Testicular tumors
--- Content provided by FirstRanker.com ---
Department of Urology
--- Content provided by FirstRanker.com ---
T
E S T I
--- Content provided by FirstRanker.com ---
C
U L AR TUMORS:
--- Content provided by FirstRanker.com ---
? Testicular cancer accounts for? Testicular cancer although
only about 1% of all human
--- Content provided by FirstRanker.com ---
rare, is the most common
neoplasms.
--- Content provided by FirstRanker.com ---
malignancy in men in 15-35years age group and
accounts for approximately
--- Content provided by FirstRanker.com ---
23% of all cancers in this
group.
WHO CLASSIFICATION OF TESTICULAR
--- Content provided by FirstRanker.com ---
TUMORS:
Germ cell tumors:
--- Content provided by FirstRanker.com ---
Precursor lesions- intratubular malignant germ cell tumor (carcinomain situ)
Tumors of one histologic type (pure forms)
--- Content provided by FirstRanker.com ---
Seminoma
variant- seminoma with syncitiotrophoblastic cells
--- Content provided by FirstRanker.com ---
Spermatocytic seminomavariant- spermatocytic seminoma with sarcoma
Embryonal carcinoma
--- Content provided by FirstRanker.com ---
Yolk sac tumor
Polyembryoma
--- Content provided by FirstRanker.com ---
Trophoblastic tumors- choriocarcinomaTeratoma
Mature teratoma
--- Content provided by FirstRanker.com ---
Dermoid cyst
Immature teratoma
--- Content provided by FirstRanker.com ---
Teratoma with malignant areasMixed tumors
CLASSIFICATION (CONT...)
--- Content provided by FirstRanker.com ---
Sex cord/ Gonadal Stromal Tumors:
-Pure forms
Leydig's cell tumor
--- Content provided by FirstRanker.com ---
Sertoli's cell tumorlarge cell calcifying
lipid rich cell
-Granulosa cell tumor
--- Content provided by FirstRanker.com ---
Adult type granulosa cell tumorJuvenile type granulosa cell tumor
-Tumors of thecoma/ fibroma group
--- Content provided by FirstRanker.com ---
-Incompletely diffrentiated sex cord/ gonadal stromal tumors-Mixed forms.
CLASSIFICATION (CONT...)
--- Content provided by FirstRanker.com ---
-Unclassified forms-Tumors containing both germ cell and sex cord/ gonadal stromal
elements
--- Content provided by FirstRanker.com ---
-Gonadoblastoma
-Mixed germ cell- sex cord/ gonadal stromal tumors,
unclassified
--- Content provided by FirstRanker.com ---
-Miscellaneous tumors
-Carcinoid tumors
-Tumors of ovarian epithelial types.
--- Content provided by FirstRanker.com ---
CLASSIFICATION (CONT...)
-Lymphoid and hematopoietic tumors:
--- Content provided by FirstRanker.com ---
-Lymphoma
- Plasmacytoma
- Leukemia
--- Content provided by FirstRanker.com ---
-Tumors of collecting duct and rete:-Adenoma
-Carcinoma
--- Content provided by FirstRanker.com ---
-Tumors of tunica, epididymis, spermatic cord, supportingstructures, and appendices:
-Adenomatoid tumor
--- Content provided by FirstRanker.com ---
- Mesothelioma- Adenoma
-Carcinoma
-Melanotic neuroectodermal tumor.
CLASSIFICATION (CONT...)
--- Content provided by FirstRanker.com ---
-Soft tissue tumors,
-Unclassified tumors, and
--- Content provided by FirstRanker.com ---
-Secondary tumors.GERM CELL TUMORS- EPIDEMIOLOGY
Low in
--- Content provided by FirstRanker.com ---
Life time
probability of
--- Content provided by FirstRanker.com ---
Africadeveloping
and Asia.
--- Content provided by FirstRanker.com ---
testicular
cancer is 0.2%.
--- Content provided by FirstRanker.com ---
The average annual ageadjusted rate is highest in
Denmark, Norway,
--- Content provided by FirstRanker.com ---
Switzerland Germany and
Intermediate
--- Content provided by FirstRanker.com ---
New Zealand.in U.S and
U.K.
