Testicular Cancers

What are the 3 functions of testosterone?
1. develop the body 2 become masculine
2. promote & maintain development of male organs
3. Promotes muscular development

What are the 2 main functions of the testes?
1. secrete testosterone
2. lodges the sperm in the different stages

Where are the testes contained in & what are the syspended by?
contained in the scrotum & suspended by the spermatic cords

Which spermatic cord is longer?
the left cord is usually longer than the right

Testicular cancer is most common between what ages?

True or False:
Testicular cancer can affect 50-55 year old males, but prognosis is better as you get older.
false. testicular cancer can affect men 50-55, but prognosis is usually WORSE as you get older 🙁

The greatest incidence of testicular cancer is in _____, US, and ___.
The greatest incidence of testicular cancer is in Denmark, US, and UK.

What cell type is most common?
Germ cell tumors

Testicular cancer incidence is lowest in ____, Africa, North American Blacks, and _______.
Testicular cancer incidence is lowest in Asia, Africa, North American Blacks, and Puerto Rico.

True or False: Testicular cancer is relatively rare.

What are the 4 etiologies associated with testicular cancer?
1. Gonadal Dysgenesis
2. Cryptorchidism
3. Family History of Testicular Cancer
4. Previously Diagnosed in Opposite Testicle

What is gonadal dysgenesis?
testicles have not descended normally

What is “cryptorchidism?”
Abdominal, undecended testicles

What familial factors increase a males risk of developing testicular cancer?
a man who has a brother or father that has had the disease

What are the two types of testicular cancer?
1. Seminoma
2. Non-Seminoma

What is the most important factor for Seminoma?
the tumor stage

Seminoma is related to the degree of _________ disease.

Non-Seminoma is related to the ____ of the disease.

True or False: Non-Seminomas tend to be less invasive than Seminomas.
FALSE: Non-Seminomas tend to be MORE invasive.

What are the two important factors with non-seminomas?
1. tumor markers
2. amount of metastases

What type of non-seminoma carries the worse prognosis?

What are the tumor markers for non-ceminomas? (2)
1. Beta HCG
2. AFP (alpha feta protein)

What are the 4 symptoms of testicular cancer?
1. swelling (painless mass or lump)
2. dull ache/heaviness
3. breast tenderness/heaviness
4. infertility

How often do patients experience advanced symptoms?

What are 2 examples of advanced symptoms?
1. abdominal pain
2. bloody sputum

What is the most common symptom associated with testicular cancer?
– Swelling, painless mass or lump

What percentage of patient’s that present with a painless mass or lump will be malignant in nature?

What is important for initial staging?
Radical Orchiectomy through inguinal incision

What is removed with a radical orchiectomy?
– testes
– spermatic cord
– anything else that is linked to the testes

What is the “initial management” for testicular cancer?
– to obtain serum tumor markers: beta HCG & AFP

If a tumor is suspected what modality should be done?

What other modality should be done?
CT- chest, pelvis, abdomen

Of the two types of testicular cancers listed previously, which one is more common?

What type of tumor cell type is a seminoma?
classic male germ cell tumor with three subtypes

What are the three subtypes of the Seminoma, germ cell tumor type?
1. classic
2. anaplastic
3. spermatocytic

True or False: Seminomas are very radiosensitive and very curable.

What are the 4 types of non-seminomas?
1. Embryonal cell
2. Teratoma
3. choriocarcinoma
4. yolk sac tumor- embryonal adenocarcinoma

The yolk sac tumor, embryonal adenocarcinoma can occur in what type of patients?
children, pre-puberty

True or false: non-seminomas can be of a mixed histology.

With a non-seminoma, will you most likely become sterile?

What are the three staging systems for testicular cancers? Which ones are the most common?
2. UICC (most common)
3. AJCC (most common)

Pure Seminoma has a ______ tendency to stay localized.

How does pure seminoma spread?
spread is very orderly to lymph nodes/retroperitoneum

Seminoma begins in the _____________ and moves to the ______.
Seminoma begins in the inguinal nodes and moves to the abdomen.

