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PostPosted: 26 Feb 2020 19:39 
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TESTICULAR TUMOR CLASSIFICATION

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GCT TESTIS/ SEMINOMA OVERVIEW
• Seminoma and non-seminomatous tumors come under germ cell tumors
• The overall incidence of testicular germ cell tumors is only 1% to 2% of all cancers in men; however, it is the most common malignancy in males between 15-45 years
• Testicular cancer is ten times more common in northern European ancestry and five times more common in Caucasians compared to races.
• They are highly responsive to chemotherapy in comparison to the other testicular cancers
• Seminoma accounts for about one third of all testicular germ tumors and highly treatable with a survival rate of 98% to 99% if diagnosed early
• Subtypes of seminoma include classic seminoma (95% cases) occurring in men 45 years or older and spermatocytic seminoma occurring in older men and having excellent prognosis

ETIOLOGY & RISK FACTORS OF SEMINOMA
• Risk of seminoma increases with age
• Most recent theory suggests that environmental endocrine disrupters exert estrogenic and/or anti-androgenic effects, resulting in arrested development of the gonadal cells
• Seminoma probably starts as carcinoma in situ during intrauterine growth phase. A widely accepted hypothesis is Testicular Dysgenesis syndrome (TDS).
• TDS includes hypospadias, cryptorchism, germ cell tumors, and impaired spermatogenesis due to reports that all these conditions share common risk factors starting as early as the fetal stage.
• Approximately 10% of all patients with germ cell tumors report history of cryptorchism.
• Aircraft maintenance personnel, farmers and firefighters exposed to organochloride pesticides seem to have a higher risk of developing testicular cancer.

SYMPTOMS AND SIGNS OF SEMINOMA
• The most common presentation is an asymptomatic painless testicular mass, although presence of pain doesn’t exclude diagnosis of seminoma
• Since testicular cancers occur can reduce spermatogenesis, infertility may be the presenting symptom in some cases
• Serious, acute pain may occur with rapid tumor growth, associated with hemorrhage or infarction (if the tumor outgrows its blood supply)
• Physical examination usually reveals unilateral, firm to hard palpable scrotal mass which is localized to the testis.
• Bulky retroperitoneal lymphadenopathy can produce an abdominal mass. Lung metastases can present as cough, chest pain, and shortness of breath
• The diagnosis is confirmed by imaging, typically with an ultrasound test initially

DIFFERENTIAL DIAGNOSIS
• Non-seminomatous germ cell tumors
• Testicular dermoid cyst
• Testicular secondaries from other primary
• Trauma

DIAGNOSIS
IMAGING TESTS
• The initial evaluation is by testicular ultrasound. Several studies have reported that non-palpable, asymptomatic masses that are 2 cm or lesser in size are more likely to be benign tumors. Benign lesions may include testicular cysts or tiny Leydig cell or Sertoli cell tumors.
X-ray chest is advised to rule out lung metastasis
• A CT scan of the abdomen and pelvis performed to stage the disease and to demonstrate abdominal or retroperitoneal lymphadenopathy
• PET scanning is generally done as part of the initial workup but is useful to assess response to treatment

STAGING OF TESTICULAR CANCER
• Stage 0 – Cancer that is within testis and confined within epithelium (testicular intraepithelial neoplasia)
• Stage 1 – Tumor confined to testis
1A – Localized to testis without lymphovascular invasion
1B Localized to testis with associated lymphovascular invasion
• Stage 2 – regional spread to retroperitoneal lymph nodes
• Stage 3 – Distant spread to lungs, brain or lymph nodes of chest and neck

BLOOD TESTS
• Several laboratory values are done to assess and follow-up tumor burden. These include beta human chorionic gonadotropin and alpha fetoprotein, and LDH. Alpha-fetoprotein (AFP) elevation indicates at least some non-seminomatous disease and those patients are then treated as non-seminomatous GCT patients.
• Beta-human chorionic gonadotropin (HCG) is present in 5% to 10% of seminoma cases and tend to be associated with metastatic disease but levels have no prognostic value or impact on overall survival rates
Lactate dehydrogenase (LDH) are measured to assess and follow-up tumor bulk post treatment.

TREATMENT OF SEMINOMA TESTIS
Treatment of testicular seminoma depends on the stage of the disease but surgery, a radical orchiectomy (removal of testis), is almost always the primary intervention.

TESTICULAR EPITHELIAL NEOPLASIA
• Radiation therapy
• Follow-up
• Orchiectomy

STAGE I SEMINOMA
• Orchiectomy followed by surveillance.
• Patients who opt for active treatment rather than surveillance, the treatment consists of surgery to remove the testis, followed by chemotherapy

STAGE II SEMINOMA
● When the tumor measures 5 centimeters or lesser in size:
 Orchiectomy, followed by radiation to lymph nodes in the abdomen and pelvis.
 Combination chemotherapy.
 Surgery to remove the testicle and lymph nodes in the abdomen.

● When the tumor is larger than 5 centimeters:
 Orchiectomy, followed by radiation to lymph nodes in abdomen and pelvis or combination chemotherapy with long-term follow-up.

STAGE III SEMINOMA
• Radical orchiectomy followed by combination chemotherapy. If there are tumors remaining after chemotherapy, following modalities can be considered
• PET surveillance with no treatment unless tumors grow
• Surveillance if tumor measures less than 3 centimeters and surgical removal of tumors larger than 3 centimeters.
• A PET scan two months after chemotherapy and surgery to remove tumors that appear on the scan.
• A clinical trial of chemotherapy

PROGNOSIS
The overall survival rate is greater than 95%. If diagnosed early, when the cancer is confined to the testicle, the survival rate is 99%. If the cancer has spread to regional lymph nodes the survival rate is 96% and even in the presence of distant metastases the survival rate is more than 70%."


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