Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Epidemiology, Staging and Management G. Pentheroudakis University of Ioannina
Epidemiology Most common tumour in males 15-35 age group. White (ratio of white to black is approximately 5:1) Incidence 3...
 
CIS
PLAP immunothistochemistry HE staining
 
 
<ul><ul><li>L ow power of showing a multiplicity of tissues , including  skin, smooth muscle, gut and respiratory mucosa <...
WHO British Tumour Panel Seminoma Classical Anaplastic Seminoma Εmbryonal Carcinoma ΜΤ U Choriocarcinoma ΜΤΤ Τeratoma Matu...
<ul><li>Common presentations: </li></ul><ul><ul><li>Testicular mass, usually painless </li></ul></ul><ul><li>Rare presenta...
 
<ul><li>Bimanual scrotal examination </li></ul><ul><li>Scrotal ultrasound </li></ul><ul><li>Physical examination </li></ul...
 
 
 
<ul><li>Stage I disease </li></ul><ul><li>IA (T1N0M0S0):  Limited to testis without vascular/lymphatic inva s ion or inva ...
<ul><li>Stage I I  disease  (AnyT, M0, S0-1) </li></ul><ul><li>I I A ( N1 ):  Lymph node metastasis < 2 cm </li></ul><ul><...
<ul><li>Seminoma </li></ul><ul><li>AFP never produced ,  elevated  HCG  in 15%. </li></ul><ul><li>70-75% are stage Ι. </li...
<ul><li>Elevated serum  AFP,  Η CG  or both in 70%. </li></ul><ul><li>Tumour markers very important for staging as well as...
 
 
 
Good risk Any HCG AFP     1000 ng/mL Any LDH HCG     5000 mIU/mL Nonpulmonary visceral metastases absent LDH     1.5     u...
NSCGT Seminomas Good prognosis 5y OS 92% 5y OS 86% Intermediate prognosis 5y OS 80% 5y OS 73% Poor prognosis 5y OS 48%
<ul><li>Observation </li></ul><ul><li>RT </li></ul><ul><li>1-2 cycles of adjuvant Carboplatin. </li></ul><ul><li>RPLND </l...
<ul><li>Observation </li></ul><ul><ul><li>Avoids overtreatment of 80-85% of patients </li></ul></ul><ul><ul><li>Risk facto...
Fewer testicular new primary tumors with carboplatin
<ul><li>Low risk for relapse :   Observation </li></ul><ul><li>High risk for relapse  (  LV invasion, embryonal Ca>50%) : ...
<ul><li>Risk factors: </li></ul><ul><li>Invasion of testicular veins </li></ul><ul><li>Invasion of testicular lymphatics <...
<ul><li>Patient selection: ¾ risk factors  (invasion of testicular veins, invasion of testicular lymphatics, absence of yo...
<ul><li>RT </li></ul><ul><li>Cures 85-90% of patients with some acute side effects and rare late effects of intestinal fib...
PE 500 B 90  x3 PE 500 B 90  x4 No. of patients 88 96 NED after Rx 86 (98%) 93 (97%) Relapse 5 (6%) 5 (5%) Continously NED...
<ul><li>Chemotherapy.   </li></ul><ul><li>IGCCCG good risk group :  3 x ΒΕΡ or 4 x EP. </li></ul><ul><li>IGCCCG intermedia...
<ul><li>Some facts: </li></ul><ul><li>Lower rate of residual mass than seminoma </li></ul><ul><li>Necrosis/fibrosis 45-50%...
<ul><li>Some facts: </li></ul><ul><li>Higher rate of residual mass: >50% in bulky tumors, one third persisting for several...
 
 
 
 
 
 
 
<ul><li>Lung toxicity </li></ul><ul><ul><li>Effect of bleomycin </li></ul></ul><ul><ul><li>Cumulative, significant risk ab...
<ul><li>Renal toxicity </li></ul><ul><ul><li>Effect of cisplatin, reduced by using carboplatin </li></ul></ul><ul><ul><li>...
<ul><li>Malignancies </li></ul><ul><ul><li>AML with a short latency period after high cumulative doses of etoposide  </li>...
Risk factors are:  Presence of CIS and radiotherapy
<ul><li>Early relapse: </li></ul><ul><ul><li>No standard therapy, combination therapy including of cis- or carboplatin, et...
<ul><li>5-10% in young patients with hx of testicular cancer and atrophic contralateral testis </li></ul><ul><li>When shou...
<ul><li>Radiotherapy   (van der Masse, Lancet 1986) </li></ul><ul><li>20 Gy to the contralateral testis abolishes CIS </li...
 
