Testicular Cancer Flashcards
Risk factors for developing testis cancer including germ cell neoplasia in situ (GCNIS)?
history of UDT/cryptorchidism (4-6x, reduced by 2-3 x if orchidopexy prior to puberty)
family history
personal history of testis cancer
Risk of occult systemic disease for stage one testis cancer is lowest for :
pure seminoma vs. NSGCT
Pure seminomas are more sensitive to chemotherapy and radiation relative to NSGCT?
YES
The most undifferentiated type of NSGCT is?
embryonal carcinoma AND has totipotential capacity (differentiate into other NSGCT - yolk sac, choriocarcinoma, teratoma)
Why is presence of teratoma important for management?
Although histologically benign, may contain genetic anomalies found in malignant GCT → uncontrollable growth and invasion or transformation into somatic-type malignancies
universally resistant to chemo and radiation
ONLY curable by surgical resection
What are the testis cancer tumor markers and their associated histologies?
alpha fetoprotein (AFP) → yolk sac and embryonal (chorio and seminoma do NOT produce) → ½ life 5-7 days
human chorionic gonadotropin (hCG) → chorio and embryonal and syncytiotrophoblastic cells in seminoma → ½ life 24-36 h
lactate dehydrogenase (LDH) → nonspecific, best for estimating disease bulk
Staging for testis cancer is based on:
pathologic stage of tumor
post orchiectomy tumor markers
staging by PE and imaging
Testis TNM
Testis TNM stage:
Testis Risk Categories:
A solid mass on PE or imaging is:
GUIDELINE STATEMENT 1
malignant neoplasm until proven otherwise
When finding solid mass on PE or imaging, what is first step?
GUIDELINE STATEMENT 2
serum tumor. markers (AFP, hCG, and LDH) prior to any treatment
Prior to intervention for testicular mass, patients should be counseled:
GUIDELINE STATMENT 3
risk of hypogonadism and infertility
offered sperm banking (consider prior to orchiectomy if unclear status of contralateral or known subfertility)
What type of scrotal imaging should be used?
GUIDELINE STATEMENT 4
scrotal ultrasound with doppler (for unilateral or bilateral masses)
What workup is required for testicular microlithiasis?
GUIDELINE STATEMENT 5
testicular microlithiasis in absence of solid mass and risk factors doe snot confer and increased risk of malignant neoplasm and doesn’t require further evaluation
Patient with normal tumor markers (hCG and AFP) and indeterminate findings on PE or US, what is next step?
GUIDELINE STATEMENT 6
Repeat imaging 6-8 weeks
(< 2 cm 50-80% are not cancer → benign tumors, infarcts, Leydig cell nodules)
In initial workup of testicular lesion, any other imaging modalities besides US?
GUIDELINE STATEMENT 7
MRI should NOT be used in initial eval and dx of testicular lesion suspicious for neoplasm
Lesion determined by US and PE suspicious for malignancy, next steps after tumor markers?
GUIDELINE STATEMENT 8
with normal contralateral testis
inguinal orchiectomy (testis sparing not recommended, trans-scrotal discouraged)
GUIDELINE STATEMENT 9
testicular prosthesis should be discussed prior to orchiectomy
What is recommended when a patient underwent a scrotal orchiectomy and found to have a testis neoplasm?
GUIDELINE STATEMENT 10
increased risk of recurrence and may be considered for adjunctive tx (excision of scar or RT) for local control
Discuss role of testis sparing surgery, considerations, and surgical considerations?
