GI cancers
how is the incidence of testicular cancer changing in the past 2 decades
increasing
what is LDH found in
less specific marker- over 100,000 isnt good
what is the most common presentation of testicular cancer
localized
tumor staging
look at notes
what are the common sites of cancer metastasis
lungs is most common also liver, brain, bone
what is the most common solid testicular mass in a man aged 50 or older
lymphoma
what tumors does Klinefelter syndrome (47, XXY) give
mediastinal extragonald GCTs
where can extragonadal tumors arise
mediastinum or retroperitonium
what has higher recurrance rate- seminoma or non seminoma
non seminoma
are most GCT seminoma or non-seminoma
non-seminoma
what does risk stratification determine
number of chemo cycles
how to decrease risk of testicular ca in crypto
ochiopexy before puberty
what are the risk categories for seminoma
only fall into good or intermediate risk
left orichetomy LN landing zone
periaortal
treatment for 1S seminoma
repeat tumor markers and assess with CT A/P for evaluable disease
what are the regional LN that testicular ca spreads to
retroperitoneal LN
what are the divisions of GCT
seminoma, non seminomas, spermatocytic
of GCT, what is the rate of seminoma v non-seminoma
seminoma- 30% non-seminoma- 70%
general summary of the treatment options for S v NS
stage 1 S or NS- active survelliance Stage 2a S- RT over chemo Stage 2a NS- surgery All other stages the chemo is recommended (BEP for NS, carboplatin for S)
what is preferred for most pts with stage 1 seminoma
surveillance- 10-15% of patients will experience relapse.
what tumors does Down Syndrome (Trisomy 21) give
testicular GCT
what is Klinefelter syndrome
testicular atrophy, absence of spermatogenesis, a eunuchoid habitus, and gynecomastia 47, XXY karyotype Increased risk for mediastinal GCT (testies and retroperitoneum)
what is the most common cancer in young men
testicular cancer
what is the cure rate in testicular cancer
very high with chemo
what race has most testicular ca
whites