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EAMC Urology > NCCN Testicular 3.2020 > Flashcards

NCCN Testicular 3.2020 Flashcards

1
Q

Initial workup

Suspicious testicular mass

A

H and PE
AFP, beta-HCG, LDH
Chemistry profile (baseline gonadal function)
Testicular ultrasound

TEST-1

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2
Q

Primary treatment

Suspicious testicular mass

A

Radical inguinal orchiectomy
Sperm banking
Consider INGUINAL biopsy
Consider testicular prosthesis

TEST-1

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3
Q

Indications for inguinal biopsy of contralateral testis

A

Ultrasound: intratesticular mass concerning for testicular CA
Cryptorchid testis
Marked atrophy
Suspicious mass

TEST-1

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4
Q 
Postdiagnostic workup
Pure seminoma (pure seminoma histology + AFP normal, -/+ elevated beta-HCG
A 
Abdominal pelvic CT
CXR --> Chest CT if (+) abd. CT or CXR
Post-orchiectomy beta-HCG, LDH, and AFP
Brain MRI, if indicated
Sperm banking

TEST-2

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5
Q

Is TNM staging based on post or pre orchiectomy values of tumor markers?

A

TNM staging is based on POST-ORCHIECTOMY values of tumor markers.

TEST-1

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6
Q

Primary treatment: Pure seminoma

IA, IB

A 
Surveillance for pT1-pT3 tumors (strongly preferred)
OR
Single-agent carboplatinp,q
(AUC=7 x 1 cycle or AUC=7 x 2 cycles)
OR
RT (20 Gy or 25.5 Gy)

TEST-3

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7
Q

Primary treatment: Pure seminoma

IS

A

Repeat elevated serum tumor marker measurement and asses with chest/abdominal/pelvic CT (with contrast) to scan for evaluable disease

TEST-3

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8
Q

Primary treatment: Pure seminoma

IIA

A

RT to include para-aortic and ipsilateral iliac lymph nodes to a dose of 30 Gy
OR
Primary chemotherapy
BEP for 3 cycles or EP for 4 cycles

TEST-4

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9
Q

Primary treatment: Pure seminoma

IIB

A

Primary chemotherapy
BEP for 3 cycles or EP for 4 cycles
OR
RT in select non-bulky (≤3 cm) cases to include para-aortic and ipsilateral iliac lymph nodes to a dose of 36 Gy

TEST-4

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10
Q

Primary treatment: Pure seminoma
IIC, III
Good risk

A

Primary chemotherapy
BEP for 3 cycles (cat 1)
OR
EP for 4 cycles (cat 1)

TEST-4

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11
Q

Primary treatment: Pure seminoma
IIC, III
Intermediate risk

A

Primary chemotherapy
BEP for 4 cycles (cat 1)
OR
VIP for 4 cycles (cat 1)

TEST-4

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12
Q 
Primary treatment: Pure seminoma
After primary chemotherapy
IIA-IIC, III
Imaging: no residual mass, or =< 3 cm 
Markers: normal AFP, beta-HCG
A

Surveillance

TEST-5

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13
Q 
Primary treatment: Pure seminoma
After primary chemotherapy
IIA-IIC, III
Imaging: Residual mass, > 3 cm 
Markers: normal AFP, beta-HCG
A

Surveillance
OR
Consider PET/CT scan from skull base to mid- thigh (6 wks
or more post- chemotherapy)
- If (+), resect residual mass or biopsy, then if (+) viable seminoma with complete resection –> 2 cycles of adjuvant chemo
- If incomplete resection: second line chemo

TEST-5

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14
Q

Primary treatment: Pure seminoma
After primary chemotherapy
IIA-IIC, III
Progressive disease: rising tumor markers, growing mass

A

Second-line therapy:

Clinical trial (preferred)
Chemotherapy
- Conventional-dose therapy (VeIP or TIP)
- High-dose chemotherapy
Consider surgical salvage if solitary site (for early relapse)
Recommend sperm banking if clinically indicated

TEST-5, TEST-13

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15
Q

Primary treatment: NSGCT

Post-diagnostic workup

A

Chest/abdominal/pelvic CT
Repeat beta-HCG, LDH, AFP
Brain MRI if indicated
Sperm banking

TEST-6

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16
Q

Primary treatment: NSGCT

Stage I WITHOUT risk factors

A 
Surveillance (preferred)
OR
Nerve-sparing RPLND
OR
Primary chemotherapy: BEP x 1 cycle

