Transcript Testicular cancer: current views

Testicular cancer: current views
Dr. M. Mangala
MD (Kin); FRCS (Ireland); MMed
(Wits); FCS (SA) Urology
38th BMA CONGRESS
Background
 1%
and 1.5% male neoplasms
 5% all urological tumors
 Prevalence 2-3/100000
 In
the 15-34 y.o 62/100000
 5%
cases bilateral
 Duplication of the short arm of X12
 Isochromosome
12p or I(12p)
Diagnosis
 Scrotal
US
 Sensitivity
100%
 MRI
 Sensitivity
100% and Specificity 95-100%
 High cost: not justified
Diagnosis
 Serum
tumour markers
 AFP produced
by yolk sac: T1/2 5-7 days
 hCG expression of trophoblasts: T1/2 2-3 days
B
subunit specific
 LDH
marker of tissue destruction (bulk)
 Inguinal
exploration and orchidectomy
 Radical
orchidectomy
Diagnosis
 False AFP elevation
 Cancers:
Hepatobiliary, pancreatic, gastric, lung
 Benign: Liver conditions
 False
elevation hCG
 Cancers:
Lung, hepatobiliary, gastric, pancreatic,
multiple myeloma
Tumour marker by histological type
hCG (%)
AFP (%)
Seminoma
7
0
Teratoma
25
38
Teratocarcinoma
57
64
Embryonal
60
70
Choriocarcinoma
100
0
On orchidectomy
 Organ-sparing
surgery
 In
suspicion of a benign-lesion
 In synchronous, bilateral testicular tumours
 In metachronous, contralateral tumours
 In a tumour in a solitary testis
The tumour should be less than 30% of the testicular
volume.
Staging and clinical classification
 To
determine the presence of metastatic or occult
disease
 Tumour
markers
 Nodal pathway screened
 Visceral metastasis excluded
 Abdominal,
supra-clavicular nodes, liver
 Status of mediastinal and lung metastasis
 Status of brain and bone if suspicion
Staging and clinical classification
 Abdominal,
pulmonary, extra-pulmonary,
mediastinal node assessed by CT
 Supraclavicular nodes. PE and CT
 Retroperitoneal nodes CT
 MRI as CT but cost limit its use.
 FDG-PET: F/U of Residual mass seminoma post
CRx
 WW
or active treatment?
Classification
 TNM
 pTX:
Primary tumour can’t be assessed
 pT0 : No evidence of primary tumour
 pTis: Intratubular germ cell neoplasia
 pT1: Tumour limited to testis and epidydimis
without vascular/lymphatic invasion
_ pT2: same with invasion
Classification
 TNM
 pT3:
Invasion of the spermatic cord
 pT4: Tumour invades scrotum with or without
vascular/lymphatic invasion
 Serum
 Sx,
markers
S0, S1, S2, S3 according to level of LDH, hCG,
AFP.
Classification
 Stage
I: Confined to the testis
 Stage
IA: pT1, N0, M0, S0
 Stage IB: pT2, N0, M0, S0
 Stage IS: pT/Tx, N0, M0, S1-3
 Stage
II: Retroperitoneal involvement
 IIA nodes
 Stage
< 2cm, IIB nodes > 2cm
III: Nodes visceral or
supradiaphragmatic
Treatment: Seminoma
 Low-stage:
 Surgery,
DXT to retroperitoneum
 High-stage:
 Primary
I,IIA
IIB, III (Bulky and elevated AFP)
CRx (Sensitivity to platinum)
 Residual mass Mx controversial
Treatment: NSGCT
 Low-stage
 RPLND
 Surveillance
 Tumour
within tunica albuginea
 Normal tumour markers after orchidectomy
 No vascular invasion
 No sign of disease on imaging
 Reliable patient
Treatment: NSGCT
 Surveillance
 Monthly
visit 1/12 for 2 years
 Bimonthly third year
 Tumour markers each visit
 CXR, CT Scan q 3/12
Treatment: NSGCT
 High-stage
 Primary
CRx
 Tumour

If residual mass excision
 Tumour

marker stable
marker raised
Salvage CRx
Follow-up
 Labour
intensive
 Don’t forget to palpate
 Remaining
testis
 Abdomen
 Lymph
node area