GUDIELINE STATMENT 11A
tss through inguinal incision in pts wishing to preserve gonadal fx with masses < 2 cm and (1) equivocal US/PE and negative hCG and AFP (2) congenital, acquired or functionally solitary testis, or (3) b/l synchronous tumors
GUIDELINE STATMENT 11B
counseled regarding (1) high risk of local recurrence (2) need for monitoring with PE/US (3) role of adjuvant RT to testis to reduce local recurrence (4) impact of RT ons perm and testosterone (5) risk of testicular atrophy and need for tRT and/or subfertility/infertility
GUIDELINE STATMENT 11C
in addition to suspicious mass, multiple bx of ipsi testis normal parenchyma (GCNIS) should be obtained and evaluated by GU pathologist
In patients with hx of GCT or GCNIS the risk of second primary tumor in contralateral testis is:
GUIDELINE STATEMENT 12
Rare but significant increase risk
(2%overall, 70% metachronous, 30% synchronous)
In patient with GCNIS on testis biopsy or malignant neoplasm after TSS, what are recommendations and options:
GUIDELINE STATEMENT 13A
with GCNIS or s/p TSS → inform patients of r/b of surveillance, radiation, or orchiectomy
GUIDELINE STATEMENT 13B
recommend surveillance in pts who prioritize preservation of fertility and testicular androgen production
GUIDELINE STATEMENT 13C
recommend RT (18-20 Gy) or orchiectomy in patients who prioritize reduction of cancer risk taking into account the less risk of hypogonadism with RT
Discuss utility of serum tumor markers in treatment planning:
GUIDELINE STATEMENT 14
Nadir makers should be repeated at appropriate T ½ time interval after orchiectomy for staging and risk stratification
GUIDELINE STATEMENT 15
for pts with elevated AFP or hCG post orchiectomy, clinicians should monitor tumor markers to establish nadir levels before treatment only if nadir would influence treatment
In metastatic GCT (Stage IIC or III) planning for chemo what is the regimen based on?
GUIDELINE STATEMENT 16
IGCCCG risk stratification based on serum tumor markers (hCG, AFP, LDH) prior to chemo, staging imaging studies, and tumor histology from orchiectomy. Any post-pubertal male, should be treated as an adult
Describe Good Prognosis risk category for Seminoma and Non-Seminoma GCT:
Non-Seminoma
Testis/retroperitoneal primary, no non-pulmonary visceral mets, good markers
(AFP < 1000, hCG < 5000, LDH < 1.5 x norm)
56% of non-seminomas
5 yr PFS 89%
5 yr OS 92%
Seminoma
any primary site, no non-pulmonary visceral mets, normal AFP, any hCG, any LDH
90% seminomas
5 y PFS 82%
5 y OS 86%
Describe Intermediate Prognosis for Seminoma and Non-Seminoma GCT:
Non-Seminoma
testis/retroperitoneal primary, no non-pulmonary visceral mets, intermediate markers
(AFP > ,1000 < 10,000, hCG > 5,000 and < 50,000, and LDH > 1.5 x N and < 10 x N)
28% non-seminomas
5 y PFS 75%
5 yr OS 80%
Seminoma
any primary site, non-pulmonary visceral mets, normal AFP, any hCG, any LDH
10% seminomas
5 y PFS 67%
5 y OS 72%
Describe Poor Prognosis for Seminoma and Non-Seminoma GCT:
Non-Seminoma
mediastinal primary, non-pulmonary visceral mets, poor markers
(AFP > 10,000, hCG > 50,000, LDH >10 x N)
16% of non-seminomas
5 y PFS 41%
5 y Survival 48%
Seminoma
No patients classified as poor
Post orchiectomy elevated (AFP and hCG - 3 x normal), what should be done before treatments?
GUIDELINE STATEMENT 17
A rising trend should be confirmed before management decisions are made as false positive elevations may occur
Patients with newly diagnosed GCT, what imaging should be done?
GUIDELINE STATEMENT 18
CT scan A/P with IV contrast or MRI (if CT contra)
GUIDELINE STATEMENT 19A
Chest imaging
GUIDELINE STATMENT 19B
In setting rising of post-orchiectomy markers, mets on CT A/P, CXR or PE, A CHEST CT
GUIDELINE STATMENT 19C
Stage 1 seminoma, CXR (superior specificity) over Chest CT
GUIDELINE STATEMENT 19D
NSGCT Chest CT over CXR (especially if recommended adjuvant tx)
GUIDELINE STATEMENT 20
Newly dx GCT, do NOT obtain PET for staging
In newly dx GCT, how do you guide management decisions?