TEST-7

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17
Q

Primary treatment: NSGCT

Stage I WITH risk factors

A 
Surveillance
OR
Primary chemotherapy: BEP x 1 cycle
OR
Nerve-sparing RPLND

TEST-7

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18
Q

Primary treatment: NSGCT

Stage IS

A 
Check for persistent marker elevation
---
Primary chemotherapy:
BEP for 3 cycles (category 1)
or
EP for 4 cycles (category 1)

TEST-8

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19
Q

Primary treatment: NSGCT

Stage IIA, markers negative

A

Nerve-sparing RPLND
OR
Primary chemotherapy:
BEP for 3 cycles or EP for 4 cycles

TEST-8

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20
Q

Primary treatment: NSGCT

Stage IIA, persistent marker elevation

A

Primary chemotherapy:
BEP for 3 cycles (category 1)
or
EP for 4 cycles (category 1)

TEST-11

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21
Q

Primary treatment: NSGCT

Stage IIB, markers negative , LN mets within lymphatic drainage sites

A

Primary chemotherapy:
BEP for 3 cycles or EP for 4 cycles
or
Nerve-sparing RPLND in highly selected cases

TEST-8

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22
Q

Primary treatment: NSGCT

Stage IIB, markers negative , multifocal symptomatic or LN mets with aberrant lymphatic drainage

A

Primary chemotherapy:
BEP for 3 cycles or EP for 4 cycles

TEST-8

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23
Q

Primary treatment: NSGCT

Stage IIB, persistent marker elevation

A

Primary chemotherapy:
BEP for 3 cycles (category 1)
or
EP for 4 cycles (category 1)

TEST-11

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24
Q

Postchemotherapy management: NSGCT
Stage IIA, IIB
Negative markers, residual mass (≥1 cm) on CT scan

A

Nerve-sparing bilateral RPLND

TEST-9

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25
Q

Postchemotherapy management: NSGCT
Stage IIA, IIB
Negative markers, no mass, or residual mass <1 cm on CT scan

A

Surveillance
OR
Nerve-sparing bilateral RPLND in selected cases (category 2B)

TEST-9

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26
Q

Postsurgical management: NSGCT
Stage I with or without risk factors, IIA, IIB treated with primary nerve-sparing RPLND

pN0

A

Surveillance

TEST-10

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27
Q

Postsurgical management: NSGCT
Stage I with or without risk factors, IIA, IIB treated with primary nerve-sparing RPLND

pN1

A 
Surveillance (preferred) or
Chemotherapy:
BEP for 2 cycles
or
EP for 2 cycles

TEST-10

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28
Q

Postsurgical management: NSGCT
Stage I with or without risk factors, IIA, IIB treated with primary nerve-sparing RPLND

pN2

A 
Chemotherapy (preferred): 
BEP for 2 cycles
or
EP for 2 cycles or
Surveillance

TEST-10

29
Q

Postsurgical management: NSGCT
Stage I with or without risk factors, IIA, IIB treated with primary nerve-sparing RPLND

pN3

A

Chemotherapy:
BEP for 3 cycles
or
EP for 4 cycles

TEST-10

30
Q

Primary treatment: NSGCT
Intermediate risk
Stage IIIB

A 
Primary chemotherapy:
BEP for 4 cycles (category 1)
or 
VIP for 4 cycles
(category 1)

TEST-11

31
Q

Primary treatment: NSGCT
Poor risk
Stage IIIC

A

Primary chemotherapy:
BEP for 4 cycles (category 1)
or
VIP for 4 cycles in selected patients (category 1)

TEST-11

32
Q

Primary treatment: NSGCT

Brain metastases

A

Primary chemotherapy ± RT ± surgery, if clinically indicated

TEST-11

33
Q

Post-chemotherapy management: NSGCT

Partial response, residual masses with normal AFP and beta-hCG levels
Surgical resection of all residual masses: Teratoma or necrosis

A

Surveillance

TEST-12

34
Q

Post-chemotherapy management: NSGCT

Partial response, residual masses with normal AFP and beta-hCG levels
Surgical resection of all residual masses: Residual embryonal, yolk sac, choriocarcinoma, or seminoma element

A

Chemotherapy for 2 cycles (EP or TIP or VIP or VeIP)