Upcoming SlideShare
Loading in …5
×

Medical Students 2011 - G. Pentheroudakis - UROGENITAL CANCER SESSION - Germ Cell Testicular Cancer

706 views

Published on

Published in: Health & Medicine
  • Be the first to comment

Medical Students 2011 - G. Pentheroudakis - UROGENITAL CANCER SESSION - Germ Cell Testicular Cancer

  1. 1. Epidemiology, Staging and Management G. Pentheroudakis University of Ioannina
  2. 2. Epidemiology Most common tumour in males 15-35 age group. White (ratio of white to black is approximately 5:1) Incidence 3/100,000 of general population. Lifetime probability: 0.2% Risk factors Cryptorchidism ( Relative risk 8-40) Prior testicular cancer ( Relative risk 25) Genetic (Klinefelter syndrome, Down syndrome, testicular feminization) Carcinoma in situ (intratubular germ cell neoplasia): 50-100% progression to invasive cancer in 10 years. Family history ( Relative risk 10 in brothers, 4 in sons)
  3. 4. CIS
  4. 5. PLAP immunothistochemistry HE staining
  5. 8. <ul><ul><li>L ow power of showing a multiplicity of tissues , including skin, smooth muscle, gut and respiratory mucosa </li></ul></ul>
  6. 9. WHO British Tumour Panel Seminoma Classical Anaplastic Seminoma Εmbryonal Carcinoma ΜΤ U Choriocarcinoma ΜΤΤ Τeratoma Mature Immature With malignant transformation ΜΤ D Yolk sac tumour Yolk sac tumour Μixed tumours ΜΤΙ
  7. 10. <ul><li>Common presentations: </li></ul><ul><ul><li>Testicular mass, usually painless </li></ul></ul><ul><li>Rare presentations (10%): </li></ul><ul><ul><li>Neck mass (supraclavicular metastasis) </li></ul></ul><ul><ul><li>Dyspnea and cough (lung metastases) </li></ul></ul><ul><ul><li>Lumbar pain (retroperitoneal metastases) </li></ul></ul><ul><ul><li>Bone pain or CNS symptoms </li></ul></ul><ul><ul><li>Gynecomastia (occurs in 5% of patients) </li></ul></ul>
  8. 12. <ul><li>Bimanual scrotal examination </li></ul><ul><li>Scrotal ultrasound </li></ul><ul><li>Physical examination </li></ul><ul><li>CT of chest and abdomen </li></ul><ul><li>Serum tumor markers </li></ul><ul><li>Consideration of sperm cryopreservation </li></ul><ul><li>Radical inguinal orchiectomy </li></ul>
  9. 16. <ul><li>Stage I disease </li></ul><ul><li>IA (T1N0M0S0): Limited to testis without vascular/lymphatic inva s ion or inva s ion of tunica vaginalis </li></ul><ul><li>IB (T2-4;N0M0S0): Vacular/lymphatic invasion, invasion of tunica vaginalis or spermatic cord </li></ul><ul><li>IS (AnyT/N0M0S1-3): Elevated LDH, AFP and or hCH </li></ul>
  10. 17. <ul><li>Stage I I disease (AnyT, M0, S0-1) </li></ul><ul><li>I I A ( N1 ): Lymph node metastasis < 2 cm </li></ul><ul><li>I I B ( N2 ): Lymph node metastasis 2-5 cm </li></ul><ul><li>IIC (N3) </li></ul><ul><li>Lymph node metastasis > 5 cm </li></ul>
  11. 18. <ul><li>Seminoma </li></ul><ul><li>AFP never produced , elevated HCG in 15%. </li></ul><ul><li>70-75% are stage Ι. </li></ul><ul><li>Affects more «mature» young ages 20-40. </li></ul><ul><li>Tumour i(12p) in only 30%. </li></ul><ul><li>Radiosensitive tumour. </li></ul>
  12. 19. <ul><li>Elevated serum AFP, Η CG or both in 70%. </li></ul><ul><li>Tumour markers very important for staging as well as for follow up. </li></ul><ul><li>Only 30-40% are diagnosed at stage I. </li></ul><ul><li>Affects youngish youths 15-30 age group. </li></ul><ul><li>i(12)p in 80%. </li></ul><ul><li>Resistant to radiotherapy. </li></ul>
