308 CHAPTER 6 Urological neoplasia

Testicular cancer: management of seminoma, IGCN, and lymphoma

Of all seminomas, 75% are confined to the testis at presentation and are cured by radical orchiectomy; 10–15% of patients harbor regional node metastasis, and 5–10% have more advanced disease.

Treatment and follow-up depend largely on disease stage similar to the stratification of NSGCT (p. 304). RPLND is not used for seminoma. Unlike NSCGT, radiation therapy is a therapeutic modality in seminoma.

Subdiaphragmatic radiation is the traditional method: 35 Gy to the paraaortic and ipsilateral iliac lymph nodes following radical orchiectomy using a “hockey stick” template. Newer radiation techniques limit radiation to the paraortic region with contralateral testicular shielding.

Generally, radiation doses in the adjuvant setting are in the range of 25 Gy, with 35 Gy used for more bulky disease.

Prophylactic mediastinal radiation therapy has been abandoned (cardiovascular side effects, failure to significantly improve outcomes, and interference with ability to administer salvage chemotherapy).

Stage I

•Radical orchiectomy and adjuvant radiation therapy in low-stage disease is the most common treatment.

•Close surveillance with imaging and serial tumor markers instead of radiation therapy for low-stage seminoma is gaining acceptance.

Stage IIA

• Non-bulky retroperitoneal nodes: RT 35 Gy or chemotherapy

Stage IIB/IIC

•Bulky lymphadenopathy (>5–7 cm nodes) or visceral metastasis with standard NSCGT: platinum-based chemotherapy (BEP/EP) (see p. 305)

Stage III

•Chemotherapy; with brain metastasis, brain radiation therapy +/ excision

Cure rate

All stages have at least a 90% cure rate:

•Stage I is 98–100%.

•Stage II (B1/B2 non-bulky) is 98–100%.

•Stage II (B3 bulky) and stage III have a >90% complete response to chemotherapy and an 86% durable response rate to chemotherapy.

Management of intratubular germ cell neoplasia (IGCN)

•Observation or orchiectomy for unilateral disease.

•Radiotherapy for unilateral disease in the presence of a contralateral tumor

•Radiotherapy for bilateral disease, to preserve Sertoli cells

•Frozen sperm storage must be offered.

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Management of testicular lymphoma

This may be a primary disease or a manifestation of disseminated nodal lymphoma. The median age of incidence is 60 years, but has been reported in children.

One-quarter of patients present with systemic symptoms; 10% have bilateral testicular tumors. These patients have a poorer prognosis following radical orchiectomy and chemotherapy, while those with localized disease may enjoy long-term survival.

310 CHAPTER 6 Urological neoplasia

Penile neoplasia: benign, viral-related, and premalignant lesions

Benign tumors and lesions (see Table 6.19)

Noncutaneous

•Congenital and acquired inclusion cysts

•Retention cysts

•Syringomas (sweat gland tumors)

•Neurilemoma

•Angioma, lipoma

•Iatrogenic pseudotumor following injections

•Pyogenic granuloma following injections

Cutaneous

•Pearly penile papules (normal in 15% of postpubertal males)

•Zoon balanitis (shiny, erythematous plaque on glans or prepuce)

•Lichen planus (flat-topped violaceous papule)

Viral-related lesions

Condyloma acuminatum

This is also known as genital warts, related to human papillomavirus (HPV) infection. There are soft, usually multiple benign lesions on the glans, prepuce, and shaft; they may occur elsewhere on genitalia or perineum.

A biopsy is worthwhile prior to topical treatment with podophyllin. 5% have urethral involvement, which may require diathermy.

HPV infection (particularly types 16 and 18) is potentially carcinogenic and condylomata have been associated with penile SCC (this is distinct from the premalignant giant condyloma acuminatum; see below).

Bowenoid papulosis

This condition resembles carcinoma in situ, but with a benign course. Multiple papules appear on the penile skin, or a flat glanular lesion. These should be biopsied. HPV is the suspected cause.

Kaposi sarcoma

This reticuloendothelial tumor has become the second-most common malignant penile tumor. It presents as a raised, painful, bleeding violaceous papule or as a bluish ulcer with local edema. It is slow growing, solitary, or diffuse. It occurs in immunocompromised men, particularly in gay men with HIV/AIDS. Urethral obstruction may occur.

Treatment is palliative, with intralesional chemotherapy, laser, cryoablation, or radiotherapy.

Premalignant cutaneous lesions

Some histologically benign lesions are recognized to have malignant potential or occur in close association with SCC of the penis. A chronic red or pale lesion on the glans or prepuce is a cause for concern. Note should be made of its color, size, and surface features. Early follow-up after use of steroid, antibacterial, or antifungal creams is recommended. If persistent, biopsy is advised.

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with penile SCC, but most pathologists would regard the lesion as benign unless epithelial dysplasia is present.

•Leukoplakia: solitary or multiple whitish glanular plaques that usually involve the meatus. Treatment is excision and histology. Leukoplakia is associated with in situ SCC; follow-up is required.

•Erythroplasia of Queyrat: also known as carcinoma in situ of the glans, prepuce, or penile shaft. A red, velvety, circumscribed painless lesion occurs, though it may ulcerate, resulting in discharge and pain. Treatment is excision biopsy if possible; radiotherapy, laser ablation, or topical 5-fluorouracil may be required. Histology reveals hyperplastic mucosal cells with malignant features.

•Bowen disease: this is carcinoma in situ of the remainder of the keratinizing genital or perineal skin. Treatment is wide local excision, laser, or cryoablation.

•Buschke–Löwenstein tumor: also known as verrucous carcinoma or giant condyloma acuminatum, this is an aggressive locally invasive

tumor of the glans. Metastasis is rare, but wide excision is necessary to distinguish it from SCC. Urethral erosion and fistulation may occur.