Germ Cell Tumours

Question 1

What is the typical tumour marker pattern in seminoma?

Answer 1

Normal AFP, BHCG raised in around 20%, LDH raised in around 50%

Question 2

What is the typical tumour marker pattern in non-seminoma?

Answer 2

AFP, BHCG and LDH raised in 40-50%

Question 3

In non seminomas which subtype typically accounts for rise in AFP?

Answer 3

York sac, embryonal and teratomas to a lesser extent

Question 4

Describe stage 2 (A-C) disease

Answer 4

Involvement of LN below the diaphragm. A= <2cm, B= 2-5cm, C= >5cm

Question 5

Describe stage 3 disease

Answer 5

Lymph node involvement above the diaphragm

Question 6

Describe stage 4 disease

Answer 6

Non lymphatic distant metastases (most commonly lung)

Question 7

What are risk factors for recurrence in localised seminomas?

Answer 7

Size >4cm and rete testis invasion

Question 8

When would you consider adjuvant treatment in localised seminoma?

Answer 8

If one risk factor then offer, strongly recommend if two risk factors. 1 cycles carboplatin AUC 7

Question 9

What is the relapse rate following adjuvant treatment for seminomas? When is relapse likely to occur?

Answer 9

Around 5%, typically within the first 3 years

Question 10

What is the risk of recurrence with one vs two risk factors for localised seminoma?

Answer 10

1 risk factor- 16-18%
2 risk factors- 30-32%

Question 11

How do you treat metastatic disease in seminoma?

Answer 11

3-4 cycles of cisplatin and etoposide or BEP, paraortic RT

Question 12

What is the management of residual masses post chemotherapy in seminomatous disease?

Answer 12

If >3cm evaluate with PET-CT in 6-12 weeks, if avid should be resected.

Question 13

Risk factors for testicular malignancy?

Answer 13

Contralateral testicular malignancy and tesicular dysgenesis

Question 14

Which subtype of non seminomatous germ cell tumours is associated with highest risk of relapse and development of metastatic disease?

Answer 14

Embryonal cell carcinoma

Question 15

When do non seminomatous germ cell tumours tend to relapse?

Answer 15

Within the first year

Question 16

Which risk factors is used to distinguish between low and high risk in non seminomatous GC tumours?

Answer 16

Lymphovascular invasion

Question 17

In high risk localised non seminomatous GC tumour what is the risk of recurrence and which chemotherapy regime is used?

Answer 17

Recurrence risk of 50%, recommend 1 cycle BEP

Question 18

Describe features of good risk non seminomatous stage II-III disease

Answer 18

Testicular or RP primary tumour and no nonpulmonary visceral mets. Post orchidectomy AFP <1000, HCG <5000, LDH <1.5 x ULN

Question 19

Management of good risk non seminomatous stage II-III disease and 5yr OS rates

Answer 19

BEP165 x 3 or EP x 4 if bleomycin contraindicated 95% 5yr OS

Question 20

Describe features of intemediate risk non seminomatous stage II-III disease

Answer 20

Testicular or RP primary tumour and no nonpulmonary visceral metastases, post orchidenctomy AFP 1,000-10,0000, BHCG 5,000-50,000 or LDH 1.5- 10x ULN

Question 21

Describe management of intermediate risk non seminomatous stage II-III disease and 5yr OS rate

Answer 21

BEP 165 x 4 the EP x1 or VIP x 4 if bleomycin contraindicated, 89% 5 year survival

Question 22

Describe features of poor risk non seminomatous stage II-III disease

Answer 22

Mediastinal primary tumour or non pulmonary visceral metastases or post orchidectomy AFP >10,000, BHCG >50,000 or LDH >10x ULN

Question 23

Describe management of poor risk non seminomatous stage II-III disease and expected 5yr OS

Answer 23

BEP x 4 then EP x1 or VIP x 4 if bleomycin contraindicated. 5ys OS 67%

Question 24

In what circumstances would you avoid bleomycin?

Answer 24

Potentially with mediastinal primary tumours due to high risk of bleomycin complications.

Question 25

Describe the management of residual mass in non seminomatous disease

Answer 25

Resect any residual mass >1cm (consider watching in extensive metastatic disease). If viable tumour may need additional chemotherapy.

Question 26

How would you manage relapsed non seminoma?

Answer 26

For single site or relapse then surgical resection is first line, if multiple site then salvage chemotherapy with TIP is most suitable followed by surgery or SABR for residual disease.

Question 27

What are the risk factors for bleomycin toxicity?

Answer 27

Age >40yrs, GFR <80mls/min, >300mg total dose and stage IV disease

Question 28

What oxygen saturations should you aim for in patients who have had bleomycin previously?

Answer 28

Sats 85-88%

Question 29

When is the highest risk of bleomycin toxicity?

Answer 29

In the first 6 months

Question 30

By what mechanism does ifosfamide cause haemorrhagic cystitis?

Answer 30

Ifosfamide metabolised in the liver and leads to the metabolite acrolein which causes urothelial damage.

Question 31

When would you stop ifosfamide due to concerns regarding haemorrhagic cystitis

Answer 31

If there is macroscopic haematuria

Question 32

How do you manage ifosfamide induced haemorrhagic cystitis?

Answer 32

Mesna given alongside, if 2+ blood on dip or 2 occasions of 1+ on dip then give mesna bolus and double all future mesna doses.

Question 33

Management of ifosfamide induce encephalopathy

Answer 33

If G2 give methylene blue and continue ifosfamide, if G3 then given methylthene blue and stop infusion.

Question 34

How do you treat symptomatic or advanced ACC?

Answer 34

Mitotane

Question 35

How do you treat symptomatic or advanced ACC?

Answer 35

Mitotane

Question 36

What is the recommended management of stage 2 seminoma after orchidectomy?

Answer 36

RT to include paraortic and ipsilateral iliac nodes or primary chemo with 3 cycles BEP or EP for four cycles

Question 37

The risk of post treatment leukaemia is highest with the use of which chemotherapy drug?

Answer 37

Cisplatin