TEST-12

35
Q

Post-chemotherapy management: NSGCT

Partial response, residual masses with abnormal AFP and/or beta-hCG levels

Elevated and rising AFP and/ or beta-hCG levels

A

Second-line therapy

Preferred Regimens
• TIP1
Paclitaxel 250 mg/m2 IV on Day 1 Ifosfamide 1500 mg/m2 IV on Days Cisplatin 25 mg/m2 IV on Days 2–5 Repeat every 21 days
• VeIP1
Vinblastine 0.11 mg/kg IV Push on Ifosfamide 1200 mg/m2 IV on Days Cisplatin 20 mg/m2 IV on Days 1–5 Repeat every 21 days

TEST-12, TEST-F

36
Q

Post-chemotherapy management: NSGCT

Partial response, residual masses with abnormal AFP and/or beta-hCG levels

Elevated but stable AFP and/or beta- hCG levels

A

Close surveillance

TEST-12

37
Q

Post-chemotherapy management: NSGCT

Partial response, residual masses with abnormal AFP and/or beta-hCG levels

Mildly elevated and normalizing AFP and/
or beta-hCG levels

A

Resection of all residual masses:

  • Teratoma or necrosis: surveillance
  • Residual embryonal, yolk sac, chorio- carcinoma, or seminoma element: Chemotherapy for 2 cycles (EP or TIP or VIP or VeIP)

TEST-12

38
Q

Recurrence: NSGCT (second-line)

Prior chemotherapy: early relapse (recurrence =< 2 years after completion of primary treatment)

A

Second-line therapy:

Clinical trial (preferred)
Chemotherapy
- Conventional-dose therapy (VeIP or TIP)
- High-dose chemotherapy
Consider surgical salvage if solitary site (for early relapse)
Recommend sperm banking if clinically indicated

TEST-13

39
Q

Recurrence: NSGCT (second-line)

Prior chemotherapy: laterelapse (recurrence > years after completion of primary treatment)

A

Surgical salvage, if resectable (preferred) Clinical trial, if unresectable
Chemotherapy
- Conventional-dose therapy (VeIP or TIP)
- High-dose chemotherapy
Recommend sperm banking if clinically indicated

TEST-13

40
Q

Recurrence: NSGCT (second-line)

No prior chemotherapy

A

Treat per risk status and recommend sperm banking

TEST-13

41
Q

Post second-line therapy: NSGCT

Complete response, negative markers

A

Surveillance
or
Nerve-sparing bilateral RPLND in selected cases (cat 2B)

TEST-14

42
Q

Post second-line therapy: NSGCT

Partial response, residual masses with normal AFP and beta-HCG levels

A

Surgical resection of all residual masses, then: any histology

Surveillance

TEST-14

43
Q

Post second-line therapy: NSGCT

Partial response residual masses with abnormal AFP and/or beta-hCG levels

Elevated and rising AFP and/or beta-hCG levels

A

Third-line therapy:

Preferred Regimens (High-Dose Chemotherapy)

• Carboplatin/etoposide
Carboplatin 700 mg/m2 (body surface area) IV
Etoposide 750 mg/m2 IV 1
Administered 5, 4, and 3 days before peripheral blood stem cell infusion for 2 cycles

• Paclitaxel/ifosfamide/carboplatin/etoposide
Paclitaxel 200 mg/m2 IV over 24 hours on Day 1
Ifosfamide 2000 mg/m2 over 4 hours with mesna protection on Days 2–4
Repeat every 14 days for 2 cycles followed by
Carboplatin AUC 7–8 IV over 60 minutes on Days 1–3
Etoposide 400 mg/m2 IV on Days 1–3 2 Administered with peripheral blood stem cell support at 14- to 21-day intervals for 3 cycles

TEST-G

44
Q

Recurrence after second-line: NSGCT

Prior first- and second-line conventional dose chemotherapy

A 
Clinical trial (preferred)
or
High-dose chemotherapy
or
Consider surgical salvage if solitary site

TEST-15

45
Q

Recurrence after second-line: NSGCT

Prior high-dose chemotherapy

A

Clinical trial (preferred)
or
Conventional dose salvage chemotherapy
or
Consider surgical salvage if solitary site
or
MSI/MMR testing if progression after high-dose chemotherapy or third-line therapy

TEST-15

46
Q

Late relapse

recurrence >2 years after completion of second- line chemotherapy

A

Surgical salvage, if resectable (preferred)
or
Chemotherapy
• Conventional-dose therapy
• High-dose chemotherapy (if not previously received)

TEST-15

47
Q

RT for pure seminoma:

RT should start ________.
Patients should be treated _______ (frequency)

A

Once the orchiectomy wound has fully healed.

