Testis Flashcards
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Suspicious Mass Work-up
- H&P
- Labs including STMs
- Scrotal US
- Radical inguinal orchiectomy
- Discuss sperm banking
- Discuss testis prostesis
- Consider CT C/A/P
- Consider contralateral biopsy if abnormal
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Seminoma Stage Ia and Ib Treatment
- Surveillance [pT1-pT3] (p)
- Single agent carboplatin
- Radiation therapy
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Seminoma Stage Is
- Repeat elevated STMs
- Repeat imaging
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Seminoma Stage IIa
- RT (including para-aortic and ipsilateral iliac nodes; 30Gy)
- BEP x3 or EP x4
- NS-RPLND
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Stage IIb
- BEP x3 or EP x4
*
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Seminoma Stage IIc or Stage III
Good Risk
* BEP x3 or EP x4
Intermediate Risk
* BEP x4 or VIP x4 (Etoposide/ Ifosfamide/ Cisplatin)
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Seminoma s/p Chemotherapy
Repeat Img and STMs
Mass 3cm or less and normal STM
* Surveillance
Mass greater than 3cm and normal STM
* Surveillance
* FDG-PET/CT negative: surveillance
* FDG-PET/CT equivocal: repeat in 6-8 weeks
* FDG-PET/ CT positive: RPLND or biopsy
Growing mass or positive STM
* VeIP x4 or TIP x4
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Seminoma Second-line Chemotherapy
- VeIP x4 (vinblastine/ ifosfamide/ cisplatin)
- TIP x4 (Paclitaxel/ Ifosfamide/ cisplatin)
- High-dose chemotherapy
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Seminoma Post-Chemotherapy RPLND Adjuvant Treatment
- Complete resection positive for seminoma: consider 2 cycles of chemotherapy (EP or TIP or VIP or VeIP)
- Complete resection negative for seminoma: Surveillance
- Incomplete resection or progression: VeIP x4 (Vinblastine/ Ifosfamide/ Cisplatin) or TIP x4 (Paclitaxel/ Ifosfamide/ Cisplatin)
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Seminoma Third-line Chemotherapy
Prior first and second-line conventional dose
* High dose chemotherapy
* Third-line chemotherapy
* Microsatellite instability/ mismatch repair testing or tumor mutational burden testing
* RT (select pts)
Prior high dose chemotherapy
* Third-line conventional dose chemotherapy
* Microsatellite instability/ mismatch repair testing or tumor mutational burden testing
* RT (select pts)
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NSGCT Pre-treatment Workup
- CT C/A/P or MRI
- Repeat STMs
- Brain MRI with and without contrast if choriocarcinoma, extensive lung mets, viceral mets, neurologic symptoms, S3 AFP or S2 bHCG
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NSGCT Risk Factors
- Lymphovascular invasion
- Predominance of embryonal carcinoma
- pT3 or pT4
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NSGCT Stage I without RFs Treatment
- Surveillance (p)
- NS-RPLND
- BEP x1
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NSGCT Stage I with RFs Treatment
- Surveillance
- BEP x1
- NS-RPLND
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NSGCT Stage Is Treatment
- BEP x3 or EP x4
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NSGCT Stage IIa Treatment
S0
* NS- RPLND
* BEP x3 or EP x4
S1
* BEP x3 or EP x4
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NSGCT Stage IIb Treatment
S0, normal LN distribution
* BEP x3 or EP x4
* NS-RPLND (select pts)
S1 or abnormal LN distribution
* BEP x3 or EP x4
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NSGCT Stage IIc and IIIa Treatment
*Good Risk BEP x3 or EP x4
* Int or Poor Risk BEP x4
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NSGCT Stage IIa or IIb s/p chemotherapy
Negative markers, Residual mass <1cm
* Surveillance (p)
* NS-RPLND (select pts)
Negative markers, Residual mass >1cm
* NS-RPLND
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NSGCT Treatment s/p post-chemo RPLND
- Viable tumor in path: adjuvant chemotherapy x2 (EP or TIP or VIP or VeIP)
- Teratoma or necrosis: surveillance (no need to resect extra-RP masses if fibrosis in the post-chemo RPLND specimen (12% chance of discordance)
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NSGCT s/p primary RPLND
- pN0: surveillance
- pN1: surveillance (p) or EP x2
- pN2: EP x2 (p) or surveillance
- pN3: BEP x3 or EP x4
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NSGCT s/p primary chemotherapy
- Complete response, negative STMs: Surveillance (p) or NS-RPLND (select pts)
- Partial response, negative STMs: RPLND
- Partial response, rising STMs: second-line chemotherapy (or third-line)
- Partial response, stable STMs: close surveillance
- Partial response, normalizing STMs: consider RPLND
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NSGCT recurrence s/p chemotherapy
Early (<2y) relapse
* VeIP x4 or TIP x4
* High dose chemotherapy
* Consider surgical resection if solitary lesion
Late (>2y) relapse
* RPLND (p)
* VeIP x4 or TIP x4
* High dose chemotherapy
Testis
pTis pT1 Staging
