Testicular

== Trials ==

Epidemiology

General

Risk Factors

Presentation and Evaluation

Anatomy

Pathology

Clinical Presentation

  • typically presents as a painless mass in the testis
  • although many patients have
    • diffuse pain
    • swelling,
    • hardness in the scrotum

Routes of Spread

Diagnostic Studies

  • scrotal ultrasound to determine whether the mass is intra- or extratesticualr. (first)
  • Labs (second)
    • alph fetoprotein
    • β-hCG
    • LDH
  • Imaging (third)
    • CT of the C/A/P
  • Pathology
    • radical inguinal orchiectomy,
    • includes removal of the testicle and spermatic cord.

Contralateral testis biopsy

  • 5% of patient have TIN of the contralateral testis
  • but patients with testicular volumes <12 ml and an age <30 years the risk of TIN in the contralateral testis is >34%
  • In patients with TIN, the cumulative probability for the development of a testicular tumour is 70% after 7 years

Staging

T-Stage

T1 limited to testis and epididymis & LVI(-)
T2 limited to testis and epididymis & LVI(+) - OR -
involves tunica vaginalis
T3 invades spermatic cord
T4 invades scrotum

N Stage

N1 LN(s) ≤ 2 cm
N2 LN(s) 2-5 cm
N3 LN(s) > 5 cm
  • Lymphnodes upto para-aortic are considered regional

Stage Group

IA T1 N0
IB T2+ N0
IIA anyT N1
IIB anyT N2
IIC anyT N3
III M1

Stage I

Prognostic Factors

2 most important prognostic factors for relapse in stage I patients on surveillance are:[4]

  • tumor > 4 cm
  • rete testis invasion
# of adverse prognostic factors* Relapse rate p-value
0 12.2%
1 15.9% < .01
2 31.5% < .01

Treatment Options

Initial Treatment

treatment1

Treatment for recurrence

recurrence

Surveillance

  • exam q4 month for 2 years
    • PE
    • Labs
    • CT a/p
    • CXR
  • exam q6 months for 2 more years
  • exam yearly for years 5-10

Chemotherapy

  • carboplatinum AUC7 (7x[glomerular filtration rate+25] mg)
  • followup like Surveillance

Radiation

Field

paraaortic
PARA-AORTIC FIELD
  • T11/T12 TO L5
  • LT Hilum covered for Lt. sided tumor
  • ~ 10 cm wide field
  • Given a pelvic relapse rate of 2%, para-aortic field is routinely given

Dose

  • 20 Gy, 2.0 Gy/fx[5]

Followup

  • HP & Labs q4 months 1st year
    • Labs: alph fetoprotein, β-hCG & LDH
  • HP & Labs q6 months 2nd year
  • HP & Labs q12 months 3+ years
  • If pelvic nodes are not treated, CT of pelvis year for 3 years.

Stage II

  • In stage IIA/B seminoma, radiotherapy continues to provide excellent results, as the majority of patients will be cured with this treatment alone.
  • Chemotherapy (BEP x 3) is the treatment of choice for stage IIC seminoma.

Radiation

dogleg
DOG-LEG FIELD
  • T9/T10 to just above obturator foramen
  • 30 Gy in 2 Gy/fx for IIA
  • 36 Gy in 2 Gy/fx for IIB
    • 26 Gy is typically delivered to an initial volume
    • boost of 10 Gy is given to nodal mass with margin
  • use testicular shield
  • 3 month post-RT CT of abdomin and pelvis to document treatment effect

== Trials ==

Bibliography
1. Cox J, Ang K. Radiation Oncology: rationale Technique Results. 8th ed. New York: Mosby, 2003.
2. Gunderson L, Tepper J: Clinical Radiation Oncology. 2nd ed. China: Elsevier 2007.
3. Devita V, Hellman S, Rsenberg S: Cancer: Principles and practice of Oncology. 7th ed. Philadelphia. Lippincott, 2005.
4. Warde P, Specht L, Horwich A, Oliver T, Panzarella T, Gospodarowicz M, von der Maase H. Prognostic factors for relapse in stage I seminoma managed by surveillance: a pooled analysis. J Clin Oncol. 2002 Nov 15;20(22):4448-52. PMID: 12431967
5. Jones WG, Fossa SD, Mead GM et al. A randomised trial of two radiotherapy schedules in the adjuvant treatment of stage I seminoma
(MRC TE 18). Eur J Cancer 2001; 37 (Suppl 6): S157 (Abstr 572) (EBM IB).
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