Σταδιοποίηση σε Ca Όρχεων

Ca Όρχεων

AJCC Stages

Stages

T

N

M

(S) Markers

0

pTis

N0

M0

S0

I

pT1-4

N0

M0

SX

IA

pT1

N0

M0

S0

IB

pT2

N0

M0

S0

pT3

N0

M0

S0

pT4

N0

M0

S0

IS

Any pT/TX

N0

M0

S1-3 (measured post orchiectomy)

II

Any pT/TX

N1-3

M0

SX

IIA

Any pT/TX

N1

M0

S0

Any pT/TX

N1

M0

S1

IIB

Any pT/TX

N2

M0

S0

Any pT/TX

N2

M0

S1

IIC

Any pT/TX

N3

M0

S0

Any pT/TX

N3

M0

S1

III

Any pT/TX

Any N

M1

SX

IIIA

Any pT/TX

Any N

M1a

S0

Any pT/TX

Any N

M1a

S1

IIIB

Any pT/TX

N1-3

M0

S2

Any pT/TX

Any N

M1a

S2

IIIC

Any pT/TX

N1-3

M0

S3

Any pT/TX

Any N

M1a

S3

Any pT/TX

Any N

M1b

Any S

(T) Primary Tumor

pTX

Primary tumor cannot be assessed (if no radical orchiectomy has been performed, TX is used)

pT0

No evidence of primary tumor (e.g., histologic scar in testis)

pTis

Intratubular germ cell neoplasia (carcinoma in situ)

pT1

Tumor limited to the testis and epididymis without vascular/lymphatic invasion; tumor may invade into the tunica albuginea but not the tunica vaginalis

pT2

Tumor limited to the testis and epididymis with vascular/lymphatic invasion, or tumor extending through the tunica albuginea with involvement of the tunica vaginalis

pT3

Tumor invades the spermatic cord with or without vascular/lymphatic invasion

pT4

Tumor invades scrotum with or without vascular/lymphatic invasion

Except for pTis and pT4, extent of primary tumor is classified by radical orchiectomy. For this reason, a pathologic stage is usually assigned. TX may be used for other categories in the absence of radical orchiectomy.

(N) Regional Lymph Nodes

Clinical

NX

Regional lymph nodes cannot be assessed

N0

No regional lymph node metastasis

N1

Metastasis with a lymph node mass ≤ 2 cm in greatest dimension; or multiple lymph nodes, none > 2 cm in greatest dimension

N2

Metastasis with a lymph node mass > 2 cm but ≤ 5 cm in greatest dimension; or multiple lymph nodes, any 1 mass > 2 cm but ≤ 5 cm in greatest dimension.

N3

Metastasis with a lymph node mass > 5 cm in greatest dimension

Pathological

pNX

Regional lymph nodes cannot be assessed

pN0

No regional lymph node metastasis

pN1

Metastasis with a lymph node mass ≤ 2 cm in greatest dimension and ≤ 5 nodes positive, none > 2 cm in greatest dimension

pN2

Metastasis with a lymph node mass > 2 cm but ≤ 5 cm in greatest dimension; or > 5 nodes positive, none > 5 cm; or evidence of extranodal extension of tumor

pN3

Metastasis with a lymph node mass > 5 cm in greatest dimension

(M) Distant Metastasis

M0

No distant metastasis

M1

Distant metastasis

M1a

No regional nodal or pulmonary metastasis

M1b

Distant metastasis other than to nonregional lymph nodes and lungs

Serum Tumor Markers (S)

SX

Tumor marker studies not available or not performed

S0

Tumor marker study levels within normal limits

S1

LDH < 1.5x normal and β-hCG < 5,000 IU/L and AFP < 1,000 ng/mL

S2

LDH 1.5-10x normal or β-hCG 5,000-50,000 IU/L or AFP 1,000-10,000 ng/mL

S3

LDH >10x normal or β-hCG > 50,000 IU/L or AFP > 10,000 ng/mL

Serum tumor markers are used as part of tumor stage grouping in testicular cancer. LDH = lactate dehydrogenase, hCG = human chorionic gonadotropin, AFP = α-fetoprotein.

Χαρακτηριστικά Επέκτασης

Direct extension

• Through tunica albuginea with involvement of scrotal skin is rare and late finding

Lymphatic spread

• Most germ cell tumors spread 1st via lymphatics rather than hematogenously
  • Choriocarcinoma is notorious for early hematogenous spread
• Lymphatic involvement occurs in predictable step-wise fashion
• Right testis → right-sided nodes around inferior vena cava (IVC) (most commonly lower retroperitoneal, aortocaval, or paracaval)
• Left testis → left paraaortic nodes in area bounded by renal vein, aorta, ureter, and inferior mesenteric artery
• If seen as only site of metastasis, histological proof of tumor involvement should be sought prior to instituting therapy
• In absence of bulky ipsilateral adenopathy, contralateral spread is unusual
• Pattern is seen in 2 groups of patients
  • Lymphatic disruption from prior scrotal or inguinal surgery
  • Tumor-contaminated scrotum
• If patient did not have scrotal or inguinal surgery, nor scrotal invasion or contamination
• Inguinal nodes are then considered nonregional (M1 disease)
• With seminoma, spread of disease above diaphragm may occur via thoracic duct into posterior mediastinum
• With nonseminomatous germ cell tumor (NSGCT), spread is more random involving anterior mediastinum, aortopulmonary window, hilar, supraclavicular, and neck lymph nodes
  • Excludes posterior mediastinum and subcarinal regions
• Pelvic adenopathy is uncommon in absence of bulky disease elsewhere
• Inguinal lymph node metastases from testicular tumors are reported in 2% of cases, primarily to ipsilateral inguinal nodes
• Nodal disease superior to level of renal hila occurs via direct spread

Hematogenous spread

• Occurs late, except in case of choriocarcinoma
• Lung is most common location (89%); other sites include liver (73%), brain (31%), bone (30%), kidney (30%), and adrenal (29%)

Κατηγοριοποίηση (Ιστολογικοί Τύποι)

Germ cell tumors constitute 95% of all testicular tumors

• Intratubular germ cell neoplasia, unclassified
• Malignant pure germ cell tumor (showing single cell type)
  • Seminoma
  • Embryonal carcinoma
  • Teratoma
  • Choriocarcinoma
  • Yolk sac tumor
• Malignant mixed germ cell tumor (showing > 1 histologic pattern)
  • Embryonal carcinoma and teratoma ± seminoma (teratocarcinoma)

• Embryonal carcinoma and yolk sac tumor ± seminoma
• Embryonal carcinoma and seminoma
• Yolk sac tumor & teratoma ± seminoma
• Choriocarcinoma and any other element

• Polyembryoma

Sex cord and stromal tumors

• Leydig cell tumor
• Sertoli cell tumor
• Granulosa cell tumor
• Fibroma-thecoma

Tumors with both sex cord and stromal cells and germ cells

• Gonadoblastoma