  13. 23. Good risk Any HCG AFP    1000 ng/mL Any LDH HCG    5000 mIU/mL Nonpulmonary visceral metastases absent LDH    1.5    upper limit of normal Any primary site Nonpulmonary visceral metastases absent Gonadal or retroperitoneal primary tumor Intermediate risk Nonpulmonary visceral metastases present AFP 1000-10,000 ng/mL Any HCG HCG 5000-50,000 mIU/mL Any LDH LDH 1.5-10.0    upper limit of normal Any primary site Nonpulmonary visceral metastases absent Gonadal or retroperitoneal primary site Poor risk       Mediastinal primary site Nonpulmonary visceral metastases present ( eg , bone, liver, brain) AFP    10,000 ng/mL HCG    50,000 mIU/mL SEMINOMAS LDH    10    upper limit of normal NSGCT
  14. 24. NSCGT Seminomas Good prognosis 5y OS 92% 5y OS 86% Intermediate prognosis 5y OS 80% 5y OS 73% Poor prognosis 5y OS 48%
  15. 25. <ul><li>Observation </li></ul><ul><li>RT </li></ul><ul><li>1-2 cycles of adjuvant Carboplatin. </li></ul><ul><li>RPLND </li></ul>
  16. 26. <ul><li>Observation </li></ul><ul><ul><li>Avoids overtreatment of 80-85% of patients </li></ul></ul><ul><ul><li>Risk factors: tumor size (4 cm) and infiltration of rete testis (Warde, JCO 2002) </li></ul></ul>
  17. 27. Fewer testicular new primary tumors with carboplatin
  18. 28. <ul><li>Low risk for relapse : Observation </li></ul><ul><li>High risk for relapse ( LV invasion, embryonal Ca>50%) : 2 adjuvant BEP . </li></ul><ul><li>RPLND </li></ul>
  19. 29. <ul><li>Risk factors: </li></ul><ul><li>Invasion of testicular veins </li></ul><ul><li>Invasion of testicular lymphatics </li></ul><ul><li>Absence of yolk sac elements </li></ul><ul><li>Presence of undifferentiated tumor </li></ul>
  20. 30. <ul><li>Patient selection: ¾ risk factors (invasion of testicular veins, invasion of testicular lymphatics, absence of yolk sac elements, presence of undifferentiated tumor) </li></ul><ul><li>Therapy: B 90 E 360 P x2 </li></ul><ul><li>Results: </li></ul><ul><li>Relapses in 2(1)/104 patients </li></ul><ul><li>No changes in sperm count pre- and postchemotherapy (N=40 patients) </li></ul><ul><li>No significant change in lung function (N=16) </li></ul><ul><li>12% loss of high-tone hearing (N=22) </li></ul>
  21. 31. <ul><li>RT </li></ul><ul><li>Cures 85-90% of patients with some acute side effects and rare late effects of intestinal fibrosis, ileus, cystitis, second cancers (16% at 25 years!). </li></ul>
  22. 32. PE 500 B 90 x3 PE 500 B 90 x4 No. of patients 88 96 NED after Rx 86 (98%) 93 (97%) Relapse 5 (6%) 5 (5%) Continously NED 81 (92%) 88 (92%)
  23. 33. <ul><li>Chemotherapy. </li></ul><ul><li>IGCCCG good risk group : 3 x ΒΕΡ or 4 x EP. </li></ul><ul><li>IGCCCG intermediate prognosis group : 4 x ΒΕΡ. </li></ul><ul><li>IGCCCG poor prognosis group : 4 x ΒΕΡ or clinical trial. </li></ul>
  24. 34. <ul><li>Some facts: </li></ul><ul><li>Lower rate of residual mass than seminoma </li></ul><ul><li>Necrosis/fibrosis 45-50%, teratoma 35%, viable tumor 15-20% (pooled series) </li></ul><ul><li>Malignant tumor or teratoma can be present in small lesions </li></ul><ul><li>Poor prognosis of late relapse </li></ul><ul><li>PET identifies malignancy, but does not differentiate between necrosis/fibrosis and teratoma (Stephens, JCO 1996) </li></ul><ul><li>Recommendations: </li></ul><ul><li>Resection, if possible, by experienced surgeon, retroperitoneal lesions before lung lesions </li></ul>
