งานนำเสนอกำลังจะดาวน์โหลด โปรดรอ

งานนำเสนอกำลังจะดาวน์โหลด โปรดรอ

Interesting case Presented by Kosin Wirasorn,MD..

งานนำเสนอที่คล้ายกัน


งานนำเสนอเรื่อง: "Interesting case Presented by Kosin Wirasorn,MD.."— ใบสำเนางานนำเสนอ:

1 Interesting case Presented by Kosin Wirasorn,MD.

2 Case ชายไทยคู่ อายุ 37 ปี อาชีพ ทำนา ปวดแน่นท้อง 5 เดือนก่อนมา โรงพยาบาล ปวดแน่นท้องบริเวณท้องน้อยตรง กลาง ร่วมกับคลำได้ก้อนขนาด 10 ซม. ปวดไม่สัมพันธ์กับมื้ออาหาร อุจจาระและปัสสาวะปกติ บางทีปวด กลางคืนร่วมด้วย มีอาการปวดร้าวไปที่ กระเบนเหน็บร่วมกับปวดหลังด้านขวา มากกว่าซ้าย

3 Past history ผู้ป่วยมีอัณฑะข้างเดียวด้านซ้ายตั้งแต่เด็ก 3 ปีก่อนมาโรงพยาบาล สังเกตพบก้อน ขนาดนิ้วหัวแม่มือด้านขวา ก้อนสามารถ เลื่อนขึ้นลงได้ ก้อนมักจะโผล่เวลาไอ จาม ยกของหนัก ก้อนนิ่มๆ ไม่เจ็บ 2 ปีก่อนมาโรงพยาบาล ก้อนเริ่มแข็ง และ โตขึ้นขนาดเท่าไข่ไก่ ดันกลับเข้าในช่อง ท้องไม่ได้ และ ปวดมากขึ้น ไม่มีอาเจียน และท้องผูก admit รพ. มหาสารคาม ได้ Rt. radical orchidectomy pathologic report : seminoma ติดตามการรักษา ตลอด

4 Past and personal history ปฏิเสธ DM and HT No family of malignancy Smoking 1 pack-year Alcohol drinking

5 Physical examination Impalpable cervical and supraclavicular lymph nodes Rt. Lower abdominal bulging and mass size 10 x 10 cms, firm consistency, smooth surface not tender Palpable bilateral groin nodes Swelling and pitting edema both legs

6 Problem lists Pelvic mass DVT History Cryptorchidiasm

7 Male pelvic anatomy

8 PELVIC MASS Bladder Ureters Skeletal muscle Bone Lymph node GI - 1 lymphoma - Metastatic Lymph node - CA colon - CA rectum - CA Bladder

9 Paraaortic lymph node receive drainage from the lower gastrointesti nal tractgastrointesti nal tract and the pelvic organspelvic

10 History of undescented testis

11 Causes : Cryptorchidiasm ↑ risk of testis cancer 10 – 40x 10% GCTs have a history of cryptorchidism Risk is greater for the abdominal VS inguinal undescended testis. Abdominal testis is more likely to be seminoma Testis surgically brought to the scrotum by orchiopexy is more likely to be NSGCT

12 CBC Hb 8.3, Hct 27% WBC 9,780 cells/mm 3 PMN 79 Lympho 13.5 Mono 4.7 Eos 2.6 Baso 0.2 Plt 338,000 /mm 3 MCV 62, RDW 26

13 Blood chem and LFT BUN/Cr 18.4 /1.3 mg/dL Cholesterol 179 Albumin 2.2 Globulin 5.5 TB 0.6 DB 0.2 ALT 27 AST 60 ALP 240 GGT 154

14 Tumor marker Beta hCG 4.73 AFP 1.16 PSA 0.083

15 Other D dimer Hepatitis profile: negative

16 Progression Plain KUB : Rt. renal calculi with hydronephrosis CT whole abdomen : enlarge paraaotic lymp node with compression to IVC and Rt. renal vein Groin node biopsy : reactive hyperplasia

17 Testicular GCTs seminoma (40%)embryonal (25%) teratocarcinoma (25%) teratoma (5%) choriocarcinoma (pure) (1%)

18 Germ cell carcinoma in situ (CIS) premalignant of seminoma or embryonal cancer. infertility, intersex disorders, cryptorchidism, prior contralateral GCTs, or atrophic testes more commonly have CIS testicular microcalcifications observed on scrotal ultrasonographic studies may suggest CIS.

19 History Common presentation –male aged years –chronic painless testicle lump –semen analysis : may be subfertile –hydrocele, and scrotal ultrasonography may identify a nonpalpable testis tumor –The testicular lump, nodule, or mass

20 Delay in diagnosis patient's failure to perform self- examinations, patient's failure to alert the physician about the mass, or delay treating for presumed epididymoorchitis or testicular trauma

21 Testicular Seminoma 75% are localized (stage I) at diagnosis 15% metastatic to regional lymph nodes 5-10% juxtaregional nodes or visceral metastases Testicular Seminoma

22 Uncommon presentation Acute testicular pain, associated with hydrocele Testis tumor : metastatic and manifest with large retroperitoneal and/or chest lesions Burned-out testis cancer Series of patients with previous nonpalpable testes that were incorrectly diagnosed as vanished testes. A subsequent seminoma was diagnosed intra-abdominally Miller et al, 1996.