True or False: Seminomas more often have blood borne mets.
FALSE: Seminomas rarely have blood borne mets (stay more confined to the lymph nodes)

Non-seminomas are more likely to spread _________ the lymphatics.

What are the two most common sites for non-seminomas to spread to?
Lungs & Liver

Initial management is to obtain serum tumor markers, AFP & beta HCG, why?
for baseline #’s after surgery

How is testicular cancer treated?

What are the treatment types used in the multidisciplinary approach for treatment of testicular cancer?
– Surgery
– Chemotherapy
– Radiotherapy

What is the goal of the treatment of testicular cancer?
– minimize toxicity without compromising the opportunity for a curative outcome

What is the standard treatment for testicular cancers?
Surgery + Post-OP radiation

For surgery + Post-op radiation for stage 1 & 2A disease, what type of treatment field is used?
Hockey Stick–includes the periaortic & ipsilateral pelvic nodes

Why are the doses lower for stage 1 & 2A disease?
– more radiosensitive
– location (decreases bad side effects)

What is the total dose & daily dose for Stage 1 & 2A disease?
Total: 2500 cGy
Daily: 160-180 cGy/fx

What is included in the treatment field for surgery + post-op radiation for stage 2B disease?
periaortic, ipsilateral pelvic nodes with modificaiton to encompass larger mass

The more advanced the disease, the more ______ the treatment will be.

For stage 2B disease, your entire nodal volume dose will be ____cGy w/ daily fractions of ________cGy.
total: 2500 cGy
daily: 160-180 cGy/fx

What is the total dose of a boost for stage 2B disease to residual tumors? daily fractionation?
total: 500-1000 cGy
Daily: 180-200 cGy/fx

The initial treatment for Non-Seminoma testicular cancer includes:
– Radical Orchiectomy
– Node Dissection (retroperiteum)
– + Cisplatin based chemotherapy

Non-Seminoma patients that recieve chemotherapy will recieve four cycles of:
– Vinblastine, Bleomycin, Cisplatin (PVB)

Non-Seminoma patients do not typically recieve radiation, why??
– irradiation dose not have a role in these tumors EXCEPT in cases of palliative TX for brain mets

________ of patients have radiographic evidence of diesease following chemotherapy.

A. 1/4
B. 1/2
C. 1/5
D. 1/3

D. 1/3

What is the technique for radiation for testicular cancer? (there are two techniques used)
– Inverted Y
– Hockey Stick

When would you used an inverted Y technique????
if disease was on both sides!

hockey stick=used after surgery

What is the upper RT border?
T10 & wide enough to include renal hilar nodes

What is the lower RT border?
at the top of the symphysis pubis or margin of the inguinal scar (from the orchiectomy)

Why do you want to make sure your field borders are wide enough?
wide enough to include bilateral para-aortic nodes + ipsilateral external iliac or by lateral external iliac if inverted Y is treated

How would you position a patient recieving testicular radiation?
supine with arms at side, elevated, or above head

What is something that you do not want to allow the patient to do when setting them up for testicular irradiation??
no crossing the legs

Fields must be shaped to avoid _________
critical structures (MLCs & blocks to avoid these)

What are some critical structures we used MLCs & blocks to block out?
– kidney
– small bowel
– bladder
– bone marrow reserves in iliac crests

What do you do with the other testicle when setting the patient up for radiation?
-must be shielded from internal scatter radiation
– TLD or diode to ensure the effectiveness of the scrotal shield

What are the 5 radiation side effects?
1. Skin Irritation
2. Bladder Irritation
3. decrease in sperm production
4. sometimes N & V
5. question of second malignancy

What would you advise your male patient to do during his treatment?
– advised to use birth control during RT, not plan pregnancy for at least one year after RT

What might “bladder irritiation” include?
– bladder spasms
– burning when urinating

What percentage incidence in second malignancy has been reported?

What are the 6 Chemotherapy side effects?
– hair loss
– N & V
– kidney damage
– sterility
– secondary malignancy
– decreased blood counts

What type of chemotherapy drugs cause kidney damage & sterility?
cisplatin based drugs

What is the survival rate for seminoma, stage 1?

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