This document provides information about testicular cancers, including:
- Testicular cancer accounts for 1% of cancers in males and is highly curable when detected early, often affecting young men.
- The testis has blood supply from the testicular artery and drains into the pampiniform plexus and internal spermatic veins. Lymphatic drainage is to retroperitoneal lymph nodes.
- The majority (95%) are germ cell tumors, including seminomas and non-seminomas. Staging involves tumor markers, imaging scans, and lymph node dissection. Treatment depends on the type and stage but may include surgery, chemotherapy, and radiation therapy.
Testicular tumors are rare.
1 – 2 % of all malignant tumors.
Most common malignancy in men in the 15 to 35 year age group.
Benign lesions represent a greater percentage of cases in children than in adults.
Most curable solid neoplasm
Testicular tumors are rare.
1 – 2 % of all malignant tumors.
Most common malignancy in men in the 15 to 35 year age group.
Benign lesions represent a greater percentage of cases in children than in adults.
Most curable solid neoplasm
Disclaimer: A lot from this slides were taken also from https://www.slideshare.net/babysurgeon/scrotal-swellings-1 (Dr Selvaraj Balasubramani)
This covers only :
ANATOMY
CAUSES
TORSION OF TESTIS
EPIDIDYMO-ORCHITIS
HYDROCELE
EPIDIDYMAL CYST
VARICOCELE
Disclaimer: A lot from this slides were taken also from https://www.slideshare.net/babysurgeon/scrotal-swellings-1 (Dr Selvaraj Balasubramani)
This covers only :
ANATOMY
CAUSES
TORSION OF TESTIS
EPIDIDYMO-ORCHITIS
HYDROCELE
EPIDIDYMAL CYST
VARICOCELE
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
2. Overview
Cancers of testis are relatively rare cancer accounting for approx. 1 % cancer in
males.
However it is important in field of oncology as it represents a highly curable
neoplasm & the incidence is focused on young patients at their peak of
productivity
3. Anatomy
• The testis is the male gonad.
• It is homologous with the ovary in female.
• It lies obliquely within the scrotum suspended by
the spermatic cord
• The left testis is slightly lower than the right
• Shape: Oval
• Size:3.75 cm long, 2.5 cm broad, 1.8 cm thick
• Weight: about 10-15 gm.
• Has 2poles , 2surface, 2 borders
4. Skin
DARTOS Muscle
External Spermatic Fascia
Cremastric Muscle
Internal Spermatic Fascia
Tunica Vaginalis
Tunica Albuginea
Coverings of testis
5. Blood Supply
Areterial supply
• The testicular artery branch of abdominal aorta .
• The testis has collateral blood supply from
1. the cremasteric artery
2. artery to the ductus deferens
Venous drainage
• The veins emerge from the back of the testis, and receive
tributaries from the epididymis;
• they unite and form convoluted plexus, called the
pampiniform plexus.
• plexus to form a single vein, which opens, on the right side,
into the inferior vena cava ,on the left side into the left
renal vein
6. Lymphatic Drainage
Drain into the retroperitoneal lymph glands between the
levels of T11 and L4, but they are concentrated at the level
of the L1 and L3 vertebrae
Lymph nodes located lateral or anterior to the inferior
vena cava are called paracaval or precaval nodes,
respectively.
Interaortocaval nodes are located between the inferior
vena cava and the aorta.
Nodes anterior or lateral to the aorta are preaortic or para-
aortic nodes, respectively
7. On the right:
Interaortocaval region, followed by the paracaval, preaortic, and para-
aortic lymph nodes.
On the left:
Preaortic and para-aortic nodes and thence to the interaortocaval
Metastatic nodal disease to the common iliac, external iliac, or
inguinal lymph nodes is usually secondary to a large volumeof
disease with retrograde spread.
If the patient has undergone a herniorrhaphy, vasectomy, or other
transscrotal procedure, metastasis to the pelvic and inguinallymph
nodes is more likely
Through the thoracic duct to lymph nodes in the posterior
mediastinum and supraclavicular fossae and occasionally to the
axillary nodes.
Contralateral spread is mainly seen with right-sided tumors.
In 15% to 20%, bilateral nodes are involved
8. INTRODUCTION
Comprise a morphologically and clinically diverse group of tumors
Predominantly affects young males
1 -2 % of all cancers in USA
Testicular cancer forms about 1% of all malignancies in males in India.
Incidence (ASR)– 0.6 per 100000
Mortality (ASR)– 0.3 per 100000
95% are Germ Cell Tumours (GCTs)
90% GCT are in testes,2-10% in extra gonadal (eg retropreitoneum, mediastinal)
Cure rate increased with introduction of platinum based chemotherapy from 10 to 80%
9. EPIDEMOLOGY OF TESTICULAR CANCER
• Age: for GCT: median age at diagnosis is 34 years, with 50% of incident
cases between 20 and 34 years.
