Genitourinary Cancer – 1
(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Thank you Chiragbhai for salient points about several uncommon but very important cancers: borderline tumor of ovary, gestational trophoblastic disease (cancers of placental tissue), germ cell tumors of ovary, sex cord stromal tumors of ovary, and cancer of vulva.
What is the next cancer we are going to discuss?
Answer: Now we will go to next important category i.e. cancers of genitourinary tract – GU cancers. We have already discussed cancers of female genital tract. Major cancers in GU category include those of prostate, bladder, kidney, ureter, and testis.
Commonest is prostate in this category, But we will start our discussion with the least common i.e. testis. Why so? Because cure rates in this tumor are the highest, in fact, probably the highest among all cancers in body. For the same reasons, during our oncology training, we had a very strong emphasis on this cancer. Testicular cancer treatment is one of the early triumphs of medical oncology, with dramatic results, and cure possible in majority of stage 4 cancers too. Once again, you may note that there are several cancers where even in stage 4 good results are possible, including cure. We have earlier discussed several such examples. You can add one more cancer to that list. It has very high cure rates, but at the same time, it is very fast growing in most cases. Hence if not diagnosed timely, it can kill as well. Due to this quality, and because diagnosis can be almost certainly established by tumor markers also, this is one cancer where it is allowed to give first dose of chemotherapy even while waiting for biopsy results.
Que: Wow! These are some very interesting points in the beginning itself. Please tell us more about this cancer. What is important for our readers to know.
Ans: Germ cell tumors arise mostly in testis.
However about 5-10% of these arise in mediastinum or retroperitoneum. Retroperitoneal tumors generally have an occult or obvious testicular tumor too. Germ cell tumors can rarely arise from other midline sites anywhere in body.
Famous cricketer Yuvraj Singh had mediastinal germ cell tumor, seminoma type.
About 95-98% of testicular germ cell tumors are cured in USA. Incidence of this tumor is rising for last two decades. Known risk factors include family history, cryptorchidism (congenital undescended testis), HIV, Klienfelter’s syndrome. Interestingly, if a child is identified with undescended testis, and his testis is brought into scrotum by a surgery in childhood, his chance of developing cancer reduces remarkably.
Most of the time, patient presents with a painless mass in scrotum. Hence just like we have seen with other cancers, painless lump actually should be investigated more urgently as possible sign of cancer. Occasionally however there may be pain.
Uncommon presentations include back pain from retroperitoneal mass or nodes, chest symptoms or other symptoms based on site of spread. In advance stages, it can also spread to brain.
Diagnostic procedure is very different compared to other cancer sites in general. Here if cancer is suspected based on sonography findings, biopsy requires removal of total testis of that side by an experienced urologist, with a procedure known as High Inguinal Orchidectomy or Radical inguinal orchidectomy. Trans scrotal biopsy must not be done. This will increase risk of disease spread and will increase stage.
Biopsy provides important histology details. There are two main types: Seminoma, Nonseminoma. Non seminoma is more aggressive, and includes various histologies: embryonal carcinoma, yolk sac tumor, choriocarcinoma, teratoma. Non seminoma tumors may have more than one of these histologies in one patient. Also, it may have component of seminoma.
Apart from biopsy, blood tests have a very important role in diagnosis, staging, prognosis, deciding treatment plan and follow up. These include AFP (alfa feto protein), beta HCG, and LDH. LDH is not very specific but has important value in initial disease assessment. AFP level is critical, since if it is high, it means presence of NONSEMINOMA component, even if not detected in biopsy. Treatment plan for seminoma and nonseminoma has important differences.
Next time we will talk about staging and some parts of treatment.
October 11th 2017.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org