GUIDELINE STATEMENT 21
assign of TNM category
(image chest, A/P, post orchiectomy nadir AFP, hCG, and LDH)
GUIDELINE STATEMENT 22
Imaging w/in 4 weeks
Markers w/in 10days
Management decisions for newly dx GCT should be made with whom and based on which histology?
GUIDELINE STATEMENT 23
Multidisciplinary team (urology, med onc, rad onc, pathology, radiology)
GUIDELINE STATEMENT 24
Expert review of pathology in clinical scenarios where treatment decisions impacted
(review of expert alters subtype in 4-6%, 27% pathology reports revised)
In newly dx patients post orchiectomy with normal STM and equivocal findings on imaging for mets, how do you decide on tx?
GUIDELINE STATEMENT 25
Consider repeating imaging 6-8 weeks to clarify extent of dz before tx
Recommended tx for Seminoma GCT stage 1:
GUIDELINE STATEMENT 26
Surveillance after orchiectomy (<20% recurrence)
adjuvant RT and carboplatin-based chemo are less preferred (3-9% recurrence)
Recommended tx for pts w/Seminoma GCT and Stage IIa/b with LN < 3 cm? For IIB w/LN > 3 cm?
GUIDELINE STATEMENT 27
IIA/B LN < 3 cm: recommend RT(dog leg up to 30 Gy) or multi-agent cisplatin-based chemo (4 cycles EP or 3 cycles BEP) based on SDM
IIB LN >3 cm: chemotherapy recommended
Long term chemotherapy for GCT a/e:
cardiovascular, gastrointestinal, hematologic, infertility, secondary malignancy, neurologic, renal, pulmonary
Recommended tx for patients with NSGCT with elevated or rising post orchiectomy serum AFP and hCG:
GUIDELINE STATEMENT 28
risk appropriate multi-agent chemotherapy
Recommended treatment for Stage 1A NSGCT:
Reminder: IA pT1N0M0S0(beyond seminiferous tubules, still in testicle)
GUIDELINE STATEMENT 29
Surveillance preferred
RPLND or BEP x 1 (decline surveillance or non-compliance)
What are independent risk factors for relapse in NSGCT?
LVI and embryonal carcinoma
Recommended treatment for Stage 1B NSGCT:
Reminder IB: pT2-T4N0M0S0
GUIDELINE STATEMENT 30
surveillance, RPLND, or 1-2 BEP based on SDM
Patients with stage 1 NSGCT and any secondary somatic malignancy (teratoma with malignant transformation) in primary tumor, what is recommended tx:
GUIDELINE STATEMENT 31
RPLND
(teratoma has capacity to de-differentiate into somatic malignancy including sarcomas and carcinomas)
Patient with stage IIA NSGCT and S0, recommended tx:
Reminder IIA: any pTN1 (<5 nodes, < 2 cm) M0 S0 or S1 (in this question S0)
GUIDELINE STATEMENT 32
RPLND (benefit avoid chemo/remove teratoma) or chemotherapy
Patient with stage IIB NSGCT and S0, recommended tx:
Reminder: Stage IIB: Any pT, N2 (1 but <5 nodes with >2cm <5 cm, OR grown outside LN, OR > 5 nodes), M0S0 (this case) or S1
GUIDELINE STATEMENT 33
Risk-appropriate BEP vs. possible RPLND (select patients, S0)
Who should perform RPLND and how?