• In a man age: 50 years or older solid testicular mass is usually lymphoma
• Age - 3 peaks
2 – 4 yrs
20 – 40 yrs
above 50 yrs
• Geographic: Highest incidence in Denmark, Norway, and Switzerland
and the lowest in eastern Europe andAsia.
• Race: more common in young white men ,less in AfricanAmericans
10. Predisposing Factors
1. Cryptorchidism
2. Klinefelter syndrome
3. Positive family history
4. Positive personal history
5. Intratubular germ cell neoplasia
6. Trauma
7. Viral infection
8. Hormonal factors
9. Exposure to environmental oestrogen
12. Seminoma
The commonest variety of testicular tumour
Adults are the usual target (4th and 5th decade); never seen in infancy
Right > Left Testis
Starts in the mediastinum: compresses the surrounding structure.
Patients present with painless testicular mass
30 % have metastases at presentation, but only 3% have symptoms related to
metastases
13. Seminoma
• Serum alpha fetoprotein is normal
• Beta HCG is elevated in 30% of patients with Seminoma
• Classification
a) classical
b) Anaplastic
c) Spermatocytic
14. Spread
1. Direct Spread:
This spread occurs by invasion.
Whole of testis in involved and restricted
Tunica albuginea is rarely penetrated
May be crossed by “blunder biopsy”
Scrotal skin involvement
Fungation on the anterior aspect
Spread to spermatic cord and epidedymis
may occur : points towards bad prognosis
15. Spread
2. Lymphatic spread:
Seminoma metastasize exclusively through
lymphatics
They drain primarily to para-aortic lymph nodes
From RPLN drain into cysterna chili, thoracic duct
,posterior mediastinum & left supraclavicular
Lymph
from medial side of testes run along the artery to
the vas to drain to nodes at the bifurcation of
common iliac
No inguinal nodes until scrotal skin involvement
16. Spread
3. Blood Spread
NSGCT spread through blood route
Lungs, liver, bones and brain are the usual sites usually involved
17. Clinical Features
1. Due to primary tumor
a) Painless testicular lump
b) Sensation of heaviness if size > than 2-3 times
c) Rarely dragging pain is complained of (1/3rd cases)
d) May mimic epidedymo-orchitis
e) Sudden pain and enlargement due to hemorrhage mimicking torsion
f) History of trauma (co-incidental)
18. Clinical Features
2. Due to metastasis
Abdominal or lumbar pain (lymphatic spread)
Dyspnoea, hemoptysis and chest pain with lung mets
Jaundice with liver mets
Hydronephrosis by para-aortic lymph nodes enlargement
Pedal oedema by IVC obstruction
Troiser’s sign
19. Clinical Features
3. Clinical examination:
a) Enlarged testis (except choriocarcinoma)
b) Nodular testis
c) Firm to hard in consistency
d) Loss of testicular sensation
e) Secondary hydrocele
f) Flat and difficult to feel epididymis
g) General examination for metastasis
20. Tumor markers
TWO MAIN CLASSES
• Onco-fetal Substances : AFP & HCG
• AFP - Trophoblastic Cells
HCG - Syncytiotrophoblastic Cells
AFP, BHCG & LDH are included in TNM staging of testicular cancers
21. Staging Work Up
• General
History (document cryptorchidism and previous inguinal or scrotal
surgery)
Physical examination
• Laboratory Studies
CBC, LFT, RFT, LDH
• Serum assays
Alpha fetoprotein (AFP)
Beta human chorionic gonadotropin
22. • Diagnostic Radiology
– Chest x-ray films, posterior/anterior and lateral views
– Computed tomography (CT) scan of abdomen and
pelvis
– CT scan of chest for non seminomas and stage II
seminomas
– Ultrasound of contralateral testis
23.
24. LDH Beta HCG AFP
(mIu/ml) (ng/ml)
S1 < 1.5 x N <5000 <1000
S2 1.5-10 x N 5000-50000 1000-10000
S3 >10 x N >50000 >10000
Serum Tumor Markers (S)
25. Surgery
Radical orchidectomy:
all patients
done via an inguinal incision, with cross
clamping of spermatic cord vasculature and
delivery of testis into the surgical field.
Scrotal violation, increased local/regional
recurrence, but no difference in distant
recurrence rate or overall survival.
26. Retro peritoneal lymph node dissection(RPLND):
Indication:
preferred treatment for low stage NSGCT
Include the precaval, retrocaval, paracaval,
interaortocaval, retroaortic, preaortic, para-aortic,
and common iliac lymph nodes bilaterally.
Disadv.:
sympathetic nerve fibers are disrupted,
resulting in loss of seminal emission. A modified
RPLND developed that preserves ejaculation in
up to 90%.
27.
28.
29.
30.
31. PRINCIPLES OF RADIOTHERAPY FOR PURE TESTICULAR SEMINOMA
Linear accelerators with >6 MV photons should be used when possible.