--- Content provided by FirstRanker.com ---
GERM CELL TUMORS- EPIDEMIOLOGY
AGE:
--- Content provided by FirstRanker.com ---
RACIAL FACTORS:
?These neoplasms
--- Content provided by FirstRanker.com ---
?More common inare the most
white population
--- Content provided by FirstRanker.com ---
common
solid
--- Content provided by FirstRanker.com ---
than in blacks.tumors of men
age 20 ? 40 years
--- Content provided by FirstRanker.com ---
and second most
common of men
--- Content provided by FirstRanker.com ---
age 15 ? 19years.
GERM CELL TUMOR- EPIDEMIOLOGY
--- Content provided by FirstRanker.com ---
The evidence for a
predominantly genetic
--- Content provided by FirstRanker.com ---
influence is notoverwhelming.
GENETIC FACTORS:-
--- Content provided by FirstRanker.com ---
The 2 ? 3% incidence of
bilateral tumors may
--- Content provided by FirstRanker.com ---
suggest the potentialimportance of genetic and
(or) congenital factors.
--- Content provided by FirstRanker.com ---
GERM CELL TUMORS- ETIOLOGY
--- Content provided by FirstRanker.com ---
CRYPTORCHIDISM:
7-10% of patients with testicular tumors have prior
--- Content provided by FirstRanker.com ---
history of cryptorchidism.The relative risk of developing a testicular cancer in
maldescent testis is 3 to 14 times the normal expected
--- Content provided by FirstRanker.com ---
incidence.
5-10% of patients with a history of cryptorchidism develop
--- Content provided by FirstRanker.com ---
malignancy in the contralateral normally descended testes.25% of patients with bilateral cryptorcidism and a history of
tetsis cancer develop second GCT.
--- Content provided by FirstRanker.com ---
GERM CELL TUMORS- ETIOLOGY
TRAUMA:
--- Content provided by FirstRanker.com ---
ATROPHY:? There is little to
? Causative role of
--- Content provided by FirstRanker.com ---
suggest a cause and
atrophy remains
--- Content provided by FirstRanker.com ---
effect relationship inspeculative.
humans.
--- Content provided by FirstRanker.com ---
? nonspecific or mumps
associated atrophy of
--- Content provided by FirstRanker.com ---
? Infact trauma in anthe testis has been
enlarged testes is an
--- Content provided by FirstRanker.com ---
suggested as a potential
event that prompts
--- Content provided by FirstRanker.com ---
causative factor inmedical evaluation.
testicular cancer.
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
GERM CELL TUMORS- ETIOLOGY
--- Content provided by FirstRanker.com ---
Offspring ofwomen exposed to
Exogenous
--- Content provided by FirstRanker.com ---
diethylstilbestrol
estrogen
--- Content provided by FirstRanker.com ---
or oraladministration has
HORMONES:
--- Content provided by FirstRanker.com ---
contraceptives has
also been linked to
--- Content provided by FirstRanker.com ---
relative risk rate of the induction ofdeveloping
leydig's cell
--- Content provided by FirstRanker.com ---
testicular cancer
tumors.
--- Content provided by FirstRanker.com ---
of 2.8 - 5.3%.GERM CELL TUMOR- CLINICAL MANIFESTATIONS:
The usual presentation of a testicular tumor is
--- Content provided by FirstRanker.com ---
a nodule or painless swelling in one gonad.
30-40% may complain of a
--- Content provided by FirstRanker.com ---
On rare occasions,dull ache or heavy
infertility is the presenting
--- Content provided by FirstRanker.com ---
sensation in the lower
complaint.
--- Content provided by FirstRanker.com ---
abdomen, anal area, orscrotum.
In 10%, acute pain is the
--- Content provided by FirstRanker.com ---
presenting complain.
--- Content provided by FirstRanker.com ---
GERM CELL TUMORS- CLINICAL MANIFESTATIONS
In 10% of patients, the presenting manifestation may be due to metastasis:-
--- Content provided by FirstRanker.com ---
A neck mass? Supraclavicular lymph node metastasis.
Gastrointestinal disturbances
--- Content provided by FirstRanker.com ---
? Retroduodenal metastasis
Lumbar back pain
--- Content provided by FirstRanker.com ---
? Involving psoas muscle or nerve rootsBone pain
? Skeletal metastasis
--- Content provided by FirstRanker.com ---
Central and peripheral nervous system manifestations
? Cerebral, spinal cord, or peripheral root involvement
--- Content provided by FirstRanker.com ---
Unilateral or bilateral lower extremity? Iliac or caval obstruction.
