PANCE Blueprint Genitourinary (5%)

Testicular cancer (Lecture)

Patient will present as → a 32-year-old male who noticed a mass on his right testicle while showering. He reports this has never happened before and denies any pain or discomfort. On physical examination, there is a firm and fixed mass on the left testicle. Bilateral scrotal ultrasound is performed and significant findings are seen here.

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What are the tumor markers for testicular tumors?

  1. Beta-human chorionic gonadotropin (βHCG)
  2. Alpha-fetoprotein (α-fetoprotein )

Presents as a firm, painless, nontender testicular mass

  • Most common solid tumor in young men ages 15-40 (average age 32 years old)
  • 5 year survival is 90% in most cases
  • Seminoma is the most common type (60%)
  • Risk factors include history of cryptorchidism

Diagnostic studies include

  • βHCG (+) and α-fetoprotein (+) in non seminoma germ cell tumors
  • Scrotal ultrasound
  • Radiologic studies to look for mets (common mets to belly, brain and lung)

Orchiectomy with or without chemotherapy and radiation depending on cell type.

  • Seminomatous tumors are radiosensitive and can be treated with radiation therapy
  • Nonseminomatous tumors are radioresistant
  • **Alpha fetoprotein (AFP) can be used to identify early relapse in testicular cancer?

Question 1
Which of the following is the most appropriate intervention for a stage I testicular seminoma?
A
Watchful waiting
Hint:
Surveillance is an option in stage I disease of a nonseminoma testicular tumor.
B
Chemotherapy initially
Hint:
Patients with stage IIC and stage III are treated with chemotherapy.
C
Orchiectomy and radiation
D
Orchiectomy and chemotherapy
Hint:
Chemotherapy is used for later stage tumors (II/III) and followed by surgery in stage III tumors.
Question 1 Explanation: 
Inguinal orchiectomy followed by retroperitoneal radiation therapy cures about 98% of patients with stage I seminoma.
Question 2
Which of the following increases the risk of developing testicular cancer?
A
Low socioeconomic status
Hint:
High socioeconomic status, not low, is a risk factor.
B
History of cryptorchidism
C
Multiple episodes of epididymitis
Hint:
Multiple episodes of epididymitis are unrelated to the development of testicular cancer.
D
Being of African-American ethnicity
Hint:
The incidence of testicular cancer is much lower in African-American men than in Caucasian men.
Question 2 Explanation: 
The major predisposing risk factor is cryptorchidism unrepaired until after age two.
Question 3
A 20 year-old male presents with a hard mass on the testicle. There has been no previous infection or trauma to the area. Which of the following is the initial diagnostic evaluation to pursue?
A
serum alpha fetoprotein levels
Hint:
Although tumor markers are useful to follow patients with testicular cancer, they are not used as the initial screen.
B
serum human chorionic gonadotropin hormone
Hint:
See A for explanation.
C
CT scan of the pelvis
Hint:
CT scanning of the pelvis is most commonly used in the evaluation for metastatic disease and not used in the initial screen for testicular cancer.
D
ultrasound of the testicles
Question 3 Explanation: 
An ultrasound of the testes will enable the clinician to discriminate between testicular tumors and epididymitis, orchitis, hematomas, hydroceles, and infiltrative diseases of the testes.
Question 4
A 28 year-old man comes to the office for his yearly follow up of testicular cancer. He was successfully treated with an orchiectomy two years ago. Which of the following tumor markers can be used to identify early relapse in testicular cancer?
A
Carcinoembryonic antigen (CEA)
Hint:
Carcinoembryonic antigen can be elevated in multiple conditions including colon cancer, gastritis, peptic ulcer disease, diverticulitis, liver disease, chronic obstructive pulmonary disease, and diabetes.
B
Prostate specific antigen (PSA)
Hint:
Prostate specific antigen is a sensitive marker for prostate cancer.
C
CA 125 glycoprotein
Hint:
CA 125 glycoprotein is a marker in epithelial ovarian cancer and can be used for post-treatment surveillance.
D
Alpha fetoprotein (AFP)
Question 4 Explanation: 
Periodic surveillance of alpha fetoprotein is a sensitive method for detecting early relapse of testicular cancer.
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