testicular cancer - department of surgery at suny ...testicular cancer is an uncommon but highly...
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Testicular Cancer PATRICIA LEUNG 8.22.13 SUNY DOWNSTATE MEDICAL CENTER
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Case Presentation
29 year old male No PMH/PSH CC: 6 weeks of painless swelling left testicle Denied any trauma, fever/chills, family history Exam: HR 70 RR 20 T 97.3 BP 134/79 Left testis enlarged, firm, nontender to palpation; no transillumination; right testis WNL No lymphadenopathy
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Labs: CBC, CMP WNL β-hCG 30 AFP negative Imaging - Ultrasound: L testicle - 6.3 x 5.5 x 3.6 cm left testicle almost completely replaced by a large solid heterogeneous mass measuring approximately 5 x 4.5 x 3.1 cm R testicle - 3.9 x 2.1 x 1.8 cm
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Left radical orchiectomy Pathology: Seminoma, 6.3 x 5 x4 cm Tumor limited to testis and epididymis without vascular/lymphatic invasion; spermatic cord uninvolved by tumor
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Introduction
Testicular cancer is most common among men aged 15 to 35 years Secondary peak in incidence after age 60 Incidence 7.5 cases per 100,000 5-fold higher in whites Highly treatable Mortality rate before 1970s was 50% compared to <5% today Most are germ cell tumors (GCT)
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Anatomy www.downstatesurgery.org
Differential Diagnosis
Abdominal hernia Epididymitis Hydrocele Lymphoma Orchitis Spermatocele, varicocele Testicular Torsion
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Risk Factors
Undescended testis (cryptorchidism) – 4-8 fold increased risk - Orchiopexy Genetics – Klinefelter syndrome, Down’s syndrome Family history of testis cancer – 1.4% have family history; risk of
testicular cancer increases 4-6 fold in sons and siblings Personal history – 1-2% patients with testicular cancer will develop a
second primary tumor in contralateral testis Environment – DES, Agent Orange, solvents Activities – horseback and motorcycle riding, local trauma, and
increased scrotal temperature (are not)
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Types of Testicular Germ Cell Tumors
Seminomas (30-60%) Nonseminomas - Embryonal carcinomas (3-5%) - Teratomas (5-10%) - Yolk sac tumors - Choriocarcinomas (1%) - Mixed (60%) Tumors with a mixture of seminoma and nonseminoma components
are managed as nonseminomas Tumors with seminoma histology but with elevated serum AFP are
treated as nonseminomas
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Seminoma vs. Nonseminoma
Seminoma Less aggressive
Radiosensitive
Diagnosed at earlier stage: CS I, II and III disease is 85%, 10% and 5%
Metastatic seminoma who experience relapse after treatment, 10-15% have NSGCT elements
Nonseminoma CS I, II and III is 33%, 33%, 33%
Higher incidence of occult metastasis
Higher risk of systemic relapse after treatment of retroperitoneum
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Diagnosis
Localized disease Painless swelling or nodule of one testicle Dull ache or heavy sensation Hematoma with trauma
Metastatic disease: Anorexia, nausea, GI symptoms Back pain (retroperitoneal disease) Cough, chest pain, hemoptysis (mediastinal adenopathy or metastatic
lung disease Gynecomastia (hCG) Hyperthyroidism (hCG)
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Serum tumor markers
Alpha-fetoprotein (AFP) – elevated in 40-60% of men with nonseminomas; seminomas do not produce AFP
β-hCG – elevation seen in 14% of patients with stage I seminoma and 50% of patients with metastatic seminoma; 40-60% of men with nonseminoma have elevated levels
LDH – elevated in both but with less clear prognostic significance Measured before and after surgery
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Imaging
Testicular ultrasound – highly specific CT Abdomen/Pelvis Chest XR, +/- CT MRI PET – no role
RadioGraphics March 2004 vol. 24 no. 2 387-404
JUM July 1, 2007 vol. 26no. 7 981-984
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Summary of initial workup
European Association of Urology 2012
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Management
NO Transscrotal biopsy – risk of local dissemination of tumor into scrotum
NO Transscrotal approach – increase in risk of local recurrence
YES Radical inguinal orchiectomy with division of spermatic cord at level of internal ring
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TNM Classification
European Association of Urology 2012
Post-orchiectomy
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Retroperitoneal Nodes Most common route – to
retroperitoneal lymph nodes Right sided tumors
Interaortocaval
Precaval and paracaval nodes
Left sided tumors Para-aortic and pre-aortic
Interaortocaval
Contralateral spread more common with right sided tumors and associated with large volume disease
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Staging
European Association of Urology 2012
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Simplified Staging
Clinical Stage I No Radiographic Evidence of Metastatic Disease
Elevated STM
Clinical Stage II Retroperitoneal Lymphadenopathy
Clinical Stage III Pulmonary, non-retroperitoneal lymph nodes or visceral metastases
Retroperitoneal nodes with STM levels 2 and 3
NO STAGE IV
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Post-orchiectomy management Seminoma
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Post-orchiectomy management Seminoma Stage 1
Surveillance Adjuvant treatment with radiation therapy Single cycle of carboplatin chemotherapy
Disease-specific survival – 99% independent of management choice Stage IIA/IIB
Paraaortic and iliac node radiation therapy Chemotherapy Both
Stage IIC/III Chemotherapy
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Post-orchiectomy management Nonseminoma
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Post-orchiectomy management Nonseminoma Stage I
Surveillance (30% relapse) Adjuvant chemotherapy Modified retroperitoneal lymph node dissection (RPLND)
Stage IIA/IIB Bilateral RPLND Multiagent platinum-based chemotherapy – overall cure rate of 85%
Stage IIC/III Chemotherapy
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Surveillance www.downstatesurgery.org
Summary
Testicular cancer is an uncommon but highly treatable cancer Germ-cell tumors comprise >95% of testicular cancers Tumors with seminoma histology but with elevated AFP are
considered nonseminomas Seminomas are radiosensitive and respond well to platin-based
chemotherapy Most common route of disease dissemination is via the lymphatic
channels from the primary tumor to retroperitoneal lymph nodes Retroperitoneal lymph node dissection is an effective therapy for
patients with high-risk clinical stage I nonseminomatous germ cell cancer.
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References NCCN Clinical Practice Guidelines in Oncology 2012
European Association of Urology: Guidelines on Testicular Cancer 2012
Campbell-Walsh Urology 10th edition
Retroperitoneal lymph node dissection in testis cancer, Urology Times: Clinical Edition June 2009
Evaluation of Lymph Node Counts in Primary Retroperitoneal Lymph Node Dissection; Cancer, Nov 2010
Retroperitoneal lymph node dissection for residual masses after chemotherapyin nonseminomatous germ cell testicular tumor, World Journal of Surgical Oncology 2010: 8:97
The Role of Primary Retroperitoneal Lymph Node Dissection in Clinical Stage I Nonseminomatous Germ Cell Testicular Cancer, American Society of Clinical Oncology 2010
Thank you Dr. Mike Tyler and Dr. Brian McNeil
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