GERM CELL TUMORS- PHYSICAL EXAMINATION
--- Content provided by FirstRanker.com ---
BIMANUAL EXAMINATION:
Beginning with the normal contralateral testis.
--- Content provided by FirstRanker.com ---
Any firm, hard, or fixed area should be consideredsuspicious.
Testicular tumors tend to remain ovoid, being limited
--- Content provided by FirstRanker.com ---
by the tough investing tunica albuginea.
A hydrocele may be present and increases the
--- Content provided by FirstRanker.com ---
difficulty of palpation.GERM CELL TUMOR-
Scrotal Sonography:
--- Content provided by FirstRanker.com ---
USGof the scrotum is basically an extension of the physicalexamination.
--- Content provided by FirstRanker.com ---
Any hypoechoic area within the tunica albuginea ismarkedly suspicious for testicular cancer.
In patients with a diagnosis of EGCT, ultrasound of the
--- Content provided by FirstRanker.com ---
testis is mandatory to be certain that one is not dealing
with a primary GCT.
--- Content provided by FirstRanker.com ---
GERM CELL TUMORS- IMAGING STUDIESChest Radiography:
?Postero-anterior and lateral chest
--- Content provided by FirstRanker.com ---
radiographs: Metastatic workup
Chest CT:
--- Content provided by FirstRanker.com ---
?Indicated in patients withabnormal X-ray scans.
GERM CELL TUMORS- IMAGING
--- Content provided by FirstRanker.com ---
Abdominal CT:Most effective means to identify
retroperitoneal lymph node involvement.
--- Content provided by FirstRanker.com ---
Excellent for visualization of kidney, ureters,
retro-crural space in the para-aortic region.
--- Content provided by FirstRanker.com ---
However cannot sufficiently distinguishbetween fibrosis, teratoma, and malignancy
by size criteria alone.
--- Content provided by FirstRanker.com ---
MRI:
Testicular tumors are hypointense on T2
--- Content provided by FirstRanker.com ---
weighted images, and show brisk and earlyenhancement after I.V Gadolinium.
PET:
--- Content provided by FirstRanker.com ---
To detect radiographic abnormalities after
chemotherapy.
--- Content provided by FirstRanker.com ---
Neither PET nor CT has the ability to detectmicroscopic nodal disease.
Applied to body fluid and tissue sections.
--- Content provided by FirstRanker.com ---
Oncofetal substances: associated withembryonic development (AFP, HCG),
Cellular enzymes: LDH, PLAP.
--- Content provided by FirstRanker.com ---
Capable of detecting small tumor burdens
(105 cells) that are not detectable by
--- Content provided by FirstRanker.com ---
currently available imaging techniques.AFP:
Not produced by pure choriocarcinoma or
--- Content provided by FirstRanker.com ---
pure seminoma.
HCG:
--- Content provided by FirstRanker.com ---
Choriocarcinoma (all patients),Embryonal carcinoma (40-60%),
Pure seminoma (5-10%).
--- Content provided by FirstRanker.com ---
LDH:Has low specificity.
There is a direct relationship between tumor
--- Content provided by FirstRanker.com ---
burden and LDH levels.PLAP:
Raised in 40% of patients with advanced disease.
GGTP:
--- Content provided by FirstRanker.com ---
Raised in one third of patients with activeseminoma.
CD30:
--- Content provided by FirstRanker.com ---
? possible marker for embryonal carcinoma.RADICAL INGUINAL ORCHIDECTOMY(HIGH
TYPE)
--- Content provided by FirstRanker.com ---
TESTIS SPARING SURGERY- Highly
controversial
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
GERM CELL TUMORS : STAGINGThe American Joint Committee on Cancer staging for GCTs:
Primary Tumor (T):
--- Content provided by FirstRanker.com ---
pTx: primary tumor cannot be assessed.
pT0: no evidence of primary tumor
--- Content provided by FirstRanker.com ---
pTis: intratubular germ cell neoplasia.pT1: tumor limited to the testis and epididymis and no vascular or lymphatic invasion.
pT2: tumor limited to the testis and epididymis with vascular or lymphatic invasion or tumor
--- Content provided by FirstRanker.com ---
extending through the tunica albuginea with involvement of tunica vaginalis.
pT3: tumor invades the spermatic cord with or without vascular/ lymphatic invasion.
