Past and personal history ปฏิเสธ DM and HT No family of malignancy Smoking 1 pack-year Alcohol drinking
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
Problem lists Pelvic mass DVT History Cryptorchidiasm
Male pelvic anatomy
PELVIC MASS Bladder Ureters Skeletal muscle Bone Lymph node GI - 1 lymphoma - Metastatic Lymph node - CA colon - CA rectum - CA Bladder
Paraaortic lymph node receive drainage from the lower gastrointesti nal tractgastrointesti nal tract and the pelvic organspelvic
History of undescented testis
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
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.
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
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
Testicular Seminoma 75% are localized (stage I) at diagnosis 15% metastatic to regional lymph nodes 5-10% juxtaregional nodes or visceral metastases Testicular Seminoma
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.
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
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
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
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
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.
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
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.
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
–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
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
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
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
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
StageExtend of disease Treatment seminomaNon seminoma IIIDistance metastasis CMTCMT,often followed by surgery(biop sy or resection) Germ cell tumor staging and treatment