The mean dose (Dmean) and dose delivered to 50% of the volume (D50%) of
the kidneys, liver, and bowel are lower with CT-based AP-PA 3D-CRT than
IMRT.
As a result, the risk of second cancers arising in the kidneys, liver, or bowel
may be lower with 3D-CRT than IMRT, and IMRT is not recommended.
3D Planning
3D planning is preferred due to potential of marginal miss, with 2D
planning based on bony anatomy .
3D planning improves target definition and kidney/small bowel shielding.
32. Para-aortic field:
Contour IVC and aorta
separately from 2 cm below the
top of the kidneys down to the
point where these vessels
bifurcate.
Use a 1.2 cm expansion
radially around IVC and a 1.9 cm
expansion around the aorta,
excluding bone and bowel.
Dogleg field:
In addition to PA field,
contour the ipsilateral
common, external, and
proximal internal iliac veins
and arteries down to upper
border of acetabulum.
Use a 1.2 cm expansion on
the iliac vessels, excluding
bone and bowel.PTV=CTV+0.5 cm
0.7 cm margin on PTV to block edge to take penumbra
into account
3D PLANNING
33. Dog Leg Field
upper border of T10 or T11
left renal hilum is
included for left-sided
tumors (only)
Traditionally, the inferior border was placed at the
superior obturator foramen (indicated in orange) to
include all external iliac nodes
10 cm wide in the para-aortic region and usually covers the
transverse processes
At the mid-L4 level, the field is extended laterally to cover
the i/l external iliac
34. Dog Leg Field- Modified
Superior border :bottom of body T11.
Inferior border : top of the acetabulum.
The medial border for the lower aspect of the modified
dog-leg fields extends from the tip of the c/l transverse
process of L5 toward the medial border of the i/l
obturator foramen.
The lateral border for the lower aspect of the modified
dog-leg fields is defined by a line from the tip of the i/l
transverse process of L5 to the superolateral border of
the i/l acetabulum.
35. Radiation therapy
Indications
Adjuvant therapy for stages I–IIb diseases
Salvage of loco-regional failure after surgery or chemotherapy
Palliative treatment to loco-regional or distant metastatic sites
Techniques
EBRT to lymph nodes
High-energy radiation (6 – 18 MV)
Seminoma is extremely radiosensitive. Radiation therapy is often used for adjuvant
therapy for early-stage seminoma, and its use in non-seminoma germ cell tumors (GCT) is
limited.
36. Position and immobilization
Supine, arms placed by the pt. side and legs straight, with feet stabilized with a
foam wedge underneath the knees.
Position penis out of field
Shielding
Contra-lateral testis is shielded with a lead clamshell device.
Mean dose values to the contralateral testicle.
PA PA + IL iliac
Without shield 1.86
cGy
3.89 cGy
With shield 0.65
cGy
1.48 cGy
37. Stage I:
Field margins
Superior: T10–T11 interspace
Inferior: L5–S1 interspace
Lateral: transverse process
For left testis: cover renal hilum
Dose
20 Gy in 10# to para-aortic ± pelivic lymph node by ap-pa field
Elective para-aortic field for stage I
seminoma
38. Stage II
Superior: T10 –T11 interspace
Inferior: superior aspect of acetabulum
Lateral: transverse process (appx 9 cm wide in PA
region) down to L5–S1 interspace then diagonally
to the lateral edge of the acetabulum, then
vertically downward to the median border of the
obturator foramen
For left testis: cover left renal hilum
Paraaortic and ipsilateral inguinal
field for stage II left testicular
seminoms, with inclusion of the renal
hilus.
39. Stage II a-
25Gy in 20 # by AP-PA
Stage II b & IIc
25 Gy in 20 #
10 Gy in 5 #
40. Complications : Radiotherapy
Acute nausea, vomiting, diarrhea
Late small bowel obstruction, chronic diarrhea, peptic ulcer disease (<2% with <35 Gy)
Second cancers: 5–10% increased risk vs. general population after RT
With testicular shielding, most patients will have oligospermia by 4 months that lasts
~1 year
Infertility: 50% of patients have subfertile counts on presentation or after surgery.
After RT, 30% able to have children
41. 50 cGy causes transient azospermia with recovery at 1 year, but only 50% of patients reach
their baseline
80–100 cGy causes total azospermia with recovery 1–2 year later for some patients
200 cGy causes sterilization
Testicular shield reduces testicle dose by 2–3x
Kidneys: limit at least 70% <20 Gy
42. Chemotherapy
Indications
As an alternative to adjuvant RT for stages I–II seminoma
Adjuvant therapy for stages II–IV seminoma
Regimens
Single-agent one cycle of carboplatin become an alternative for stage I
seminoma
Regimens including BEP x 3 cycles, EP x 4 cycles, PVB, and VIP for stages II–IV
diseases
43. “I always had the size difference there, but I didn’t
know…I would’ve still been waiting if it hadn’t started
hurting, it just got so painful I couldn’t sit on my bike
anymore.”
-Lance Armstrong