Testicular cancer current views
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Testicular cancer: current views. Dr. M. Mangala MD (Kin); FRCS (Ireland); MMed (Wits); FCS (SA) Urology 38 th 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

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Testicular cancer: current views

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Testicular cancer current views

Testicular cancer: current views

Dr. M. Mangala

MD (Kin); FRCS (Ireland); MMed (Wits); FCS (SA) Urology

38th BMA CONGRESS


Background

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

Diagnosis

  • Scrotal US

    • Sensitivity 100%

  • MRI

    • Sensitivity 100% and Specificity 95-100%

    • High cost: not justified


Diagnosis1

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


Diagnosis2

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

Tumour marker by histological type


On orchidectomy

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

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 classification1

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

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


Classification1

Classification

  • TNM

    • pT3: Invasion of the spermatic cord

    • pT4: Tumour invades scrotum with or without vascular/lymphatic invasion

  • Serum markers

    • Sx, S0, S1, S2, S3 according to level of LDH, hCG, AFP.


Classification2

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 < 2cm, IIB nodes > 2cm

  • Stage III: Nodes visceral or supradiaphragmatic


Treatment seminoma

Treatment: Seminoma

  • Low-stage: I,IIA

    • Surgery, DXT to retroperitoneum

  • High-stage: IIB, III (Bulky and elevated AFP)

    • Primary CRx (Sensitivity to platinum)

    • Residual mass Mx controversial


Treatment nsgct

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 nsgct1

Treatment: NSGCT

  • Surveillance

    • Monthly visit 1/12 for 2 years

    • Bimonthly third year

    • Tumour markers each visit

    • CXR, CT Scan q 3/12


Treatment nsgct2

Treatment: NSGCT

  • High-stage

    • Primary CRx

      • Tumour marker stable

        • If residual mass excision

      • Tumour marker raised

        • Salvage CRx


Follow up

Follow-up

  • Labour intensive

  • Don’t forget to palpate

    • Remaining testis

    • Abdomen

    • Lymph node area


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