pTis -> Germ cell neoplasia in situ
pT1 -> Limited to testis without LVI
pT1a -> Seminoma less than 3cm
pT1b -> Seminoma greater than 3cm
Testis
pT2 Staging
pT2 -> Tumor limited to testis with LVI, invading hilar soft tissue, epididymis or tunica albuginea
Testis
pT3
pT3 -> Invading spermatic cord
Testis
pT4
pT4 -> Invades scrotum
Testis
cN Staging
cN1 -> RP LNs less than 2cm
cN2 -> RP LNs between 2-5cm
cN3 -> RP LNs greater than 5cm
Testis
pN Staging
pN1 -> RP LNs less than 2cm and less than 5 positive nodes
pN2 -> RP LNs between 2-5cm or more than 5 positive nodes or ENE
pN3 -> RP LNs greater than 5cm
Testis
M staging
M1a -> Non RP LNs or pulmonary metastasis
M1b -> Visceral metastasis
Testis
S Staging
S1 -> AFP less than 1,000; BCG less than 5,000; LDH less than 1.5xN
S2 -> AFP 1,000-10,000; BCG 5,000-50,000; LDH 1.5xN to 10xN
S3 -> AFP greater than 10,000; BCG greater than 50,000; LDH greater than 10xN
Testis
Stage I
Stage Ia -> pT1 N0 M0 S0
Stage Ib -> pT2-4 N0 M0 S0
Stage Is -> pT1-4 N0 M0 S1-3
Testis
Stage II
Stage IIa -> T1-4, N1, M0, S0-1
Stage IIb -> T1-4, N2, M0, S0-1
Stage IIc -> T1-4, N3, M0, S0-1
Testis
Stage III
Stage IIIa -> T1-4, N0-3, M1a, S0-1
Stage IIIb -> T1-4, N0-3, M1a, S2
Stage IIIc -> T1-4, N0-3, M1a-M1b, S0-3
Testis
Risk Categories
Seminoma Good Risk -> no nonpulmonary mets
Seminoma Intermediate Risk -> visceral mets
NSGCT Good Risk -> Stage IIIa or less with testis or RP primary tumor
NSGCT Intermediate Risk -> Stage IIIb with testis or RP primary
NSGCT Poor Risk -Stage IIIc or Mediastinal primary
TCa
Stage I Seminoma s/p AS: Follow up
- H&P: q4 x1y, q6 x3y, annual
- A/P Img: q4 x1y, q6 x1y, q6-12 x1y, annual x2
- CXR: q4 x1y, q6 x1y, annual, as indicated
medium
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Stage I Seminoma s/p treatment: Follow up
- H&P: q6 x2y, annual x3
- A/P Img: annual x2, as indicated
- CXR: as indicated
super mild
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Stage IIA and NB IIB Seminoma s/p RT or chemo: Follow up
- H&P: q3 x1y, q6 x4y
- A/P Img: q6 x1y, annual x2y, as indicated
- CXR: q6 x2y, annual x1, as indicated
hot
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Stage IIA Seminoma s/p RPLND w/chemo: Follow up
- H&P: q3 x1y, q6 x4y
- A/P Img: q6 x1y, annual x2y, as indicated
- CXR: q6 x2y, annual x1, as indicated
hot
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Stage IIB, IIC and III Seminoma: Follow up
- H&P: q2 x1y, q3 x1y, q4-6 x1y, q6 x1y, annual
- A/P Img: q4 x1, q6 x1, annual x3y
- CXR: q2-4 x1y, q4-6 x1y, annual x3y
muy caliente
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Stage I NSGCT w/o RF s/p AS: Follow up
- H&P: q2 x1y, q3 x1y, q4-6 x1y, q6 x1y, annual
- A/P Img: q4 x1, q6 x1, annual x3y
- CXR: q2-4 x1y, q4-6 x1y, annual x3y
muy caliente
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Stage I NSGCT w/RF s/p AS: Follow up
- H&P: q2 x1y, q3 x1y, q4-6 x1y, q6 x1y, annual
- A/P Img: q4 x1, q6 x1, annual x3y
- CXR: q2-4 x1y, q4-6 x1y, annual x3y
muy caliente
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Stage I NSGCT s/p RPLND or chemo: Follow up
- H&P: q3 x1y, q6 x4y
- A/P Img: q6 x1y, annual x2y, as indicated
- CXR: q6 x2y, annual x1, as indicated
hot
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Stage II-III NSGCT s/p chemo (CR): Follow up
- H&P: q2 x1y, q3 x1y, q4-6 x1y, q6 x1y, annual
- A/P Img: q4 x1, q6 x1, annual x3y
- CXR: q2-4 x1y, q4-6 x1y, annual x3y
muy caliente
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Stage II NSGCT s/p primary RPLND and adjuvant chemo: Follow up
- H&P: q6 x2y, annual x3
- A/P Img: annual x2, as indicated
- CXR: q6 x1y, annual x2, as indicated
mild
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Stage II NSGCT s/p primary RPLND w/o adjuvant chemo: Follow up
- H&P: q2 x1y, q3 x1y, q4-6 x1y, q6 x1y, annual
- A/P Img: q4 x1, q6 x1, annual x3y
- CXR: q2-4 x1y, q4-6 x1y, annual x3y
muy caliente
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Stage IIA Seminoma s/p RPLND: Follow up
- H&P: q4 x1y, q6 x3y, annual
- A/P Img: q4 x1y, q6 x1y, q6-12 x1y, annual x2
- CXR: q4 x1y, q6 x1y, annual, as indicated
medium
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RT long-term toxicity
- CVD RR 2.4
- 2nd malignancy RR 2.0
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Chemo long-term toxicity
- CVD RR 2.6
- Metabolic syndrome RR 2.2
- 2nd malginancy RR 1.8
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TSS indications
Major function is hormonal preservation
* Synchronous bilateral tumors
* Solitary testis
* Radiographically benign in appearance
* Non-palpable tumor less than 2cm (<1cm is 50% benign)
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TSS principles
- Inguinal approach
- Frozen section with possible reflex radical orchiectomy
- Biopsy of adjacent parenchyma
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TSS counceling
- High risk of local recurrence
- Risk of testis atrophy, infertility or hypogonadism
- Role of adjuvant radiation
- Need for continued surveillance