--- Content provided by FirstRanker.com ---
pT4: tumor invades the scrotum.GERM CELL TUMORS : STAGING
N2:
--- Content provided by FirstRanker.com ---
N1:
lymph
--- Content provided by FirstRanker.com ---
lymphnode mass
node
--- Content provided by FirstRanker.com ---
more than
mass
--- Content provided by FirstRanker.com ---
2cm but2cm or
not more
--- Content provided by FirstRanker.com ---
less in
than 5 cm
--- Content provided by FirstRanker.com ---
inN3:
greatest
--- Content provided by FirstRanker.com ---
lymph
Region
--- Content provided by FirstRanker.com ---
Nx:N0:
greatest
--- Content provided by FirstRanker.com ---
no
dimensio
--- Content provided by FirstRanker.com ---
dimension,node
al
--- Content provided by FirstRanker.com ---
regional
lymph
--- Content provided by FirstRanker.com ---
regionaln or
or
--- Content provided by FirstRanker.com ---
mass
lymph
--- Content provided by FirstRanker.com ---
nodeslymph
multiple
--- Content provided by FirstRanker.com ---
multiple
more
--- Content provided by FirstRanker.com ---
nodeslymph
cannot
--- Content provided by FirstRanker.com ---
node
lymph
--- Content provided by FirstRanker.com ---
thanmetastas
node
--- Content provided by FirstRanker.com ---
node
5cm in
--- Content provided by FirstRanker.com ---
(N)be
masses,
--- Content provided by FirstRanker.com ---
assessed.
is.
--- Content provided by FirstRanker.com ---
masses,greatest
none
--- Content provided by FirstRanker.com ---
anyone
dimensio
--- Content provided by FirstRanker.com ---
moremass
greater
--- Content provided by FirstRanker.com ---
n.
than
--- Content provided by FirstRanker.com ---
than 2 cm2cm in
but not
--- Content provided by FirstRanker.com ---
greatest
more than
--- Content provided by FirstRanker.com ---
dimensio5 cm in
n.
--- Content provided by FirstRanker.com ---
greatest
dimension.
GERM CELL TUMOR STAGING:
--- Content provided by FirstRanker.com ---
Distant
M0: no
--- Content provided by FirstRanker.com ---
metastasisevidence of
(M)
--- Content provided by FirstRanker.com ---
distant
metastasis.
--- Content provided by FirstRanker.com ---
M1: nonM2:
regional nodal
--- Content provided by FirstRanker.com ---
nonpulmonary
or pulmonary
--- Content provided by FirstRanker.com ---
visceralmetastasis.
metastasis.
--- Content provided by FirstRanker.com ---
GERM CELL TUMOR STAGING:
Serum tumor markers (S)
--- Content provided by FirstRanker.com ---
LDHhCG (mIU/ml)
AFP (ng/ml)
--- Content provided by FirstRanker.com ---
S0
N
--- Content provided by FirstRanker.com ---
NN
S1
--- Content provided by FirstRanker.com ---
<1.5 x N
< 5000
--- Content provided by FirstRanker.com ---
< 1000S2
1.5-10 N
--- Content provided by FirstRanker.com ---
5000 ? 50000
1000-10,000
--- Content provided by FirstRanker.com ---
S3> 10 N
>50,000
--- Content provided by FirstRanker.com ---
> 10,000
PROGNOSIS
SEMINOMA
--- Content provided by FirstRanker.com ---
Good Prognosis:
Intermediate prognosis:
--- Content provided by FirstRanker.com ---
? Any primary site? Any primary site
? No pulmonary or visceral
--- Content provided by FirstRanker.com ---
? Nonpulmonary visceral
metastasis
--- Content provided by FirstRanker.com ---
metastasis? AFP: Normal;
? AFP: Normal;
--- Content provided by FirstRanker.com ---
Poor prognosis:
? hCG: Any value
--- Content provided by FirstRanker.com ---
? hCG: Any valueNo patients classified as
? LDH: Any value
--- Content provided by FirstRanker.com ---
? LDH: Any value
poor prognosis
--- Content provided by FirstRanker.com ---
PROGNOSISNONSEMINOMA
Good Prognosis:
--- Content provided by FirstRanker.com ---
Intermediate prognosis:
Poor prognosis:
--- Content provided by FirstRanker.com ---
? Testis or retroperitoneal? Testis or retroperitoneal
Any of the following
--- Content provided by FirstRanker.com ---
primary
primary,
--- Content provided by FirstRanker.com ---
criteria:? No pulmonary or visceral
? No nonpulmonary
--- Content provided by FirstRanker.com ---
? Mediastinal primary
metastasis
--- Content provided by FirstRanker.com ---
visceral metastasis? Nonpulmonary visceral
? AFP<1000ng/ml;
--- Content provided by FirstRanker.com ---
? Any of: AFP1000-
metastasis
--- Content provided by FirstRanker.com ---
hCG<5000IU/L;10,000ng/ml; hCG5000-
? AFP>10,000ng/ml;
--- Content provided by FirstRanker.com ---
LDH<1.5times upper
50,000IU/L; LDH1.5-10
--- Content provided by FirstRanker.com ---
hCG>50,000IU/L;limit.
