Page 1347 - TNFlipTest

Toronto Notes 2019 Urological Neoplasms
Investigations
• diagnosisisestablishedbypathologicalevaluationofspecimenobtainedbyradicalinguinal orchidectomy
• tumourmarkers(β-hCG,LDH,AFP)
■ β-hCGandAFParepositivein85%ofnon-seminomatoustumours
■ elevated marker levels return to normal post-operatively if no metastasis
■ β-hCG positive in 7% of pure seminomas, AFP never elevated with seminoma
• testicularU/S(hypoechoicareawithintunicaalbuginea=highsuspicionoftesticularcancer)
• evidenceoftesticularmicrolithiasisisnotariskfactorfortesticularcancer
• needleaspirationcontraindicated
Staging
• clinical:CXR(lungmets),markersforstaging(β-hCG,AFP,LDH),CTabdomen/pelvis (retroperitoneal lymphadenopathy)
■ Stage I: disease limited to testis, epididymis, or spermatic cord
■ Stage II: disease limited to the retroperitoneal nodes
■ Stage III: disease metastatic to supradiaphragmatic nodal or visceral sites
Table 21. 2010 TNM Classification of Testicular Carcinoma
TNM
Urology U29
Testes and scrotum have different lymphatic drainage, therefore trans-scrotal approach for biopsyororchiectomyshouldbeavoided
Tis: intratubular germ cell neoplasia T1: limited to testis and epididymis
without vascular/lymphatic invasion
T2: limited to testis and epididymis with vascular/lymphatic invasion
T3: invasion of the spermatic cord ± vascular/lymphatics
T4: invasion of the scrotum ± vascular/ lymphatics
Management
• orchiectomythroughinguinalligamentforallstages • considerspermbanking,testicularprosthesis
• adjuvanttherapies(seefigure19)
Prognosis
• 99%curedwithstageIandIIdisease
• 70-80%completeremissionwithadvanceddisease
M0: no distant mets M1: distant mets
M1a: nonregional lymph node(s) or pulmonary mets
M1b: distant mets other than to regional lymph nodes and lung
N0: no regional lymph node metastasis N1: Metastasis with a lymph node mass
2 cm or less in greatest dimension; or multiple lymph nodes, none more than 2 cm in greatest dimension
N2: Metastasis with a lymph node mass more than 2 cm but not more than 5 cm in greatest dimension
N3: Metastasis with a lymph node mass more than 5 cm in greatest dimension
Orchiopexy
Surgical descent (orchiopexy) of undescended testis does not eliminate the risk of malignancy, but allows for earlier detection
by self-examination and reduces the risk of infertility
Germinal cell Epithelium
Surveillance P Radiation
50% Seminoma
10% Stage II+III
P P
50%
Non Seminoma
20% Stage II
P P
Germ Cell Testis Tumour
Teratoma Embryonal CA Mixed cell type Yolk sac CA Chorio CA
90% Stage I
40% Stage I
P
±
?
20% Stage III
RPLND Chemotherapy
?
P(residual mass) P
Figure 19. Adjuvant management of testicular cancer post-orchiectomy
Adapted from Dr. MAS Jewett