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Testicular cancer: current views

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

  2. 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)

  3. Diagnosis • Scrotal US • Sensitivity 100% • MRI • Sensitivity 100% and Specificity 95-100% • High cost: not justified

  4. 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

  5. Diagnosis • False AFP elevation • Cancers: Hepatobiliary, pancreatic, gastric, lung • Benign: Liver conditions • False elevation hCG • Cancers: Lung, hepatobiliary, gastric, pancreatic, multiple myeloma

  6. Tumour marker by histological type

  7. 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.

  8. 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

  9. 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?

  10. 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

  11. 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.

  12. 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

  13. 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

  14. 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

  15. Treatment: NSGCT • Surveillance • Monthly visit 1/12 for 2 years • Bimonthly third year • Tumour markers each visit • CXR, CT Scan q 3/12

  16. Treatment: NSGCT • High-stage • Primary CRx • Tumour marker stable • If residual mass excision • Tumour marker raised • Salvage CRx

  17. Follow-up • Labour intensive • Don’t forget to palpate • Remaining testis • Abdomen • Lymph node area

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