GUIDELINE STATMENT 34
referral to experience surgery at high volume center
GUIDELINE STATEMENT 35
experience and expertise with MIS can consider, acknowledge lack of long-term oncologic data
Describe an RPLND with curative intent:
GUIDELINE STATEMENT 36
*full b/l template with pts with suspicious LN on CT or intra-op or teratoma
*full b/l or modified template may be performed in clinically neg nodes
*right modified template may omit para-aortic LN below IMA (omission para-aortic LN above IMA controversial)
*left modified template may omit paracaval, precaval, and retrocaval LN (omission of interaortocaval LN controversial)
*nerve-sparing should be offered to preserve ejaculatory function
*nerve-sparing should NOT compromise quality of dissection
*complete retroaortic and/or retrocaval LND w/dissection and division of lumbar vessels should be performed within planned template
*ipsilateral gonadal vessels removed in ALL patients
*cephalad extent is crus of diaphragm to level of RA, caudad extent crossing of ureter over ipsilateral common iliac
After primary RPLND, what is recommended mgmt based on staging features:
GUIDELINE STATEMENT 37
Surveillance or chemo with stage II (not pure teratoma)
pN1 and/or pN1-3 pure teratoma → surveillance
pN2-3 → multi-agent chemotherapy (BEP)
What is surveillance protocol for Stage I seminoma:
GUIDELINE STATEMENT 38
H&P, cross-sectional imaging of abd +/- pelvis q 4-6 mo x 2 y, q6-12 mo yrs 3-5
routine chest and STM as indicated clinically
What is surveillance protocol for Stage I NSGCT:
GUIDELINE STATEMENT 39
After Orchiectomy: H&P and STM (AFP, hCG, +/- LDH) q2-3 mo x 1 year, q 2-4 mo in year 2, q 4-6 mo in year 3, q 6-12 mo years 4-5, >5 if indicated
GUIDELINE STATEMENT 40
CXR + CT A +/- P q 3-6 mo year 1 (start 3 mo), q 4-12 mo in year 2, once year 3-5
Men with higher risk of relapse should be imaged at shorter intervals (e.g. LVI)
Patients who relapse should be treated according to what? Stage 1 GCT on surveillance have what risk of relapse > 5 years?
GUIDELINE STATMENT 41
pts with relapse on surveillance should be fully restaged and treated based on new TMN-s status
GUIDELINE STATEMENT 42
Stage I GCT on surveillance < 1% late relapse after 5 y, annual serologic and radiographic assessment should be performed as indicated based on clinical concerns
How should survivors of GCT be monitored for hormonal status and long term sequelae of treatment?
GUIDELINE STATEMENT 43
monitor for s/s hypogonadism, if present serum AM testosterone and LH
GUIDELINE STATEMENT 44
survivors s/p chemo and/or RT → elevated risk CVD, establish PCP to manage modifiable risk factors (diet, exercise, smoking, lipids, BP, glucose)
GUIDELINE STATEMENT 45
survivors s/p chemo and/or RT → elevated risk secondary malignancy, establish PCP for checkups and cancer screening
What are important questions to ask a young man who presents with scrotal swelling?
urethral discharge/unprotected sex
dysuria/hematuria
back pain (myalgia)
hx of UDT
Shortness of breath
trauma
constitutional sxs (weight loss/night sweats)
headache
pain
What are important aspect of physical exam with suspected testicular mass?
lung exam
testis/spermatic cord
hydrocele
gynecomastia
inguinal exam
abdominal exam
what are all possible elements of post orchiectomy workup and why?
MRI brain if headache or neuro sxs
sperm banking if not done prior
repeat STM
CT A/P
CXR (ok if CT A/P normal and STM normal after orchiectomy) vs. CT (poor prognostic features or sob)
Bone scan: clinical features warrant ALP + scan (pain, fracture?)
what is the primary mechanism of spread of testicular tumors?
lymphatic
what is important testing to conduct prior to chemo, if lung mets or pulm sxs/hx?
PFTs
If abnormal avoid Bleomycin
What are short term and long term a/e of Bleomycin?
Pulmonary fibrosis
Raynaud’s
What are short term and long term a/e of Etoposide?
Myelosuppression
What are short term and long term a/e of Cisplatin?
Neurotoxicity
Nephrotoxicity
Ototoxicity
Describe risks and concerns for consent for post-chemo RPLND?
risks retrograde ejaculation, vascular injury, blood txfn, possible grafting of vessels, nephrectomy. chylous ascites, ileus, bowel/ureteral injury
*minimize perioperative FiO2 and fluid overload (Bleo)
Describe operative steps of RPLND?