5 days per week.

48
Q

Risk Classification for Advanced Disease (post-orchiectomy:

GOOD RISK, NSGCT

A

Testicular or retroperitoneal primary tumor
and
No nonpulmonary visceral metastases and
Post-orchiectomy markers- all of: AFP < 1,000 ng/mL
hCG < 5,000 iu/L
LDH < 1.5 x upper limit of normal

TEST-D

49
Q

Risk Classification for Advanced Disease (post-orchiectomy:

GOOD RISK, Seminoma

A 
Any primary site
and
No nonpulmonary visceral metastases and
Normal AFP
Any hCG
Any LDH

TEST-D

50
Q

Risk Classification for Advanced Disease (post-orchiectomy:

INTERMEDIATE RISK, NSGCT

A

Testicular or retroperitoneal primary tumor
and
No nonpulmonary visceral metastases and
Post-orchiectomy markers- any of: AFP 1,000–10,000 ng/mL
hCG 5,000–50,000 iu/L
LDH 1.5–10 x upper limit of normal

TEST-D

51
Q

Risk Classification for Advanced Disease (post-orchiectomy:

INTERMEDIATE RISK, Seminoma

A 
Any primary site
and
Nonpulmonary visceral metastases and
Normal AFP
Any hCG
Any LDH

TEST-D

52
Q

Risk Classification for Advanced Disease (post-orchiectomy:

POOR RISK, NSGCT

A 
Mediastinal primary tumorb
or
Nonpulmonary visceral metastases or
Post-orchiectomy markers- any of: AFP > 10,000 ng/mL
hCG > 50,000 iu/L
LDH > 10 x upper limit of normal

TEST-D

53
Q

Risk Classification for Advanced Disease (post-orchiectomy:

POOR RISK, Seminoma

A

No patients classified as poor prognosis

54
Q

Staging

pTis

A

Germ cell neoplasia in situ

55
Q

Staging
pT1
pT1a
pT1b

A

Tumor limited to testis (including rete testis invasion) without lymphovascular invasion

T1a Tumor smaller than 3 cm in size
T1b Tumor 3 cm or larger in size

ST-1

56
Q

Staging

pT2

A

Tumor limited to testis (including rete testis invasion) with lymphovascular invasion
OR
Tumor invading hilar soft tissue or epididymis or penetrating visceral mesothelial layer covering the external surface of tunica albuginea with or without lymphovascular invasion

ST-1

57
Q

Staging

pT3

A

Tumor directly invades spermatic cord soft tissue with or without lymphovascular invasion

ST-1

58
Q

Staging

pT4

A

Tumor invades scrotum with or without lymphovascular invasion

ST-1

59
Q

Staging

cN1

A

Metastasis with a lymph node mass 2 cm or smaller in greatest dimension
OR
Multiple lymph nodes, none larger than 2 cm in greatest dimension

ST-2

60
Q

Staging

cN2

A

Metastasis with a lymph node mass larger than 2 cm but not larger than 5 cm in greatest dimension
OR
Multiple lymph nodes, any one mass larger than 2 cm but not larger than 5 cm in greatest dimension

ST-2

61
Q

Staging

cN3

A

Metastasis with a lymph node mass larger than 5 cm in greatest dimension

ST-2

62
Q

Staging

pN1

A

Metastasis with a lymph node mass 2 cm or smaller in greatest dimension and less than or equal to five nodes positive, none larger than 2 cm in greatest dimension

ST-2

63
Q

Staging

pN2

A

Metastasis with a lymph node mass larger than 2 cm but not larger than 5 cm in greatest dimension; or more than five nodes positive, none larger than 5 cm; or evidence of extranodal extension of tumor

ST-2

64
Q

Staging

pN3

A

Metastasis with a lymph node mass larger than 5 cm in greatest dimension

ST-2

65
Q

Staging
M1a
M1b

A

M1a: Non-retroperitoneal nodal or pulmonary metastases
M1b: Non-pulmonary visceral metastases

66
Q

Staging

S1

A

LDH <1.5 x N* and hCG (mIU/mL) <5,000 and AFP (ng/mL) <1,000

67
Q

Staging

S2

A

LDH 1.5–10 x N* or hCG (mIU/mL) 5,000–50,000 or AFP (ng/mL) 1,000–10,000

68
Q

Staging

S3

A

LDH >10 x N* or hCG (mIU/mL) >50,000 or AFP (ng/mL) >10,000

EAMC Urology (7 decks)

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