  25. 35. <ul><li>Some facts: </li></ul><ul><li>Higher rate of residual mass: >50% in bulky tumors, one third persisting for several months </li></ul><ul><li>Non-responders exceedingly rare </li></ul><ul><li>Pronounced fibrosis results in increased operative risk </li></ul><ul><li>Vital malignant tumor is rare (17% in patients who underwent surgery, pooled series). Mature teratoma is very rare </li></ul><ul><li>Size and malignancy: controversial </li></ul><ul><li>PET scan is of benefit to detect residual tumor (Becherer, Europ J Radiol 2005 </li></ul><ul><li>Recommendations: </li></ul><ul><li>No surgery for residual (PET negative) mass </li></ul>
  26. 43. <ul><li>Lung toxicity </li></ul><ul><ul><li>Effect of bleomycin </li></ul></ul><ul><ul><li>Cumulative, significant risk above 450 units </li></ul></ul><ul><ul><li>Increased with age, prior thoracic radiotherapy, renal dysfunction </li></ul></ul><ul><ul><li>Associated with half of treatment related deaths </li></ul></ul><ul><ul><li>Fatal toxicity <1% with 3 courses of BEP </li></ul></ul><ul><ul><li>Acute respiratory failure after general anesthesia, avoidance of high concentration of inspired oxygen </li></ul></ul>
  27. 44. <ul><li>Renal toxicity </li></ul><ul><ul><li>Effect of cisplatin, reduced by using carboplatin </li></ul></ul><ul><ul><li>20% long term reduction in GFR </li></ul></ul><ul><li>Cardiovascular toxicity </li></ul><ul><ul><li>Up to 25% of patients develop hypertension after cisplatin </li></ul></ul><ul><ul><li>Hyperlipidemia </li></ul></ul><ul><ul><li>Ischemic events </li></ul></ul><ul><ul><li>Raynoud phenomenon </li></ul></ul>
  28. 45. <ul><li>Malignancies </li></ul><ul><ul><li>AML with a short latency period after high cumulative doses of etoposide </li></ul></ul>
  29. 46. Risk factors are: Presence of CIS and radiotherapy
  30. 47. <ul><li>Early relapse: </li></ul><ul><ul><li>No standard therapy, combination therapy including of cis- or carboplatin, etoposide, ifosfamide, paclitaxel and gemcitabine </li></ul></ul><ul><ul><li>High dose chemotherapy with ASCT </li></ul></ul><ul><li>Late relapse (after 2 years): </li></ul><ul><ul><li>Rare event </li></ul></ul><ul><ul><li>Surgery must be part of therapy </li></ul></ul><ul><li>Refractory disease </li></ul>
  31. 48. <ul><li>5-10% in young patients with hx of testicular cancer and atrophic contralateral testis </li></ul><ul><li>When should the contralateral testis be checked with US and FNA? </li></ul><ul><li>- History of cryptorchism or maldescented testis </li></ul><ul><li>- Suspicious US findings </li></ul><ul><li>- Patients<30 with atrophic testis<16 ml or oligospermia </li></ul>
  32. 49. <ul><li>Radiotherapy (van der Masse, Lancet 1986) </li></ul><ul><li>20 Gy to the contralateral testis abolishes CIS </li></ul><ul><li>has no effect on libido or sexual function </li></ul><ul><li>but induces sterility </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Elim in ation of CIS (van der Masse, Lancet 1988; Thompson, Br J Urol 1989) </li></ul><ul><li>Persistence of CIS in about 1/3 of patients (Dieckmann, APMIS 1998) </li></ul>

×