- Transabdominal midline incision (xiphoid to below umbilicus)
- (can do robotic if can justify)
- Incise posterior peritoneum from ileocecal valve to ligament of Treitz
- Mobilize right colon, small bowel, and duodenum off RP to expose great vessels with clear exposure of renal veins; IMV can be divided to facilitate mobilization of left colon mesentery if necessary
- Split and roll technique with ligation/division of all lumbar vessels to allow complete mobilization of great vessels to facilitate a complete dissection; L3 most important for ejaculation (sympathetic chains just above common iliacs
- Complete resection of remainder of right spermatic cord
- Nerve sparing can be attempted if no compromised of oncologic principles/complete resection, but not required
Describe template for post chemo RPLND:
lateral → right and left ureter
Inferior → ureter crossing iliac
Superior → renal vessels (suprahilar not routinely required)
How do you diagnose chylous ascites?
CT A/P shows fluid ascites, air in small and large bowel
JP triglycerides elevated (like 1000)
What are the management steps for chylous ascites?
1st line: diuretic with fluid & salt restriction and low fat diet with medium chain fatty acid supplement
2nd line: if persistent for weeks, NPO/TPN
What do you do for 3 cm RP mass after RPLND for NSGCTin patient with known teratoma?
High dose chemo/BMT
VeIP (etoposide, ifosfamide, cisplatin, mesna)
TIP (paclitaxel, ifosfamide, cisplatin, mesna)
What is treatment for stage Ib (pT2N0M0S0) seminoma?
Surveilance, XRT or chemo - Carboplatin 1 (preferred) or 2 cycles
What are the side effects of carboplatin?
short term myelosuppression
long term secondary malignancy and heart disease
What are side effects of RT?
short term: nausea, emesis, diarrhea, leukopenia
long term: dyspepsia, PUD, oligospermia, secondary malignancy
Patient with recurrent seminoma s/p EP x 4, with residual RP mass (originally 6 cm now 4 cm). Next steps? If positive, next steps?
PET scan (CT PET)
> 6 weeks after completion chemo
Next steps:
RPLND vs. Surveillance (controversy, both acceptable per NCCN)
What are common presentations in testicular carcinoma?
- Painless testicular enlargement–most common
- Testicular mass–firm lump or nodule
- Testicular pain–heaviness, aching, acute pain~10%
- Gynecomastia–%5
- Abdominal mass or pain
- Respiratory problems
When performing orchiectomy for testicular mass, when would you recommend biopsy of contralateral side?
US abnormal
UDT or poor spermatogenesis
Marked atrophy (volume <12)
Half lives of STM?
BhCG 24-46 h (check 1 week)
AFP 5-7 days (check 4 weeks)
LDH 4 days
Treatment options for IB seminoma?
- Surveillance: best option with low risk (tumor size < 4 cm, no rete testis invasion, recurrence as low as 6%); need compliance, concern for radiation (CTs)
- EBRT: seminoma very radiosensitivity, long term radiation toxicity < 2% (cardiac disease doubled, risk secondary malignancy); para aortic field and ipsi nodes (“dog leg”) 20 Gy in 10 fx; relapse 1-3%
- Single dose carboplatin: noncompliant patients; equivalent relapse to RT, short term a/e thrombocytopenia and GI toxicity
Describe surveillance for IB seminoma post orchiectomy? After RT or chemo?
Orchiectomy:
HPI: 1 year: q3-6 mo, 2-3 year: q6-12 mo, 4-5 year: 1 x year
A/P CT: at 3, 6, 12 mo, 2-3 year q 6-12 mo, 4-5 year: q 12-24 mo
CXR: if clinically indicated, sxs consider CT
Chemo/RT
HPI: 1-2 year: q6-12 mo, 3-5 year 1 x year
A/P CT: 1-3 year: q1 x year, 4-5 year not indicated
CXR: if clinically indicated, sxs consider CT
Tx of IIA seminoma? And IIB?
IIA:
Traditional (preferred): EBRT to para-aortic and ipsi iliac PLN → 30 Gy
OR
Primary chemotherapy: EP x 4 or BEP x 3 for multiple positive LN
IIB:
Preferred: Primary chemotherapy: EP x 4 or BEP x 3
RT in non-bulky cases include para-aortic and ipsi iliac LN → 36 Gy
For stage IIC or III seminoma what determines tx?