23 Orchiopexy –earlier detection by physical examination –but not alter the risk of GCT. Genetic : 12p11.2-p12.1 –12p : invasive growth of both seminomas and NSGCTs –chromosome 9 : spermatocytic seminoma –infantile yolk sac tumors and teratomas : no chromosomal changes Other risks include trauma, mumps, and maternal estrogen exposure Causes

24 Lab Studies Yolk sac elements secrete AFP : Nonseminoma Lactate dehydrogenase (LDH) : –less-specific marker for GCTs –but levels can correlate with overall tumor burden. Placentalike alkaline phosphatase : –elevated in seminoma, especially tumor burden increases; –also increase with smoking

25 beta-human chorionic gonadotropin ( β- hCG) glycoprotein with the same α- unit as TSH, FH, and LH. 24-hour half-life secreted by syncytiotrophoblast cells within GCTs. 5-10% seminomas, its elevation may correlate with metastatic disease If bHCG levels do not normalize after orchiectomy, suggests treat as NSGCT

26 Imaging Studies Scrotal ultrasonography consider for any male with a suspicious or questionable testicular mass acute scrotal pain (especially when associated with a hydrocele), nonspecific scrotal pain, swelling, or the presence of a mass asymptomatic hydrocele obscures physical examination of the testicleScrotal ultrasonography commonly shows a homogeneous hypoechoic intratesticular mass. Larger lesions may be more inhomogeneous. calcifications and cystic less common in seminomas than in nonseminomatous tumors

27 Scrotal ultrasonography Testicular seminoma. This scrotal ultrasound of a 37-year-old man with a painless mass in his right testis shows a right testis with hypoechoic solid masses compared to the homogeneous, more hyperechoic, healthy left testis.

28 CT scanning of the abdomen and pelvis with IV and oral contrast : identify metastatic disease to the retroperitoneal lymph nodes Chest CT scanning : indicated only when abnormal findings are observed on a chest radiograph Imaging Studies

29 CT scanning of the abdomen Testicular seminoma. A 57-year-old man presents with abdominal pain of slow onset. CT scanning shows a large 25-cm retroperitoneal lesion encompassing the aorta and renal vasculature and displacing the right kidney laterally. history of cryptorchidism repaired at age 8 years.

30 Histologic Findings: Classic seminoma Anaplastic seminoma Spermatocytic seminoma Classic seminoma

31 External beam radiation therapy for stage I and nonbulky stage II disease –2500 cGy hockey-stick field( the para- aortic, paracaval, bilateral common iliac, and external iliac nodal regions) –Recent protocols are reducing the radiation field to the para-aortic area only. –A compared adjuvant radiotherapy at 30 Gy versus 20 Gy for stage I seminoma. The lower dose had equivalent associated relapse rates and reduced morbidity, especially regarding fatigue. Medical Research Council,2005

32 –3% : relapse after radiation therapy –Short-term adverse effects : fatigue, nausea, vomiting, and GI upset. –Secondary malignancies are rarely reported External beam radiation therapy for stage I and nonbulky stage II disease

33 The Medical Research Council compared adjuvant carboplatin with radiotherapy and found equivalent relapse rates after a median follow-up period of 4 years. Long-term success of carboplatin therapy is unknown so should be considered experimental at this time (Oliver, 20 External beam radiation therapy for stage I and nonbulky stage II disease

34 Chemotherapy for stage II bulky or stage III disease Clinical trials have evaluated numerous chemotherapeutic regimens. While the optimal regimen is debatable, 4 cycles of bleomycin, etoposide, and cisplatin (BEP) is standard. Ongoing clinical trials are evaluating the omission of the fourth cycle, or bleomycin, in good-risk patients. For poor-risk and salvage cases, physicians may use alternative regimens using ifosfamide and vinblastine with dose escalation

35 stageExtent of diseaseTreatment seminomanonsemino ma IATestis only,no vascular/lymphatic invasion(T1) RadiationRPLND or observatio n IBTestis only,with vascular/lymphatic invasion(T2)or involve spermatic cord(T3) or scrotum(T4) RadiationRPLND Germ cell tumor staging and treatment

36 StageExtend of disease Treatment seminomaNon seminoma IIANode <2 cmRadiation therapy RPLND+/- CMT IIBNode2-5cmRadiationRPLND+/- adjuvant CMT IICNode>5 cmCMTCMT followed by RPLND Germ cell tumor staging and treatment

37 StageExtend of disease Treatment seminomaNon seminoma IIIDistance metastasis CMTCMT,often followed by surgery(biop sy or resection) Germ cell tumor staging and treatment

38 CASE : BEP regimen Bleomycin –Antitumor antibiotics –Mucositis –Fever –Skin change –No myelosuppression And N/V Cisplatin –Alkylating agents –N/V –nephrotoxicity Etoposide –Topoisomerase inhibitor –Myelosuppression –N/V –Alopecia –Mucositis –Hypersensitivity –Hypotension –Second leukemia

39 Young male with cryptorchidiasm Elevate b hCG Pelvic mass Testicular seminoma stge IIc BEP regimen


ดาวน์โหลด ppt Interesting case Presented by Kosin Wirasorn,MD..

งานนำเสนอที่คล้ายกัน


Ads by Google