times upper limit
--- Content provided by FirstRanker.com ---
LDH>10 times upper
limit.
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
TREATMENT
Stage 1 T1-
--- Content provided by FirstRanker.com ---
3N0M0S0
Spematocytic
--- Content provided by FirstRanker.com ---
seminoma:age >65yrs;
Typical and
--- Content provided by FirstRanker.com ---
exclude
anaplastic
--- Content provided by FirstRanker.com ---
sarcoma,seminoma
benign tumor
--- Content provided by FirstRanker.com ---
Risk factors
No adjuvant
--- Content provided by FirstRanker.com ---
primary tumortratment
>6cm; vascular
--- Content provided by FirstRanker.com ---
or lymphatic
invasion
--- Content provided by FirstRanker.com ---
No risk factorsRisk factors
present
--- Content provided by FirstRanker.com ---
Radiation- low
Chemotherapy
--- Content provided by FirstRanker.com ---
surveillancedose, abdominal
single agent-
--- Content provided by FirstRanker.com ---
and pelvic
carboplatin
Radiation therapy:
--- Content provided by FirstRanker.com ---
Today most centers administer 25Gy to para-
aortic nodes only.
--- Content provided by FirstRanker.com ---
This has a 5 year survival in excess of 95%.Primary Chemotherapy:
Single agent carboplatin compare favorably
--- Content provided by FirstRanker.com ---
with adjuvant radiation therapy.
2 courses of carboplatin were associated with
--- Content provided by FirstRanker.com ---
no relapse and favorable toxicity profile.Surveillance:
Appropriate for patients with:
1. tumors smaller than 6 cm,
--- Content provided by FirstRanker.com ---
2. absence of vascular invasion, and3. normal hCG levels.
in motivated and reliable patients.
--- Content provided by FirstRanker.com ---
GERM CELL TUMORSSEMINOMA: STAGE I A AND I B
Radiation-
--- Content provided by FirstRanker.com ---
abdominal and
Stage IIA and
--- Content provided by FirstRanker.com ---
pelvicIIB seminoma
Chemotherapy-
--- Content provided by FirstRanker.com ---
if lymph nodes
close to kidney
--- Content provided by FirstRanker.com ---
GERM CELL TUMORSSEMINOMA: STAGE I A AND I B
Radiation therapy:
--- Content provided by FirstRanker.com ---
N1 disease receive 30 Gy, and N2 disease receive 35 Gy.Patients with stage II seminoma have 5 year survival rates
of 70% to 92%.
--- Content provided by FirstRanker.com ---
Chemotherapy:Irradiation to kidney is avoided- parenchyma is sensitive.
So, chemotherapy is preferred in this region.
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
GERM CELL TUMORS
Stage IIC and III seminoma
--- Content provided by FirstRanker.com ---
Chemotherapy- cisplatin basedResidual retroperitoneal mass following chemotherapy
Diffuse desmoplastic
--- Content provided by FirstRanker.com ---
reaction- observation
Descrete well deliniated mass>3cm
--- Content provided by FirstRanker.com ---
Surgical resectionHistology-
Histology- germ cell
--- Content provided by FirstRanker.com ---
necrosis/fibrosis
tumor
--- Content provided by FirstRanker.com ---
observationSalvage chemotherapy
GERM CELL TUMORS
--- Content provided by FirstRanker.com ---
Cisplatin based chemotherapy:
>90% of patients achieve a complete response.
Residual masses are resected if on CT scan:
--- Content provided by FirstRanker.com ---
-if they are well delineated,-distinct from surrounding structures, and
-diameter is larger than 3 cm.
