Testicular

Question 1

Seminoma good risk

Answer 1

No non-pulmonary visceral mets
Any primary site
Normal AFP
Any HCG, LDH

Question 2

Seminoma intermediate risk

Answer 2

+Non-pulmonary visceral mets

Question 3

Non-seminoma good risk

Answer 3

Testicular or RP primary
No non-pulmonary visceral mets
Post-orchiectomy markers with all of:
-AFP < 1,000
-HCG < 5,000
-LDH < 1.5 x ULN

Question 4

Non-seminoma intermediate risk

Answer 4

Testicular or RP primary
No non-pulmonary visceral mets
Post-orchiectomy markers with any of:
-AFP  1,000-10,000
-HCG 5,000-50,000
-LDH 1.5 - 10 x ULN

Question 5

Non-seminoma poor risk

Answer 5

Mediastinal primary or
Non-pulmonary visceral mets or
AFP > 10,000
HCG > 50,000
LDH > 10 x ULN

Question 6

Stage I definition

Answer 6

Any T N0 M0 S0

Stage 1A = T1 (limited to testis without LVI)
Stage 1B = T2-4

Question 7

Stage I seminoma treatment

Answer 7

Active surveillance (preferred)
Carbo AUC 7 x 1 cycle
Radiation (20-25 Gy)

Question 8

Stage IIA definition

Answer 8

any T N1 M0 S0-1

N1 = 1-5 nodes and all < 2cm
S1 = LDH < 1.5x ULN AND HCG < 5,000 AND AFP < 1,000

Question 9

Stage IIA seminoma treatment

Answer 9

Radiation to para-aortic and ipsilateral iliac LNs (30 Gy)

Question 10

Stage IIB definition

Answer 10

any T N2 M0 S0-1

N2 = Lymph node mass 2-5cm or more than 5 nodes but all < 5cm
S1 = LDH < 1.5x ULN AND HCG < 5,000 AND AFP < 1,000

Question 11

Stage IIB seminoma treatment

Answer 11

Prefer BEP x3 or EP x4

Can consider RT in select patients with non-bulky (<3cm) nodes (36 Gy)

Question 12

Stage IIC definition

Answer 12

any T N3 M0 S0-1

N3 = LN mass > 5cm

Question 13

Stage III definition

Answer 13

Tany Nany M1 Sany

M1a = non-RP nodal or pulm mets
M1b = non-pulm visceral mets
All S2-3 is stage III

Question 14

Stage IIC-III seminoma treatment

Answer 14

Good risk = BEP x3 or EP x4 (no non-pulm visceral mets)

Intermediate risk = BEP x4 or VIP x4 (+non-pulm visceral mets)

Question 15

Post chemo seminoma management

Answer 15

Normalization of markers and CT scan with no residual mass > 3cm –> surveillance
Residual mass > 3cm –> PET scan (at least 6 weeks after chemo)
PET positive mass > 3cm –> resect mass
Markers not normalized or growing mass –> 2nd line chemo

Question 16

Stage I non-seminoma treatment

Answer 16

Active surveillance (preferred)
RPLND
BEP x1

Stage I = Tany N0 M0 S0

Question 17

Stage IS non-seminoma treatment

Answer 17

BEP x3 or EP x4

Stage IS = Tany N0 M0 S1-3

Question 18

Stage IIA non-seminoma treatment

Answer 18

Markers negative:
RPLND or
BEP x3 or EP x4

Markers positive (S1):
BEP x3 or EP x4

Stage IIA = Tany N1 M0 S0-1

Question 19

Management of non-seminoma treated with primary RPLND with normalization of tumor markers

Answer 19

pN0 -> surveillance
pN1 -> surveillance preferred
pN2 -> BEP or EP x2
pN3 -> BEP x3 or EP x4

Question 20

Stage IIB non-seminoma treatment

Answer 20

BEP x3 or EP x4
Consider RPLND in select cases

Stage IIB = Tany N2 M0 S0-1

Question 21

Stage IIC/III non-seminoma treatment

Answer 21

Good risk -> BEP x3 or EP x4

Intermediate or poor risk -> BEP x4 or VIP x4

Question 22

Non-seminoma post-chemo management

Answer 22

Normal markers and no residual masses > 1cm -> surveillance
Normal markers but residual mass > 1cm -> RPLND
Positive markers -> 2nd line chemo

Question 23

2nd line or later seminoma/non-seminoma treatment

Answer 23

Salvage chemo with TIP x4
High dose chemo with stem cell rescue (TI-CE)

TIP = paclitaxel, ifos, cisplatin
TI-CE = paclitaxel, ifos, carbo, etop