Testicular Flashcards
pathophysiology -4
>95% germ cell
---seminoma (45%) #most frequent 4th decade(30s), secrete beta-hCG only
---nonseminoma (50%) #most frequent 3rd decade(20s), secrete beta-hCG, alpha fetoprotein
presentation by stage -5
I: 70%
II: 17%
III: 11%
no stage IV
1st site of dissemination is retroperitoneal LN - need to remove
tumor markers - AFP -3
nonseminoma only
elevated in 40-60%
half-life 4-6 days (IMPT WHEN FOLLOWING TX)
tumor markers - beta-hCG -3
10-20% seminoma
40-60% nonseminoma
half life 1 d (easier to monitor b/c shorter)
tumor markers - LDH -3
nonspecific
80% seminoma
60% nonseminoma
seminoma prognosis -3
HOW MANY RISK STRATIFICATION GROUPS?
better than nonseminoma
good: no nonpulmonary visceral mets
intermediate: nonpulmonary mets
nonseminoma prognosis - POOR -5
afp >10,000
bhCG >50,000
LDH >10 xULN
other mets BESIDES lung
primary TUMOR mediastinal
treatment - seminoma - stage IA or IB -4
three tx options
radical inguinal orchiectomy
all cat 1
1. XRT to RPLN and ipsilateral pelvic LN
- may use carbo 7 x1-2 cycles in place of XRT
- surveillance an option
treatment - seminoma - stage IIA or IIB -2 tx options
IIA = N1 IIB = N2
- XRT
2. if IIB may receive EP x4cycles
treatment - seminoma - stage IIC or III -2 tx algorithms - 3 tx choices
WHAT IS RISK STRATIFICATION?
use risk stratification
all cat 1 recs
good: EP x4 or BEP x3 cycles
int: BEP x4 cycles
treatment - nonseminoma - stage IA or IB -2
IA = tumor limited to testis, NOT tunica vaginalis IB = everything else
- observation vs nerve sparing RPLND, if LN (+) give systemic tx
- IB can receive BEP x2 cycles instead of LN dissection
treatment - radical inguinal orchiectomy -1
ALL pts have this surgery
treatment - nonseminoma - stage IIA -2 algorithms 3 tx choices
WHAT DOES TX CHOICE DEPEND ON?
depends on tumor markers
IF normal:
- BEP x3 or EP x4 (cat 2B)
- RPLND
IF elevated:
1. BEP x3 or EP x4 FOLLOWED BY RPLND OR SURVEILLANCE
treatment - nonseminoma - stage IIB -3
DOES TX CHOICE DEPEND ON ANYTHING?
DOES NOT DEPEND ON TUMOR MARKERS
EP x4 or BEP x3
+/- RPLND as in IIA elevated (outcomes equal if tumor markers nml)
treatment - nonseminoma - stage III - good or int prognosis -2
PAY ATTENTION TO PROGNOSIS
good: EP x4 or BEP x3 FOLLOWED BY RPLND OR SURVEILLANCE
int: BEP x4
EP 3 vs 4 cycles -1
OS decreases if only 3 cycles - give 4
cisplatin vs carboplatin -2
IS ONE BETTER THAN THE OTHER?
cis is significantly better than carbo in both EP and BEP designs
4x relapses, 3x deaths with carbo in EP
treatment - nonseminoma - stage III - poor prognosis -3 tx choices
PAY ATTENTION TO PROGNOSIS
IS HIGH DOSE CIS BETTER THAN STD DOSE = 20 daily x5d q21d?
- BEP x4 is TOC
high dose cis NOT better than std dose (20 qd x5d q21d)
- VIP x4 is no better than BEP (which is better tolerated) but is also cat 1.
- clinical trial - current study looking at front line autoSCT
relapsed dz tx with prior chemo- stage I or II -2 choices
EP x4
BEP x3
relapsed dz tx with prior chemo- stage III -3 choices
- VIP(etoposide=VP-16) or VeIP(vinblastine) - long term remission 25%
- TIP(taxol) - 63% remain in CR
- high dose chemo (usually carbo based) prior to autoSCT -20-90% long term remission, (90% in seminoma)
nonseminoma prognosis - INTERMEDIATE
afp 1,000-10,000
bhCG 5,000-50,000
LDH 1.5-10 xULN
ONLY lung METS
primary TUMOR testis
nonseminoma prognosis - GOOD
afp <1.5 xULN
ONLY lung METS
primary TUMOR testis
staging
I: not node (+), IS: = S1-3 serum markers
II: node (+); S0 = serum markers wnl
III: M, S1-3
serum markers 1 good, 2 int, 3 poor
