Testes Flashcards
RP tumor in male 15-35
assume testis origin
workup of tumor for germ cell tumor men
CT AP, CXR, US bilateral, AFP, HCG, LDH; if non-seminoma, then CT chest. You do NOT need PET/brain MRI. get brain MRI if very high bHCG
not needed workup of testis
PET/CT
AFP
only embryonal or yolk sac, NOT seminoma
HCG
seminoma (15%), embryonal, choriocarcinoma
teratoma markers
NO markers
AFP half life
5-7 days
HCG half life
1-3 days
R testis landing zone
between IVC and aorta- interaortacaval (R in between)
L testis landing zone
lateral to aorta- para-aortic (L stands on own)
landing zone nodes
if 5-10mm-50%; 10-15 70%; 15-20 90% likely disease
herniorraphy, orchiopexy
need to look more broadly in pelvis for mets because of altered anatomy
seminoma: intermediat risk
non-pulm mets; all others low risk
seminoma
don’t worry about markers for staging
nonseminoma good risk
low markers, no non-pulm mets
nonseminoma poor risk
S3 markers, nonpulm mets, or primary mediastinal
S1 POST-ORCHIECTOMY
HCG<1000
S2 POST-ORCHIECTOMY
HCG 5-50k, AFP 1-10,000; LDH 1.5-10ULN “1k,1.5x,5k”
S3 POST-ORCHIECTOMY
> 10ULN LDH; HCG>50k, AFP>10k “10k:10x:50k”
first line-Tx
cis/etop +/- bleomycin
favorable response
CR or PR with negative markers (PR means major shrinkage with normal markers)
if markers elevated post-orchiectomy
needs chemo, have systemic disease
chemo for good risk
BEPx3 (Indiana) or EPx4 (MSK)
reduced chemo
worse survival, not reduced CR rate
etoposide dose
500
cisplatin dose
100
fair dose mods
delay 1 week for neutropenia; or no VP16 on day 5 if WBCt reduce dose!
Toxicities with BEP3 or EP4
BEP3 worse, more neurologic
carbo instead of cis?
NO inferior! 72% v 92% survival
intermediate and poor risk disease
BEPx4 OR (BEPx2 and HD-CEC x 2) or VIPx4; cure rate 45-70% with surgery
absolute refractory disease
very rare, incurable
favorable prognosis in second line
prior CR/favorable response >6months
unfavorable relapse
mediastinal relapse, prior CR<6mo, extragonadal primary
salvage approach second line favorable group
VeIPx4 v. TIPx4
unfavorable group second line salvage
TI–>HD-CE or VIP–>HD-CE
salvage therapy cure rate
65-70% cure rate; if late relapse/mediastinal/ovarian–>, low 20% cure rate unfavorable 50-60% cure;
after salvage do you need surgery
yes! you will find teratoma in 50%, viable germ cell in 30%
germ cell tumor primary
2% will have bilateral, need both ultrasound
scrotal orchiectomy
not indicated- predisposes to mets, leaves inguinal spermaticord in place
seminomas markers
15% make hCG, NEVER AFP
embryonal carcinoma
hCG and AFP
AFP half life
marker 5-7 d
HcG
marker 1-3 day
teratoma
no markers
york sac tumor
AFP
choriocarcinoma
only hcg
R testis landing zone
between IVC and aorta (in between IVC and sorta
L testis tumor landing zone
para-aortic space L testis (L of aorta)
landmark landing zone likelihood of disease for germ cell tumors
5-10mm node–>50% have disease, 10-150–> 70% have disease. important for deciding whether to do RP dissection after chemo in non-seminoma.
seminoma risk strata
good risk- no Non-Pulm mets; intermediate risk- non-pulmonary mets.
toxicities of good-risk regimens for germ cell (BEPx3, EPx4)
more toxicity in BEP3- neurologic, and dermatologic
CS 1-S and CS-2A with elevated/rising AFP/HCG
do chemo first.