Risk factors
Good risk: any primary site, no non-pulm visceral mets, normal AFP, any hCG or LDH
Intermediate risk: any primary site, non-pulmonary visceral mets, normal AFP, any hCG or LDH
Poor risk: no seminoma is poor risk
Treatment for good risk IIC or III seminoma? intermediate risk?
Good risk: Primary chemo EP x 4 or BEP x 3
Intermediate risk: BEP x 4 or VIP x 4 or clinical trial
How do you manage post-chemo residual mass for seminoma?
Likely fibrosis or necrosis
< 3 cm → surveillance
>3 cm → PET scan > 6 weeks after chemo, if + RPLND or chemo (conventional dose VeIP or TIP, or high dose chemo)
risk factors for testicular carcinoma?
gonadal dysgenesis
h/o prior testis tumor
CIS or intraepithelial germ cell neoplasia
UDT (intra-abd → seminoma, inguinal after pexy → NSGCT)
HIV
FHx
Infertility with Klinefelter’s
Hypospadias
Name primary GCT (relative frequency) and non-GCT?
Primary Germ Cell Tumors: seminoma (60%), embryonal carcinoma (20%), teratocarcinoma (15%), teratoma (5%), chorio (1%), yolk sac (<1%)
Non Germ Cell Tumors: only 10% malignant, orchiectomy and surveillance: Leydig cell tumor, Sertoli cell tumor
Describe path of testicular carcinoma spread?
Primarily via Lymphatics
RP node mets → cisterna chyli → thoracic duct → supra-diaphragmatic nodes → extra-nodal/distant mets
**exception is chorio or yolk sac which can demonstrate hematogenous spread
Describe nodal spread pattern for right testis tumor? left testis tumor?
Right: Interaortocaval → precaval → preaortic → right common iliac → right external iliac
Left: paraaortic → preaortic → left common iliac → interaortocaval → precaval → paracaval
*lymphatic spread goes from right to left in RP
What are treatment options for stage IB NSGCT?
- Surveillance (only pT2)
- Patient needs to be very compliant with rigorous surveillance
- >50% embryonal may increase risk of relapse and make surveillance inferior to tx
- LVI most important factor to predict occult mets
- SWENOTECA trial, all men stage I NSGCT no LVI underwent surveillance, BPE x 1, or BEP x 2, recurrence 12%, 1%, 0%
- Chemo
- 1 cycle BEP or 2 cycles (teratoma resistant, risk of infertility, secondary cancer, cardiac dz)
- NS-RPLND (appropriate for stage I and IIA
Risk of teratoma at RPLND? if in orchiectomy and if not?
In orchiectomy: 2-19%
Not in orchiectomy: 5-7%
What are the types of RPLND? Templates?
- Standard: includes full b/l dissection from above the RV to below aortic bifurcation, anejaculation approached 100% since sympathetic ganglia were sacrificed
- Superior: L adrenal, renal veins, below SMA
- Inferior: aortic bifurcation, IMA is sacrificed
- Medial: to contralateral ureter
- Lateral: renal hilum, ureter, iliac bifurcation
- Limited: area overlying aorta below IMA spared, most post-ganglionic sympathetics preserved, ejaculation 80-90% pts
- Superior: L adrenal, renal veins, below SMA
- Inferior: above IMA (IMA spared)
- Medial: lateral to aorta
- Lateral: renal hilum, ureter, iliac bifurcation
- NS-RPLND: preserves branches sympathetic chain over aorta, 100% ejaculation; not usually recommended for grossly pos nodes, usually performed in combo with limited dissection
What percentage of IB are upstaged to stage II on RPLND?
30%
If LN are grossly positive on RPNLD (stage IIB: >2 cm < 5 cm) what intraoperative template adjustment is made?
bilateral suprahilar dissections extending 4-6 cm above renal arteries to expose crura of diaphragm, IMV ligated, SMA identified and preserved, cisterna chyli is clipped
Superior: first hepatic vein (IVC)
Inferiorly: renal arteries
Laterally: medial aspect of adrenal glands
If nodes + near IMA → extend to lower aorta and contralateral common iliac (retrograde lymph spread)
If nodes + superior to IMA → lower aorta preserved
Potential complications of RPLND?
