Germ Cell Tumors Flashcards
What is the chromosome mutation that is seen with all germ cell tumors?
12p amplification
Remember, what hormone will seminomas never secrete? What do they actually secrete? What do non-seminomas secrete?
AFP! They only secrete beta HCG. LDH may normal or elevated.
Choriocarcinoma secretes what marker?
HCG
Yolk sac tumor secretes what marker?
AFP
What tumor do Teratomas secrete?
Nothing
When is a brain MRI indicated in staging workup?
HCG>5K, extensive lung mets, predominance of choriocarcinoma, neurologic symptoms, non-pulm visceral mets, AFP>10K
Remember for Stage I non seminoma what high risk features should you look for and how do you manage these patients depending on if the risk features are absent?
Risk features: lymphovascular invasion, spermatic cord invasion or invasion of scrotum. If absent preferred option is to do surveillance, an alternative option is RPLND, last preferred option is adjuvant BEP for 1 cycle.
For Stage I non-seminoma that has high risk features, what is the preferred way to treat these patients?
Surveillance is the preferred option, the 2nd option is adjuvant chemo w/BEP for 1 cycle, 3rd preferred option is PLND
What is Stage Is for non-seminoma and what is the tx?
Tumor marker elevation despite orchiectomy. You give BEP for 3 cycles or EP for 4 cycles.
For Stage IIA non-seminoma if the markers are negative what do you do? What if they are persistent?
Negative-RPLND or you can consider BEPx3 cycles or EPx4 cycles. Tumor markers persistent-BEPx3 cycles or EPx4 cycles.
Stage IIB non-seminoma what is the tx?
So the preferred option is BEPx3 cycles or EPx4 cycles. You can consider RPLND in highly selected cases if the markers are neg and they have limited lymph node dx in the RP.
For those patients who undergo a RPNLD in non seminoma with stage IA, IB, or IIA, or IIB what do you do depending on the lymph node size?
Remember pN2-EPx2 cycles and N2-BEPx3 cycles or EPx4 cycles, but N3 is rare. For N0-surveillance. N1-prefer surveillance but can consider EPx2 cycles.
Remember for germ cell tumors that were treated with chemotherapy what do you need to look for to see if a response occurred?
Look to see if either the tumor markers are still elevated and/or there are residual masses!
What do you do for non-seminoma after primary chemo where imaging shows no mass or residual mass less than 1cm and neg markers?
Surveillance is preferred. Can also consider RPLND (Cat 2B) Viable tumor found-give 2nd line chemo options.
What do you do for non seminoma after getting primary chemo and they have residual mass greater than 1cm, but neg tumor markers?
RPLND is preferred here. Remember if viable tumor is found: VIP, TIP, VeIP, or EP for 2 cycles
If after chemotherapy for non seminoma they have a PR: there are residual masses with normal tumor markers or mildly elevated and normalizing tumor markers and repeat biopsy shows residual tumor (e.g. embryonal, yolk sac) what do you do?
2nd line chemo options: EP, TIP, VIP, VeIP for 2 cycles.
What if after chemo for non-seminoma they have a PR where there is a residual mass with elevated and rising tumor markers?
You consider VeIP, TIP, VIP or you can do high dose chemo w/stem cell transplant: Carbo or Cis/Etoposide or Paclitaxel/ifosfamide/Carbo/Etoposide.
What if after primary tx of a non-seminoma they have a PR w/residual masses, but the tumor markers are normal, what do you do?
So the only option here is to surgically resect (if it may also require node dissection), you have to rule out if there is viable tumor left or teratoma/necrosis. A small minority of patients will need additional chemo here. Teratoma-observation. Viable tumor-EP, TIP, VIP, or VeIP for 2 cycles.
For Stage IA or IB seminoma what is the preferred tx and what are the other options? Giving RT can lead to what late term? IA: pT1, N0, S0 IB: pT2-4, N0, S0
Observation! But you can do Carboplatin for 1-2 cycles, or consider RT. RT long term can lead to bladder, gastric, kidney, colorectal, and pancreatic cancer.
