Post on 24-Feb-2016
description
transcript
Testicular Cancers
Ashray GunjurIntern, Royal Melbourne Hospital
Did you know?
• That the words testify, testimonial and testament are derived from...
Anatomy
http://www.aboutcancer.com/testicle_anatomy1.jpg
Differentials
HISTORY?* Pain??* Time course of symptoms?
PHYSICAL EXAM?* pain?* reducibility?* Lie of teste?
Differentials
Toronto Notes 2010
Differentials
• 2) Epidydymal cyst/Spermatocele
Differential
• 3) Varicocele
Typical case
• Young man with painless growth of unilateral teste
• On examniation, firm nontender, non-transilluminating mass in one of the testes
Epidemiology
• Relatively rare- 1-2% of men, but..• Most common malignancy in age 20-40• Three peak model: infancy, 30-34 years, >60
years
Risk factors
• Cryptorchidism- 4-8x risk of germ cell tumour– Risk still increased after orchiopexy in pt <6yrs old-
2.23x*– Risk still increased in contralateral testis- 5-20% of
malignancy in normal descended testis!• Prior testicular cancer- 500x– Approx 1-2% of testicular cancer patients will
develop a second primary contralaterally...
*Pettersson A, Richiardi L, Nordenskjold A, Kaijser M, Akre O. Age at surgery for undescended testis and risk of testicular cancer. N Engl J Med. May 3 2007;356(18):1835-41
Risk factors
• Genetics– E.g. Klinefelter syndrom (47XXY)- germ cell
tumours• Diethylstilbestrol (DES) exposure in utero– E.g. ‘Agent Orange’, Industrial occupation
Diagnosis
• Best first testhypoechoic lesion
Diagnosis
• Gold standard?
- inguinal orchidectomy!!
Histologic types
Germ cell tumors (>95%):Seminoma (40%) versus Non seminomatous germ
cell tumors (NSGCT) (40%) vs. mixed (15%)
Non-germ cell tumors (rare, <5%)Leydig cell tumors (precocious puberty)Sertoli cell tumors Mixed sex chord-stromal tumors
Germ cell tumours
• Seminoma (40%)– Generally favourable prognosis, tend to be in older men– Rarely make B-HCG (15%), no aFP (0%)
• Non-seminoma (40%)– Choriocarcinoma
(elevated b-HCG (50%), haematogenous spread)– Embryonal cell– Teratoma (mature and immature)– Yolk sac
(elevated AFP)
Tumour markers
• AFP levels are elevated 50%-70% NSGCT• hCG levels are elevated in 40%-60% NSGCT. • AFP has a half-life of 5-7 days• hCG has a half-life of 36 hours. • Important to follow response after
orchiectomy• LDH is non-specific measure of tumor burden
Risk stratification• Good-risk nonseminoma• Testicular or retroperitoneal primary tumor, and• No nonpulmonary visceral metastases, and• Good markers; all of:Alpha-fetoprotein (AFP) < 1,000 ng/mL, and• Human chorionic gonadotropin (hCG) < 5,000 IU/mL (1,000 ng/mL), and• Lactate dehydrogenase (LDH) < 1.5 times the upper limit of normal
• Intermediate-risk nonseminoma• Testicular or retroperitoneal primary tumor, and• No nonpulmonary visceral metastases, and• Intermediate markers; any of:AFP 1,000 to 10,000 ng/mL, or• hCG 5,000 IU/L to 50,000 IU/L, or• LDH 1.5 to 10 times the upper limit of normal
• Poor-risk nonseminoma• Mediastinal primary, or• Nonpulmonary visceral metastases, or• Poor markers; any of:AFP > 10,000 ng/mL, or• hCG > 50,000 IU/mL (10,000 ng/mL), or• LDH > 10 times the upper limit of normal
Risk stratification• Good-risk seminoma• Any primary site, and• No nonpulmonary visceral metastases, and• Normal AFP, any hCG, any LDH• Intermediate-risk seminoma• Any primary site, and• Nonpulmonary visceral metastases, and• Normal AFP, any hCG, any LDH• Poor-risk seminoma• No such thing!!
TreatmentPost Orchidectomy…
SeminomaStage IA and B: radiation therapy vs surveillance (? Chemo)NSGCTStage IAretroperitoneal lymph node dissection vs surveillanceStage IBretroperitoneal lymph node dissection vs surveillance vs
chemotherapy
Higher stages-chemo, f/b surgery as needed
Retroperitoneal Lymph Node Dissection
Why?
• Non-seminomas are more aggressive than seminomas
• RPLND is used to guide chemotherapy– No of +ive nodes correlates to cycles of chemo
Surveillance
NCCN guidelines• CT q 2-3 months for first year or two• Then q4, q6• Labs, CXR q month for year one, then q 2
months, etc
• Issues are compliance, anxiety
Question 1
The most common presenting complaint for a testicular cancer is:
a) a painless swelling of a single testeb) a red, painful scrotumc) haematuriad) back pain
Question 2
• All of the following are a risk factor for testicular cancers, save
a) Cryptorchidismb) Maternal DES exposurec) Caucasian raced) Repeated testicular trauma
Question 3
The following statements are false, savea) Testicular cancer is the most common cancer of
infancyb) There are more men aged 15-25 diagnosed with
testicular cancer than >50c) Unilateral surgical orchidectomy precludes the
chance of testicular cancer recurringd) Unilateral surgical orchidectomy is the gold
standard diagnostic procedure for testicular cancer
Question 4
Routine workup and staging of diagnosed testicular cancer should include:
a) a-FPb) B-HcGc) CT A/P + Cd) PET scan
Question 5
The following are incorrect about Seminomas, save
a) Ultrasound features often involve heterogenous cystic components
b) aFP is often raised and used for prognosticationc) Para-aortic radiotherapy is often indicatedd) Patients with metastatic disease have a poor
prognosiss