Definitions of Metabolic SyndromePresentation Transcript
How to follow-up patients
Professor Gordon Rustin
Director of Medical Oncology
Mount Vernon Cancer Centre
Why do we follow-up patients who have had germ cell tumors?
To detect relapse: in the belief that earlier detection improves chance of cure
To detect contralateral testis tumors
To manage late toxicity
For reassurance, support and counselling
To collect data
First indication of relapse in TE08 stage I surveillance trial Rustin et al J Clin Oncol 25: 1310-15, 2007 6% 4 Chest + abdo + pelvic CT 1% 1 Chest CT 8% 5 Chest X-ray 39% 26 Abdominal CT 3% 2 Markers + abdominal mass 1% 1 Markers + palpable mass 42% 28 Markers
Characteristics of relapse following therapy for germ cell tumour Analysis of 96 relapses in 547 patients achieving remission Median time to relapse 6 months (1-89), 85% within 18 months Elevated markers 54% Retro-peritoneal nodes 58% Lung 26% Liver 15% CNS 8% Flechon et al European Urology 48, 957-964: 2005
Relapses > 2 years after completion of therapy for germ cell tumours
119 / 3704 ( 3.2% ) Nonseminoma
150 / 5880 ( 2.6% ) Seminoma
10-year cause-specific survival
68% in all patients
50% in patients relapsing with vital malignant tumour
100% in those with teratoma/ necrosis before or after salvage chemotherapy.
Oldenburg, Martin & Fossa J Clin Oncol 24: 5503-11, 2006
Adapting frequency of follow-up investigations to risk of relapse Risk Nonseminoma Seminoma >10% Monthly 3 monthly 5-10% 2 monthly 4 monthly 1-5% 3-4 monthly 6 monthly 0.3-1% 6-12 monthly 12 monthly <0.3% discharge unless TD discharge or residual mass
ESMO Minimum Clinical Recommendations for Follow-up of NSGCT stage 1 on surveillance Clincal review, chest X-ray, and serum HCG & AFP monthly for 1 year 2 monthly for 2 nd year, 4 monthly 3 rd year, 6 monthly year 4 to 8 CT scans after 3 and 12 months Huddart RA, Ann Oncol; 18 suppl 2, ii42-ii43, 2007
ESMO Minimum Clinical Recommendations for Follow-up of NSGCT after chemotherapy Clinical review, chest X-ray, and HCG & AFP 2 monthly for 1 year, 3 monthly for 2 nd year 6 monthly to 5 years then annually CT scans only as clinically indicated Huddart RA, Ann Oncol; 18 suppl 2, ii42-ii43, 2007
Royal Marsden Minimum Clinical Recommendations for Follow-up for stage 1 seminoma on surveillance Clincal review and serum HCG, AFP & LDH 3 monthly for 2 years 4 monthly for 3 rd year, 6 monthly year 5 and 6 12 monthly years 6-10 Chest X-ray alternate visits for 2 years then annually to 5 years CT scans abdomen only unless pelvis at high risk at 6, 12, 18, 24, 36, 48, and 60 months Van As et al BJC 2008
ESMO Minimum Clinical Recommendations for Follow-up for stage 1 seminoma after adjuvant therapy Chest X-ray and clinical examination at 1 month, Then three monthly for 2 years Then 6 monthly to 5 years Pelvic CT in patients treated by paraaortic strip (and abdominal CT in patients treated by carboplatin) at year 1,2 and 5 Huddart RA Ann Oncol 18, Suppl2; ii40-ii41, 2007
ESMO Minimum Clinical Recommendations for Follow-up of seminoma after metastatic disease If normal CT scan: follow-up as for stage 1 If abnormal post-treatment CT scan: repeat CT scan every 6 months until normal or abnormalities stabilised A PET scan may help identify residual active cancer Consider biopsy or resection for large residual or growing masses Huddart RA Ann Oncol 18, Suppl2; ii40-ii41, 2007
Risks of excess CT scans
Typical chest CT has an associated radiation dose equivalent to 400 chest X-rays (8 vs 0.02 mSv) (Royal College of Radiologists, 1998)
Whole trunk CT produces dose of 10 to 30 mSv
Typical whole trunk CT scan associated with a 1:1000 risk of cancer/leukaemia
Definitions of Metabolic Syndrome NCEP definition Norwegian definition At least 3 of: At least 2 of: BP > 130/85 or medication BP > 140/90 or medication Waist circum > 102 BMI > 30 Fasting glucose > 5.6 mmol/l Self reported diabetes / medication Triglycerides > 1.7 mmol/l Cholesterol > 5.2 mmol/l or medication HDL cholesterol < 1.0 mmol/l
Investigations to be performed at 2, 5 and 10 years to detect late effects of therapy for germ cell tumors Blood pressure Creatinine Fasting cholesterol, HDL, LDL , triglycerides and glucose FSH, LH and testosterone ? Hip examination ? Osteoporosis screen
Questions related to follow-up of patients with germ cell
How many different follow-up schedules should be running?
Could follow-up be nurse led?
Is AFP necessary if pure seminoma?
Is LDH of value in follow-up?
Is Chest X-Ray necessary if no lung metastases at time of treatment for metastases?
LDH should not be measured routinely in follow-up of germ cell tumours 125 of 494 stage I patients had elevated LDH at relapse but in no case was it the first or only sign of relapse Ackers & Rustin BJC 94; 1231-2, 2006 499 patients on surveillance or follow up 26 of 1777 samples (1.4%) true positive, 137 (7.7%) false positive Only elevated marker at relapse in 1 of 15 relapses. Contributed to relapse detection in 4 of 35 (11%) seminomas Venkitaraman et al BJU Int 100; 30-32, 2007
Malignant teratoma 32 years after treatment of germ cell tumor confined to testis. Pavic M , Meeus P , Treilleux I , Droz JP . Urology. 2006 Apr;67(4):846 Is this the latest relapse after treatment of a germ cell tumour?
How should we organise our follow-up to detect the rare very late relapse? Relapse after 10 years is seen in < 1% of germ cell patients These patients can be cured by treatment that usually includes surgery Patients should be warned about late relapse but their rarity should not lead to prolonged follow-up