4 Past and personal history ปฏิเสธ DM and HTNo family of malignancySmoking 1 pack-yearAlcohol drinking
5 Physical examinationImpalpable cervical and supraclavicular lymph nodesRt. Lower abdominal bulging and mass size 10 x 10 cms, firm consistency, smooth surface not tenderPalpable bilateral groin nodesSwelling and pitting edema both legs
6 Problem listsPelvic massDVTHistory Cryptorchidiasm
11 Causes : Cryptorchidiasm ↑ risk of testis cancer 10 – 40x10% GCTs have a history of cryptorchidismRisk is greater for the abdominal VS inguinal undescended testis.Abdominal testis is more likely to be seminomaTestis surgically brought to the scrotum by orchiopexy is more likely to be NSGCT
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 CIStesticular microcalcifications observed on scrotal ultrasonographic studies may suggest CIS.
19 History Common presentation male aged 15-35 years chronic painless testicle lumpsemen analysis : may be subfertilehydrocele, and scrotal ultrasonography may identify a nonpalpable testis tumorThe 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, ordelay treating for presumed epididymoorchitis or testicular trauma
21 Testicular Seminoma 75% are localized (stage I) at diagnosis 15% metastatic to regional lymph nodes5-10% juxtaregional nodes or visceral metastasesTesticular Seminoma
22 Uncommon presentation Acute testicular pain, associated with hydroceleTestis tumor : metastatic and manifest with large retroperitoneal and/or chest lesionsBurned-out testis cancerSeries of patients with previous nonpalpable testes that were incorrectly diagnosed as vanished testes. A subsequent seminoma was diagnosed intra-abdominallyMiller et al, 1996.
23 Causes Orchiopexy earlier detection by physical examination but not alter the risk of GCT.Genetic : 12p11.2-p12.112p : invasive growth of both seminomas and NSGCTschromosome 9 : spermatocytic seminomainfantile yolk sac tumors and teratomas : no chromosomal changesOther risks include trauma, mumps, and maternal estrogen exposure
24 Lab Studies Yolk sac elements secrete AFP : Nonseminoma Lactate dehydrogenase (LDH) :less-specific marker for GCTsbut 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-lifesecreted by syncytiotrophoblast cells within GCTs.5-10% seminomas, its elevation may correlate with metastatic diseaseIf 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 massacute scrotal pain (especially when associated with a hydrocele), nonspecific scrotal pain, swelling, or the presence of a massasymptomatic 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 Imaging StudiesCT scanning of the abdomen and pelvis with IV and oral contrast : identify metastatic disease to the retroperitoneal lymph nodesChest CT scanning : indicated only when abnormal findings are observed on a chest radiograph
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.
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 External beam radiation therapy for stage I and nonbulky stage II disease3% : relapse after radiation therapyShort-term adverse effects : fatigue, nausea, vomiting, and GI upset.Secondary malignancies are rarely reported
33 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
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 Germ cell tumor staging and treatment stageExtent of diseaseTreatmentseminomanonseminomaIATestis only,no vascular/lymphatic invasion(T1)RadiationRPLND or observationIBTestis only,with vascular/lymphatic invasion(T2)or involve spermatic cord(T3) or scrotum(T4)RPLND
36 Germ cell tumor staging and treatment StageExtend of diseaseTreatmentseminomaNon seminomaIIANode <2 cmRadiation therapyRPLND+/-CMTIIBNode2-5cmRadiationRPLND+/-adjuvant CMTIICNode>5 cmCMTCMT followed by RPLND
37 Germ cell tumor staging and treatment StageExtend of diseaseTreatmentseminomaNon seminomaIIIDistance metastasisCMTCMT,often followed by surgery(biopsy or resection)
38 CASE : BEP regimen Bleomycin Cisplatin Etoposide Antitumor antibiotics MucositisFeverSkin changeNo myelosuppression And N/VCisplatinAlkylating agentsN/VnephrotoxicityEtoposideTopoisomerase inhibitorMyelosuppressionN/VAlopeciaMucositisHypersensitivityHypotensionSecond leukemia
39 Young male with cryptorchidiasm Pelvic massElevate b hCGTesticular seminoma stge IIcBEP regimen