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
NON-SEMINOMATOUS GERM CELL TUMORS
--- Content provided by FirstRanker.com ---
STAGE 1: TREATMENT PRINCIPLES.Stage 1
Risk factors: T2 or higher, embryonal>40%,
--- Content provided by FirstRanker.com ---
vascular/lymphatic invasion.
Stage 1S
--- Content provided by FirstRanker.com ---
Risk factorsChemotherapy
absent
--- Content provided by FirstRanker.com ---
Risk factors present
BEP 3 cycles
--- Content provided by FirstRanker.com ---
Primarysurveillance
Modified RPLND
--- Content provided by FirstRanker.com ---
chemotherapy
BEP 3 cycles
--- Content provided by FirstRanker.com ---
Stage N0Stage N1
Stage N2
--- Content provided by FirstRanker.com ---
Adjuvant
observation
--- Content provided by FirstRanker.com ---
observationchemotherapy
BEP 2 cycles
--- Content provided by FirstRanker.com ---
NONSEMINOMATOUS GERM CELL TUMORS
STAGE 1: TREATMENT PRINCIPLES
--- Content provided by FirstRanker.com ---
Retro-peritoneal lymph node dissection:? Capable of eradicating resectable disease in the majority
of N1-N2 tumors.
--- Content provided by FirstRanker.com ---
? 5 year survival for stage 1 is 95%.? 5-10% experience relapse: high cure rates with
chemotherapy.
--- Content provided by FirstRanker.com ---
Modified (template) RPLND:? Complete dissection in the most likely area, and
modification in less likely area.
--- Content provided by FirstRanker.com ---
? Ejaculation is preserved in 100%, and fertility noted in75% of patients.
NONSEMINOMATOUS GERM CELL TUMORS
--- Content provided by FirstRanker.com ---
STAGE 1: TREATMENT PRINCIPLESPrimary radiation therapy:
? 5 year survival for stage 1: 80-95% when chemotherapy is
--- Content provided by FirstRanker.com ---
used to treat relapses.? Relapse rate after radiation therapy: 24%.
The main objections to radiation therapy:
--- Content provided by FirstRanker.com ---
? Inaccuracy of clinical staging,? Lack of survival data,
? Prior radiation makes it difficult for future surgical or
pharmacological intervention, and
--- Content provided by FirstRanker.com ---
? Risk of second malignancy: 18% in 25 years.
NONSEMINOMATOUS GERM CELL TUMORS
--- Content provided by FirstRanker.com ---
STAGE 1: TREATMENT PRINCIPLESPrognostic factors for clinical stage 1 tumors:
? Invasion of testicular veins,
? Invasion of lymphatics,
--- Content provided by FirstRanker.com ---
? Absence of yolk sac elements,? presence of embryonal cell carcinoma, and
? Angiogenesis: factor VIII stain positive.
NONSEMINOMATOUS GERM CELL TUMORS
--- Content provided by FirstRanker.com ---
STAGE 1: TREATMENT PRINCIPLESSurveillance:
Surveillance is indicated in stage 1 disease:-
? without any risk factors for relapse,
--- Content provided by FirstRanker.com ---
? in motivated patients, and? who fully understands the risk of failure to comply.
NONSEMINOMATOUS GERM CELL
--- Content provided by FirstRanker.com ---
TUMORSSTAGE 1: TREATMENT PRINCIPLES
Surveillance protocol:
--- Content provided by FirstRanker.com ---
Physical examination, chest radiographs, and
tumor markers: monthly for 1st year, every 2
--- Content provided by FirstRanker.com ---
months for second year, and every 3-6months thereafter.
CT abd: every 2-3 months for the first 2
--- Content provided by FirstRanker.com ---
years, and every 6 months thereafter.
Finally, surveillance is necessary for
--- Content provided by FirstRanker.com ---
minimum of 5 years, possibly 10 years afterorchiectomy.
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
NONSEMINOMATOUS GERM CELL TUMORS
--- Content provided by FirstRanker.com ---
STAGE 1: TREATMENT PRINCIPLESPrimary chemotherapy:
2 cycles of bleomycin, cisplatin, and etoposide are used.
5 year survival: 95%-100%.
--- Content provided by FirstRanker.com ---
Added advantage of treating metastatic disease outsidethe retroperitoneum.
Suitable for centers where expertise for RPLND are not
--- Content provided by FirstRanker.com ---
available.
