Interesting case

1
Interesting case

• Presented by
• Kosin Wirasorn,MD.

2
Case ????????? ???? 37 ?? ????? ????

• ??????????? 5 ????????????????????
• ????????????????????????????????
  ????????????????????? 10 ??. ?????????????????????
  ????? ????????????????????? ??????????????????????
  ? ????????????????????????????????????????????????
  ??????????????

3
Past history

• ??????????????????????????????????????????
• 3 ????????????????? ??????????????????????????????
  ?????? ?????????????????????????
  ??????????????????? ??? ????????? ?????????
  ???????
• 2 ????????????????? ????????????? ???
  ???????????????????? ???????????????????????????
  ??? ?????????? ?????????????????????? admit
  ??.????????? ??? Rt. radical orchidectomy
  pathologic report seminoma ??????????????????

4
Past and personal history

• ?????? 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
Skeletal muscle
Bladder
GI
Lymph node
Ureters
Bone
- 1 lymphoma - Metastatic Lymph node
- CA colon - CA rectum
- CA Bladder
9
Paraaortic lymph node
receive drainage from the lower gastrointestinal
tract and the pelvic organs
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/mm3
• PMN 79 Lympho 13.5 Mono 4.7 Eos 2.6 Baso 0.2
• Plt 338,000 /mm3
• 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 1.331
• 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 15-35 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
Causes

• 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

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 (ß-hCG)

• glycoprotein with the same a-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
Imaging Studies

• 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

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
External beam radiation therapy for stage I and
nonbulky stage II disease

• 3 relapse after radiation therapy
• Short-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
36
Germ cell tumor staging and treatment
37
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
Pelvic mass
Elevate b hCG
Testicular seminoma stge IIc
BEP regimen