- IVC laceration: proximal and distal control, oversew with 4-0 Prolene, hold pressure, if cannot control, consult vascular
- IMA injury: ligate if necessary since collateral circulation (marginal artery of Drummond)
- IMA supplies distal half of transverse colon, descending colon, sigmoid, and rectum
- SMA supplies proximal half of transverse colon, ascending colon, and small bowel
- Cisterna Chyle laceration: located right of L1-L2, ligate if recognized intraop, unrecognized will result in chylous ascites
- Dx by paracentesis, NPO, TPN or low fat, high protein, medium chain triglycerides diet, possible somatostatin analogues
NSGCT stage IA, IB without risk factors, IIA, IIB treated with primary RPLND, what is tx for various nodal stages?
N0 → surveillance
N1 → surveillance (preferred) or chemotherapy (EP x 2)
N2 0→ chemotherapy (preferred - EP x 2) or surveillance
N3 → chemotherapy (BEP x 3 or EP x 4)
NSGCT IIA/IIB s/o RPLND, WITHOUT adjuvant chemo surveillance?
H&P and markers: 1 year: q2 mo, 2 year
NSGCT IIA/IIB s/o RPLND, WITH adjuvant chemo surveillance?
NSGCT Stage I s/p RPLND or chemo, surveillance?
NSGCT Stage 1 primary active surveillance w/o risk factors?
Risk factors: LVI, invasion of spermatic cord or scrotum, embryonal
NSGCT Stage 1 primary active surveillance w/ risk factors?
Risk factors: LVI, invasion of spermatic cord or scrotum, embryonal
NSGCT II/III after complete response to chemo +/- RPLND?
What can cause AFP elevation?
hepatoma, pancreas carcinoma, bronchogenic carcinoma
elevated in fetal yolk sac tumor, embryonal, teratocarcinoma
infants < 1 yo
Liver dysfunction (hepatitis, cirrhosis)
What can cause bhCG elevation?
chorio, seminoma, teratocarcinoma, embryonal
cross reacts with FSH, LH, TSH
marijuana users
What can cause LDH elevation?
seminoma and non-seminoma
Isoenzyme 1 is most useful
monitor treatment when AFP and bhCG normalized
useful for “bulky” seminoma
Stage IIC NSGCT, how do you determine the number of chemo cycles?
- Good risk: treat with EP x 4 or BEP x 3
AFP < 1,000, HCG < 5,000, LDH < 1.5 X N (S0 or S1)
- Intermediate risk: treat BEP x 4
AFP 1,000-10,000, HCG 5,000-50,000, LDH 1.5-10 x N (S2)
- High risk: treat BEP x 4 or VIP x 4
AFP > 10,000, HCG >50,000, LDH 10 x N (S3)
Mediastinal primary
Potential complications and treatment from RPLND?
- ARDS → bleomycin → increases w/ increased FIO2 and over-hydration
- Ventilate patients with RA and do not use FIO2 > 25-30%
- Use colloid to crystalloid ratio 2:1
- Prefer RBC over crystalloid
- Mass invades duodenum → perform duodenal resection
- IMA is encased in tumor → divide IMA as long as marginal artery intact
- Ureter is encased or invaded by tumor → nephroureterectomy
- Tumor invades aorta, IVC, lilac vessels → excise and replace affected vessels, perform vascular patch
- Psoas muscle involved by tumor → resect psoas fascia and affected muscle
- Tumor thrombus present in IVC below renal veins → ligate vena cava below renal veins, pts will develop temporary lower extremity edema
- Tumor invades the wall of IVC below the renal veins → legate the vena cava below renal veins, pts will develop temporary lower extremity edema
- Sigmoid mesentery is adherent to mass → resect the mesentery and mesenteric vessels, make sure the marginal artery and vein remain intact
What chemotherapy regimens are used in salvage setting for testicular cancer?
