Editing Germ Cell Tumours (section)

== Special scenarios ==

=== <span style="color:#ff0000">Brain metastases</span> ===
* '''<span style="color:#ff0000">Associated with choriocarcinoma; should be suspected in any patient with a very high serum hCG level</span>'''
** '''Choriocarcinomas are highly vascular and tend to hemorrhage during chemotherapy, with death rates of 4-10% secondary to intracranial hemorrhage'''
* Management
** Brain metastases at diagnosis: BEP×4 chemotherapy followed by resection of residual masses.
** Relapse in the brain after first-line chemotherapy: second-line chemotherapy followed by resection and/or radiation therapy
*** Relapse in the brain after achieving a complete response to chemotherapy have a worse prognosis than patients with brain involvement at diagnosis.

=== <span style="color:#ff0000">Primary extra-gonadal GCTs</span> ===
* '''<span style="color:#ff0000">Site of origin of GCTs: gonadal (95%) vs. extra-gonadal (5%)</span>'''
* '''<span style="color:#ff0000">Develop in midline anatomic locations</span>'''
** '''<span style="color:#ff0000">Most common sites (descending order) of origin: mediastinum, retroperitoneum,</span>''' sacrococcygeal region, and pineal gland, although many unusual sites have also been reported [SASP 2014]
** '''Primary mediastinal GCT'''
*** '''NSGCT'''
**** '''Compared to NSGCTs originating in the testicle or retroperitoneum, primary mediastinal NSGCTs are (4):'''
****# '''More likely to have yolk sac tumour components and be associated with elevated AFP'''
****# '''Associated with Klinefelter syndrome'''
****# '''Less sensitive to chemotherapy'''
****# '''Associated with a poor prognosis'''
*** '''Seminoma'''
**** '''Primary mediastinal seminomas have similar prognosis to testicular seminomas'''
** '''Primary retroperitoneal GCT'''
*** '''Behave similarly to testicular GCTs and carry the same prognosis.'''
* Of patients with metastatic GCT without a testis mass:
** 1/3 definitively have a primary extra-gonadal GCT
** 1/3 have ITGCN in the testis
** 1/3 have sonographic evidence of a “burned-out” primary tumor
* '''Diagnosis and evaluation'''
** '''If midline mass in male age < 40, consider GCT'''
*** Midline mass in male age < 40 with elevated AFP and/or hCG is diagnostic of GCT, even if testicular evaluation is normal; histologic confirmation by biopsy is unnecessary before starting treatment
*** Midline mass in male age < 40 with normal serum tumor markers, perform biopsy of the midline mass to confirm the diagnosis before beginning treatment
* '''Management'''
** '''Inguinal orchiectomy'''
*** '''Indications in patients with suspected extra-gonadal GCT (2):'''
**# '''Pattern of metastasis is consistent with a right-sided or left-sided testicular primary tumor'''
**# '''Sonographic evidence of a “burned-out” primary tumor'''

=== Small (<10 mm), impalpable intratesticular lesions ===
*'''Small (<10 mm), impalpable intratesticular lesions in the absence of disseminated GCT or elevated serum tumor markers are a diagnostic dilemma'''
* '''<span style="color:#ff0000">Most of these lesions are benign (testicular cysts, small infarcts, or small Leydig cell or Sertoli cell tumors), however, 20-50% may represent small GCTs (usually seminomas).</span>'''
** '''Risk of malignancy increases with the size of the lesion.'''
* '''Management options (3):'''
*# '''Inguinal orchiectomy'''
*# '''Testis-sparing surgery involving inguinal exploration and excision (with frozen-section analysis to rule out GCT)'''
*#* '''Intraoperative ultrasonography is useful during surgical exploration of the testis to locate the lesion.'''
*# '''Close observation with serial ultrasound scans (with exploration of growing lesions).'''