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DOM Morning Report: Testicular Cancer

Objectives. To understand the epidemiologic trendsTo understand the definitive diagnostic procedure and postoperative monitoringTo know the treatment side effects. Risk Factors. Patients with cryptorchid testis3- to 17-foldIntra-abdominal > inguinal Contralateral malignancy in ~20%Gonadal

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DOM Morning Report: Testicular Cancer

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    1. DOM Morning Report: Testicular Cancer Week of November 3, 2008

    2. Objectives To understand the epidemiologic trends To understand the definitive diagnostic procedure and postoperative monitoring To know the treatment side effects

    3. Risk Factors Patients with cryptorchid testis 3- to 17-fold Intra-abdominal > inguinal Contralateral malignancy in ~20% Gonadal dysgenesis as in Klinefelter’s

    4. Epidemiology 9000 cases in US per year 350 deaths in US per year Most common solid malignancy in 20-35yo 1% of call cancers overall Incidence = 5.2/100,000 men/year in US Rose ~ 1.2% per year over past decade Absolute mortality stable or decreasing

    5. Germ Cell Tumor Anatomy Gross Testis Mediastinum Pineal gland Retroperitoneum Ovaries

    6. Germ Cell Tumor anatomy Micro Seminoma ~ 50% Very radiosensitive Nonseminoma Subtypes Embryonal carcinoma Teratoma Yolk sac carcinoma Choriocarcinoma Early metastasis Mediastinal nodes Lung parenchyma

    7. Diagnosis Mass is most common initial finding Scrotal Unilateral Self diagnosed Other symptoms Discomfort Swelling

    8. Diagnosis Considering cancer ? tumor markers a-fetoprotein (AFP) Only nonseminomatous tumors Beta subunit of human chorionic gonadotropin (ß-hCG) Seminomatous or nonseminomatous tumors Definitive procedure Radical inguinal orchiectomy

    9. Staging Evaluation AFP ß-hCG Lactate dehydrogenase (LDH) CT chest/abdomen/pelvis TNM system Stage I: limited to testis and adnexa Stage II: retroperitoneal/paraaortic nodes Stage III: distant nodes or metastasis

    10. Staging Prognostic Factor-based System Histologic type Seminoma Nonseminoma Level of serum tumor markers AFP = < 1000; 1000-10,000; > 10,000 ß-hCG = < 5000; 5000=50,000; > 50,000 LDH = 1.5x; 1.5-10x; > 10x Site of primary tumor Mediastinum Non-mediastinum

    11. Staging Five-year survival Favorable prognosis = 85-95% Intermediate prognosis = 70-80% Poor prognosis = 50%

    12. Management Monitor tumor markers Half-lives ß-hCG = 24-36 hours AFP = 5-7 days Persistence/recurrence indicated by… Failure to decline Reappearance

    13. Management Additional treatment modalities Stage I seminomas Retroperitoneal radiation vs. careful surveillance Recurrences nearly always curable with chemo Nonbulky stage II seminomas Retroperitoneal radiation Bulky stage II seminomas Cisplatin-based combination chemotherapy

    14. Management Stage I nonseminoma Retroperitoneal lymph node dissection Active surveillance Stage II nonseminoma Retroperitoneal lymph node dissection +/- two courses of cisplatin-based chemotherapy Stage III seminoma and nonseminoma Chemotherapy is cornerstone Cure rate > 70%

    15. Prognosis and Follow-up Highly treatable and usually curable Even when brain mets present at diagnosis 2-5% risk of contralateral recurrence Treatment complications Retrograde sperm ejaculation Oligospermia or azoospermia Production returns in 1-2 years Storage is an option before treatment

    16. Prognosis and Follow-up Acute nonlymphoblastic leukemia Patients treated with etoposide 11q23 chromosomal translocation present 15- to 25-fold relative risk Absolute risk < 0.5% at 5 years Adverse effects of bleomycin Life-threatening acute pulmonary toxicity Chronic pulmonary fibrosis Raynaud’s phenomenon

    17. Prognosis and Follow-up Adverse effects of Cisplatin Long-lasting subclinical nephrotoxicity Peripheral neuropathy Bilateral hearing deficits

    18. Objectives Revisited Epidemiologic trends Incidence increasing Mortality stable or decreasing Diagnosis/Treatment and Monitoring Radical inguinal orchiectomy Serial AFP and ß-hCG Treatment side effects Retrograde ejaculation Oligospermia or azoospermia

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