Testicular cancer Flashcards
Testicular cancer RF
1) crypto-orchidism (undescended testes at birth)
*Both testes at risk, including descended testes
2) Agent orange
3) infertility
*Not smoking or obesity
Half life of beta-HCG and AFP
HCG half life one day
AFP 5 days
Management of primary mediastinal NSGCT
- VIP x 4 cycles (Preferred - Bleo not used Require surgery and post-op complications higher with BEP)
OR BEP x 4 cycles - Consult thoracic surgery for resection of residual mediastinal disease
Primary mediastinal seminoma management
BEP
Follow residual mass with surveillance CT chest
cytogenetic finding associated with testicular cancer
isochromosome 12p
Testicular mass tissue sampling
- inguinal orchiectomy
Lymphatic spread of testicular cancer
- to ipsilateral RP nodes, never to inguinal or pelvic unless anatomy has been altered (cryptoorchidism, bad urologist doing testicular biopsy)
1) general management of primary mediastinal NSGCT 2) preferred systemic therapy
- VIP (not bleomycin)
- thoracic surgery then resects residual mediastinal disease
management of primary mediastinal seminoma
- good risk disease
- BEP, then you follow residual mass w/ CT chest
clinical significance of path showing seminoma with AFP elevation
- non seminoma component, by definition
other cause of beta-HCG elevation
marijuana
What to think with very high beta-HCG
choriocarcinoma
Seminoma risk categories
- only 2: good or intermediate
Pulmonary mets in seminoma are classified as
good risk
Management of bleo toxicity in terms of continuing treatment
IF poor or intermediate risk, switch to ifosfamide
IF good risk, drop bleo and don’t substitute
1) Stage 1 seminoma mgmt options 2) Preferred option
- surveillance (preferred)
- consider XRT or 1-2 cycles carboplatin
Stage 2 seminoma mgmt
BEP x 3 cycles
EP x 4 cycles
(CONFIRM)
Stage 3 seminoma mgmt
BEP x 4 cycles
VIP x 4 cycles
(CONFIRM)
What defines Good risk seminoma?
All of the following:
Any primary site
No metastases to organs other than the lungs and/or lymph nodes
Normal serum AFP
***Just remember that intermediate is presence of nonpulmonary visceral mets
Intermediate risk seminoma
All of the following:
Any primary site
Metastases to organs other than the lungs and/or lymph nodes
Normal serum AFP
What defines Good risk NSGCT?
All of the following:
Testicular or retroperitoneal primary tumors
No metastases to organs other than the lungs and/or lymph nodes
Serum AFP <1000 ng/mL, beta-hCG <5000 milli-international units/mL, and LDH <3 times the upper limit of normal*
Intermediate risk NSGCT
All of the following:
Testicular or retroperitoneal primary tumors
No metastases to organs other than the lungs and/or lymph nodes
Serum AFP 1000 to 10,000 ng/mL* or
Serum beta-hCG 5000 to 50,000 milli-international units/mL* or
LDH 3 to 10 times the upper limit of normal*
What defines poor risk NSGCT?
Any of the following:
Mediastinal primary with or without metastases
Metastases to organs other than the lungs and/or lymph nodes
Serum AFP >10,000 ng/mL*
Serum beta-hCG >50,000 milli-international units/mL*
LDH more than 10 times the upper limit of normal*
Size cutoff for residual mass in seminoma
3 cm
Management of residual mass in seminoma
IF residual mass <3cm → active surveillance
IF residual mass >3cm → PET
IF PET negative → active surveillance
IF PET positive → surgery
Stage II seminoma mgmt
Stage IIA
RT (preferred -Including para-aortic and ipsilateral iliac lymph nodes to a dose of 30 Gy)
chemotherapy (EP for 4 cycles vs. BEP x 3 cycles)
Stage IIB
Given elevated beta-HCG, BEP x 3 cycles vs. EP x 4 cycles (Preferred)
Germ cell subtype in which PET/CT has utility
Only in seminoma
NSGCT and radiosensitivity
NSGCT is radioresistant so radiation not typically offered
Stage IIB and IIC NSGCT mgmt
BEP x 3 cycles (Preferred) vs. EP x 4 cycles
IF residual mass >1cm, RPLND
Stage IIA NSGCT mgmt
RPLND
IF deferring RPLND, BEP 3 cycles
Advanced NSGCT mgmt
- Good risk - BEP 3 cycles
- Intermediate and poor risk disease
BEP 4 cycles
Size cutoff for residual mass in NSGCT + management
1) 1 cm
2) IF residual mass >1cm, immediate RPLND
IF residual mass <1cm, consider RPLND vs. surveillance
Management of growing teratoma syndrome
immediate surgery
Second line options for advanced NSGCT
Conventional-dose chemotherapy (CDCT) w/
TIP for 4 cycles (Preferred - Superior outcomes, but studied in a more favorable/chemo sensitive population)
VeIP for 4 cycles (Studied in a more broad group) (vinblastine, ifosfamide, cisplatin *different than VIP)
High-dose chemo (HDCT) w/ sequential (2-3) auto-HSCT (Much more toxic, unclear whether HDCT superior to CDCT
long term toxicities of treatment for testicular cancer
- secondary malignancies
- neuropathy
- Raynaud’s syndrome
Good risk metastatic seminoma management
BEP for 3 cycles
Seminoma radiographic findings on US
hypoechoic + well defined
seminoma tumor markers
- can have elevated beta-hCG
- NO AFP elevation by definition
Long term survival rate of seminoma
> 90%
5 yr survival of good risk seminoma
91%
5 yr survival of intermediate risk seminoma
79%
5 yr survival of poor risk NSGCT
48%
What is stage II disease in testicular cancer
Node positive
What is stage III disease in testicular cancer
M1 disease