seminomas >3cm
give chemo BEP3/EP4, NOT RT
CS 2A and CS2B seminoma <3cm
RT acceptable or EP4/BEP3
germ cell tumor: carbo v. cis, and dose
DO NOT USE CARBOPLATIN; DO NOT DOSE REDUCE either platinum or etoposide! you can delay a week if needed
intermediate and poor risk GCT
adding high dose chemotherapy is not necessary. you can give either BEP4 or VIPx4 (VIP has more tox- etoposide, ifosfamide,cisplatin)
good risk GCT prognsosis,
> 90% with surgery, inter/high 70%
first salvage chemo for GCT
VeIPx4 (vinblastine, ifos, cis), TIPx4, or standard chemo x 2–>high dose carbo/etop x 2
3 groups of GCT in salvage setting: favorable prognosis (testis/RP primary, >6months CR before relapse)
can cure 60-80% with VeIPx4, TIP4 or high dose therapy with TICE (high-dose
salvage GCT- unfavorable prognosis- late relapse , prior CR
give TICE (high dose).taxol, ifos, carbo, etop. 50-60% cured
salvage GCT- absolute refractory in untreated patients
these pts are incurable with high dose therapy, just palliate
surgery in germ cell tumors (non-seminomas)
pts ALL need surgery to ensure that there is no recurrence
i12 or 12p amplification
on 100% of germ cell tumors.
primary teratomas of testis
ALWAYS has malignant potential, over 50% met
if residual nodes are >1cm following chemo with GCT
NEED RPLND
if no RP at chemo start with GCT
no RPLND
if RP node <1cm following chemo with GCT
MSKCC-RPLND, indiana, leave in place and monitor
late relapses with GCT
> 2 years. mostly probable of failure to control abdomen. cure rate is lower
growing teratoma syndrome
resect and continue chemo. common.
PET/CT in GCT?
valuable tool only for pure seminoma, but lots of false positive
seminoma RP dissections?
not done. give chemo. if >3cm residual, PET can be done, then resect if positive.
bleomycin tox
reynaud’s, pulm
BEP tox
MI (7x risk, similar to hodgkin’s) 6x
genetics of germ cell tumors
iso(12) or amp of 12p–> CCND2, SOX5, JAW1, KRAS
surgery for testicular
radical inguinal orichectomy, ligate spermatic cord at internal ring
markers of seminoma
+PLAP, c-Kit, OCT-4, SALL4, -CK, -CD30
markers of embryonal ca
CK+, CD30+ OCT-4+ SALL4+
yolk sac tumor
+CK, +AFP +SALL4, -CD117(ckit), - CD30
invasion into epidydimis/spermatic cord
could result in iliac LN involvment
scrotal invasion
inguinal LN
Tx stage 1 seminoma
i.e. LN-neg. observe. may consider para-aortic RT (morbidity tho) or 1 dose carbo.
Tx stage IIA seminoma
Tx stage IIB seminoma
> 5LNs or 2-5cm. RT or chemotherapy (EP x 4 or BEP x 3)
Tx stage IIC-and up seminoma
good risk tx with EP x 3, if >3cm mass and normal tumor marker, get PET/CT >6wk, and surgery if positive. other wise observe
bleo dose
30KU x 3= 90KU per cycle
intermediate risk chemo
BEPx4
high risk nonseminoma chemo
BEPx4. some studies show possible improvement of adding high dose if slow decline in tumor markers
excess 12p material
correlates with response to cisplatin
stage Ib non-seminoma treatment
i.e. -LN but at least 1 high risk feature, but no markers after orchiectomy–> surveillance OR RPLND, adjuvant chemo IF stage II pathologically
stage IIA nonseminoma treatment
i.e. RPLND and surveillence
stage IIB nonseminoma treatment
i.e. >5LN or 2-5cm–> RPLND and 2 cycles chemo. if looks like 2B before surgery, give primary chemo.
stage IIIC non-seminoma treatment
i.e. >5cm. primary chemo. if incidental on RPLND, then give 3-4 cycles adjuvant chemo.