- VeIP (VP-16, Ifosfamide, Cisplatin) → mesna to protect bladder from Ifosfamide, 30% durable responses
- TIP (Paclitaxel, Ifosfamide, Cisplatin) → mesna to protect bladder from Ifosfamide, 25% durable responses
- Gemcitabine/Ifosfamide/Cisplatin → small study reporting 54% response rate
- High dose chemotherapy → with autologous peripheral blood derived stem cell support, unfavorable prognosis group (incomplete previous response, high markers, high volume, extratesticular primary, late relapse)
- 2 cycles of high dose Carboplatin plus Etoposide, w/ or w/o Cyclophosphamide (or Ifosfamide) → 20% durable responses
Follow up regimen after salvage chemotherapy for testicular cancer?
CXR and markers q3 mo x 2 years, then q6 mo x 3
CT A/P q 6 mo
How do you manage post chemotherapy residual mass for NSGCT? Seminoma?
NSGCT → residual mass should be excised as completely as possible if > 1 cm
Markers have to normalize before RPLND, if elevated → further chemotherapy
Seminoma → residual mass > 3 cm and normal markers → PET CT vs. surveillance → Indeterminate → repeat PET 6-8 weeks vs. bx → Positive → RPLND vs. bx
If there is mixed pathology seminoma and nonseminoma, how do you treat?
NSGCT recommendations
what are primary landing sites for left and right testicular tumors?
Left → para-aortic → preaortic
Right → interaortocaval → precaval → right iliac
describe the nerve sparing elements of RPLND? why important?
prevent anejaculation or other ejaculatory dysfunction
ID and preserve sympathetic trunks (L1-4) as they course posterior to the IVC on the right and anterior to aorta on the left, they coalesce just inferior to the IMA at inferior hypogastric plexus
What are treatment options for scrotal contamination in testis cancer?
- Stage 1 pure seminoma → extend RP radiation to include ipsi scrotum and inguinal nodes (risk of azoospermia)
- Stage 1 NSGCT → widely excise previous scar and spermatic cord at time of RPLND, or separate procedure if no RPLND, perform formal hemiscrotectomy in case of gross contamination but ill not eliminate risk of relapse
- Advanced dz → tx with full dose platinum chemo → examine inguinal nodes at f/up
**contamination increased recurrence but not OS
Which nodal status is chemo indicated for post RPLND Stage IA/B or IIA/B treated with primary RPLND? Which regimens?
Follow up post primary RPLND in need of adjuvant chemotherapy?
CXR and markers q3 mo x 2 years, the q 6 mo x 3 years
CT scan q 6 mo
Treatments for clinical stage IIA NSGCT with negative markers?
Primary NS-RPLND
OR
Primary chemotherapy EP x 4 or BEP x 3
Treatments for clinical stage IIB NSGCT with negative markers?
Treatments for clinical stage IIA NSGCT with persistent markers elevation?
Primary chemotherapy → BEP x 3, EP x 4
Treatments for clinical stage IIB NSGCT with positive markers?
Primary chemotherapy: BEP x 3, EP x 4
Primary chemotherapy for early clinical stages with persistent marker elevation:
What is growing teratoma syndrome?
RP masses that contain teratomas enlarge (sometimes quickly) in the face of normal STM. Usually benign, but warrant surgical excision, if left alone may spread and compromise vital organ function (bowel, ureters, vessels) by local invasion
Why can testis tumors cause gynecomastia?
NSGCT can produce elevated levels of estradiol
Leydig cell tumors promote peripheral conversion of testosterone to estrogen (but will not cause elevation in STM)
What if you remove a testicular tumor in a patient with clinical symptoms (e.g. gynecomastia), elevated STM, and a supraclavicular node, and the pathology shows scar and no active malignancy?
“burned” out testis tumor or extragonadal
Must perform excisional bx or FNA of supraclavicular node
Describe risk classification post-orchiectomy for NSGCT and seminoma
Post orchiectomy for NSGCT, with NED, with isolated bHCG elevation, what can be the cause?
Elevated LH
Single testicle → low testosterone → anterior pituitary increased LH which has cross reactivity with bhCG
Give testosterone injection and retest (if goes down, no further action)