For Stage Is for seminoma, what is the preferred treatment here?
So this means there is disease present somewhere and there is a risk it is beyond the retroperitoneum. So the preferred option is to tx w/1st line chemo: BEP or EP or VIP(more preferred for patients w/intermediate or poor risk)
Serum markers help determine the stage of germ cell tumors, what is the def of S0, S1, S2
S0-tumor markers are normal
S1: LDH less than 1.5 times the upper limit and bHCG<5000 and AFP<1000
S2: LDH 1.5-10 times the upper limit, or HCG 5000-50,000, or AFP 1,000-10,000
S3: LDH>10 times the upper limit, or HCG>50K, or AFP>10K
LDH>1.5 is in the 300s
How does the N stage work in staging of germ cell tumors?
N0-no nodes
N1-No lymph node greater than 2cm
N2-Lymph node 2-5cm
N3-Lymph node greater than 5cm
For Stage IIA seminoma what are the tx options? (N1,S0) or (N1,S1)
You can give chemo (BEP for 3 vs EP for 4), RT to a dose of 30Gy, or RPLND
For Stage IIB seminoma what are the tx options? (Any p, N2, S0)
BEP for 3 cycles vs EP for 4 cycles is the preferred option. You can do RT w/36 gy , but only for nodes less than or equal to 3cm.
What is the def of good and intermediate risk seminoma?
Good-Any primary site, no non-pulmonary visceral mets, normal AFP, any HCG and LDH. Intermediate-has non-pulmonary mets
What is the def of good risk non-seminoma?
Testicular or RP primary tumor, no non-pulmonary mets, and S0 or S1 disease. All 3 must be present
What is the def of intermediate risk non-seminoma?
Testicular or RP tumor, no non-pulmonary mets, and S2 disease
What is poor risk non-seminoma?
Mediastinal primary tumor, or non-pulmonary mets is present, or S3 disease is present.
What is the tx for Stage IIC (Any p, N3, S0 or Any p, N3, S1) or Stage IIIC (Any p, N1-3, S3, M0 or Any p, any N, S3, M1a or if M1b is present, any S)?
Good risk: BEP for 3 cycles or EP for 4 cycles.
Intermediate (M1b disease, they have non-pulmonary mets present): BEP for 4 cycles (Cat 1) or VIP for 4 cycles
If for seminoma after primary tx there is a residual mass less than 3cm and the tumor markers are normal what do you do?
Surveillance!
If after primary tx for a seminoma there is a residual mass greater than 3cm w/normal tumor markers what do you do?
You can do surveillance or get a PET/CT scan. If the PET scan is positive you need to get a biopsy and consider resection. If it is incompletely resected they need 2nd line chemo:
(VeIP for 4 cycles or TIP for 4 cycles) or high dose chemo (Carbo/Etoposide or adding Paclitaxel and Ifosfamide).
If after primary tx of a seminoma they have a growing mass or they have rising markers what do you do?
You give second line chemo: VeIP for 4 cycles or TIP for 4 cycles or high dose chemo (Carbo/Etoposide or adding Ifosfamide and Paclitaxel to this regimen).
When determining the stage of germ cell tumors what tumor marker tells you what the stage is?
It’s the tumor marker after surgery that defines the stage of the patient.
What patients are not candidates for BEP? This is super important!
Patients over the age of 50, heavy smoking history, underlying lung dx, and renal insufficiency. GW lecture also mentions Thoracic RT.
For non-seminoma after chemotherapy is given as primary treatment but there is mass that is residual and/or elevated tumor markers, if the biopsy shows teratoma/necrosis what do you do?
Surveillance! Remember this, they will definitely ask it!
What is the one thing for men that require additional treatment after orchiectomy?
Sperm Banking!
