Wednesday, January 6, 2010
January 5th - LBJ - Testicular Cancer
Testicular cancer is the most common solid malignancy in adult males under the age of 35. The case presented was testicular lymphoma - essentially for boards, suspect testicular lymphoma with a testicular mass in any man above the age of 45!!! PEARL: If you think a patient has epididymitis, and they fail a course of antibiotics - U/S!!!! - it's cancer!!!!
The vast majority of testicular cancers overall (>95%) are germ cell tumors (i.e. Seminomas and Non-Seminomas, more on this later). Others, such as the aforementioned lymphoma as well as sertoli/leydig are rare. You will not likely be tested on these "other" cancers on boards.
Risk Factors for testicular cancer include cryptoorchism, family history, Klinefelters, and HIV/AIDS. Remember that men with cryptoorchism have increased risk of cancer in BOTH testicles, and the longer you wait to perform orchiopexy, the higher the risk of developing cancer.
You should know about workup as well as tumor markers and classification for the boards. If your ultrasound is suggestive of cancer, NEVER NEVER NEVER biopsy. Always do an inguinal orchiectomy with pathology. If you are suspecting testicular cancer on U/S you should order LDH, AFP and hCG. These makers are never used to diagnose (with one exception - mentioned below) and are used for staging and monitoring therapy/relapse.
Seminomas: ALWAYS AFP Negative, can produce hCG, but rarely do so (about 10% secrete hCG)
- Teratoma - ALWAYS Negative for BOTH AFP and hCG)
- Choriocarcinoma - ALWAYS Positive for ONLY hCG)
- Yolk Sac - ALWAYS Positive for ONLY AFP)
- Embryonal - ALWAYS Negative for AFP, about half secrete hCG)
The exception - So, the take away from these markers for boards (besides knowing them) from a diagnostic purpose is the classic question - testicular pathology reveals that the cancer is a seminoma, but the AFP is high - well, the pathology is wrong, and there is some non-seminoma component!!!!! Therefore, the patient is treated along the non-seminoma pathway per below...
Staging for both Seminomas and Non-Seminomas: There are pretty involved details, but you'll just need to know the basics for knowing the treatment approach. Know that markers and levels are also used, but you do not need to know the specifics, only this:
Stage I: Testicle Along
Stage II: Retroperitoneal LN involvement
Stage III: Mets
Treatment: When Combo Chemo is Given it's usually either BEP (Bleomycin, Etoposide and Cisplatin) or EP alone.
Stage I: Orchiectomy alone or combined with surveillence or single agent chemo or radiation. [NOTE: Surveillance is generally only used for patients that have a risk of side effects from radiation... Chemotherapy is sometimes slightly favored over radiation due to the side effect profile of single agent chemo being better than radiation.... so the boards will not ask you which is better, chemo or rads....)]
Stage II: Orchiectomy + Chemo or Orchiectomy + Radiation
Stage III: Orchiectomy + Chemo
Non-Seminoma: Treat based on stage
Stage I: Orchiectomy + Chemo (favored) or Orchiectomy with surgical removal of the LN (I.e. RPLND)
Stage II: Orchiectomy + Chemo or Orchiectomy + RPLND, although most will do Orchiectomy + both Chemo and RPLND
Stage III: Orchiectomy + Chemo
Some info on relapse: If tumor markers rise after Surgery or Radiation - More chemo is given. Be aware that alternative regimens to BEP and EP are used, but you don't need to know them (...so I won't list them!) If patient has a non-seminoma and have masses found on re-imaging - consider teratoma with surgical removal.
Complications: Infertility, so recommend sperm banking prior to Tx
Secondary Malignancies, esp AML, from Chemo
Overall, there is a lot of info on testicular tumors that technically can be asked on boards, but like I stated - just know basic workup, markers and some info about treatment options...