NONSEMINOMATOUS GERM CELL TUMORS
--- Content provided by FirstRanker.com ---
STAGE I A AND I B: TREATMENT PRINCIPLESStage IIA and
IIB
--- Content provided by FirstRanker.com ---
RPLND-
Primary
--- Content provided by FirstRanker.com ---
bilateralchemotherapy
BEP- 3 cycles
--- Content provided by FirstRanker.com ---
Minimal nodal
Nodal
--- Content provided by FirstRanker.com ---
involvementinvolvement
<2cm
--- Content provided by FirstRanker.com ---
>2cm
Adjuvant
--- Content provided by FirstRanker.com ---
surveillancechemotherapy
BEP- 2 cycles
--- Content provided by FirstRanker.com ---
NONSEMINOMATOUS GERM CELL TUMORSSTAGE I A AND I B: TREATMENT PRINCIPLES
RPLND:
--- Content provided by FirstRanker.com ---
A complete bilateral lymphadenectomy is recommended.? Patients with minimal retroperitoneal disease on RPLND:
careful follow-up.
--- Content provided by FirstRanker.com ---
? Patients with more extensive disease on RPLND: two
cycles of adjuvant chemotherapy.
--- Content provided by FirstRanker.com ---
NONSEMINOMATOUS GERM CELL TUMORSSTAGE I A AND I B: TREATMENT PRINCIPLES
Primary chemotherapy:
--- Content provided by FirstRanker.com ---
? If nodes are larger than 3 cm on CT.? Avoids ejaculatory failure.
Disadvantages: azoospermia, secondary malignancy.
17% of stage IIa patients and 39% of stage IIb patients
--- Content provided by FirstRanker.com ---
require RPLND after chemotherapy for relapse.
NONSEMINOMATOUS GERM CELL TUMORS
--- Content provided by FirstRanker.com ---
Stage IIC and Stage III
Good risk disease
--- Content provided by FirstRanker.com ---
Poor riskdisease
Chemotherapy
--- Content provided by FirstRanker.com ---
Chemotherapy BEP- 3 cycles
ifosfamide
--- Content provided by FirstRanker.com ---
substitutesetoposide
Response to
--- Content provided by FirstRanker.com ---
Resolution of disease
Residual retroperitoneal mass-
--- Content provided by FirstRanker.com ---
Persistent elevationchemotherapy
bilateral RPLND with tumorectomy
--- Content provided by FirstRanker.com ---
of tumor markers
poor, or elevated
--- Content provided by FirstRanker.com ---
tumor markers-Exclude false
observation
--- Content provided by FirstRanker.com ---
Histology- necrosis,
Germ cell
--- Content provided by FirstRanker.com ---
Salvageefibrosis, teratoma
tumor
--- Content provided by FirstRanker.com ---
positive-
chemotherapy
--- Content provided by FirstRanker.com ---
chemotherapyRecurrent disease
observation
--- Content provided by FirstRanker.com ---
Salvage
Inadequate
--- Content provided by FirstRanker.com ---
chemotherapyresponse
Salvage chemotherapy
--- Content provided by FirstRanker.com ---
Desperation
surgery
--- Content provided by FirstRanker.com ---
CompleteNo response;
response
--- Content provided by FirstRanker.com ---
elevated tumor
markers
--- Content provided by FirstRanker.com ---
observationDesperation
surgery
--- Content provided by FirstRanker.com ---
NONSEMINOMATOUS GERM CELL TUMORS
STAGE I C AND I I: TREATMENT PRINCIPLES
--- Content provided by FirstRanker.com ---
Contraindication to adjunctive surgery in patients afterchemotherapy: The presence of elevated levels of tumor
markers.
--- Content provided by FirstRanker.com ---
Salvage Chemotherapy:
? residual cancer that has been resected after
chemotherapy,
--- Content provided by FirstRanker.com ---
? who do not respond to traditional courses of induction
therapy.
NONSEMINOMATOUS GERM CELL TUMORS
--- Content provided by FirstRanker.com ---
STAGE I C AND I I: TREATMENT PRINCIPLES
Patients who failed initial chemotherapy regimens:
Ifosfamide in combination with vinblastine and cisplatin.
--- Content provided by FirstRanker.com ---
Patients who failed 1st and 2nd line therapy:
Autologous bone marrow transplant or stem cell support
with high dose chemotherapy regimens.
--- Content provided by FirstRanker.com ---
THANKS