>Management of Non Seminomatous Germ cell tumors of Testis >NCCN 2015 guidelines incorporated

1. Management of Non
Seminomatous Germ Cell
Tumors of Testis
Dr. Akhil Kapoor
Acharya Tulsi Regional Cancer
Treatment & Research Center, Bikaner

2. Post Orchiectomy Tests
• Post Orchiectomy Serum Marker Status:
Decides Staging
• Usually performed after 3 weeks of Surgery
• Discuss Sperm Banking in young patients,
preferably before surgery.

3. • CE CT Abdomen & Pelvis
• A Chest CT is indicated if :
 the abdominopelvic CT shows retroperitoneal
adenopathy or,
 the CXR shows abnormal results.
• Brain MRI and Bone Scan. If clinically indicated.
• No role of PET-CT

4. Treatment options
Stage dependent treatment options after inguinal
orchiectomy include
• Surveillance,
• Chemotherapy, and
• RPLND.
• Although the timing of the RPLND may vary, most
patients will undergo an RPLND at some point during
treatment.
• Major morbidity with bilateral dissection : Retrograde
ejaculation, resulting in infertility.
• Nerve dissection techniques preserve antegrade
ejaculation in 90% of cases.

5. Bilateral RPLND
Involves removal of lymphatic tissue extending from:
• Lateral: between both ureters,
• Superior: diaphragmatic crus
• Inferior: bifurcation of the common iliac arteries.

6. Stage IA, IB (T2 only)
(1) Surveillance,
(2) Nerve-sparing RPLND.
• Cure rate with either approach exceeds 95%.
• With surveillance, up to 30% patients will develop
relapse which must be identified early.
• RPLND is recommended within 4 weeks of a CT
scan and within 7 to 10 days of repeat serum
marker testing to ensure accurate presurgical
staging.

7. Stage IB (T2 only)
• Vascular invasion is a significant predictor of
relapse when orchiectomy is followed by
surveillance alone.
• Surveillance generally not recommended for T2
disease with vascular invasion due to 50% chance
of relapse.

8. Post RPLND
• pN0: Surveillance
• pN1: Surveillance (preferred) vs. BEP- 2Cycles
• pN2: BEP- 2Cycles
• pN3: BEP- 3Cycles

9. F/U during Surveillance

10. Stage IB
1. Nerve-sparing RPLND, or
2. Primary chemotherapy: BEP for 2 cycles
After primary Chemo,
• Residual mass of 1 cm or greater : Nerve-sparing
RPLND
• Residual mass <1cm: Surveillance vs. RPLND

11. F/U for Stage IB

12. Stage IS
Elevated levels of AFP and beta-HCG after
orchiectomy :
• Disseminated nonseminoma
• hepatobiliary disease,
• marijuana use, and
• Hypogonadism.
• After excluding other causes, 3 cycles of BEP

13. Stage IIA with Normal Markers
1. Nerve-sparing RPLND (Preferred), or
2. BEP 3 Cycles.
• For patients with persistently elevated AFP or HCG
levels, induction chemotherapy.

14. Post Treatment in Stage IIA
After primary Chemo,
• Residual mass of 1 cm or greater : Nerve-sparing
RPLND
• Residual mass <1cm: Surveillance vs. RPLND
After primary RPLND,
• pN0: Surveillance
• pN1: Surveillance (preferred) vs. BEP- 2Cycles
• pN2: BEP- 2Cycles
• pN3: BEP- 3Cycles

15. IGCCCG Risk Grouping

16. For Good Risk Stage IIA-S1, IIB, IIC, IIIA
BEP for 3 cycles
• If CR: Surveillance vs. RPLND
• If Partial response (residual mass with normal
AFP & hCG levels) :
• If Incomplete Response, 2nd line CT

17. For Intermediate & Poor Risk IIIB & IIIC
BEP 4 Cycles
• If CR: Surveillance vs. RPLND
• If Partial response (residual mass with normal
AFP & hCG levels) :
• If Incomplete Response, 2nd line CT

18. F/U in Stage II, III Non Seminoma

19. Comparison of F/U Schedules

20. Second Line Therapy for Metastatic
Germ Cell Tumors
• Prognostic factors to decide whether patient is a
candidate for conventional dose therapy or high-
dose therapy with stem cell support as a second-
line option.
Favorable prognostic factors to conventional dose
second-line chemotherapy include:
• testicular primary site,
• prior complete response to first-line therapy,
• low levels of post- orchiectomy serum tumor
markers, and
• low-volume disease

21. Conventional Dose CT

22. High Dose CT

23. Resistance to High Dose CT
• For patients who do not experience CR to second-
line high-dose therapy, the disease is nearly always
incurable;
• Only exception is the rare patient with elevated
serum tumor markers and a solitary site of
metastasis (usually retroperitoneal) that undergoes
surgical resection.
• Other options are participation in a clinical trial or
best supportive care.

24. Palliative Chemotherapy
• Gemcitabine with paclitaxel
• Gemcitabine with oxaliplatin
• Gemcitabine with paclitaxel and oxaliplatin
• Oral Etoposide (50mg/sqm)

25. Summary
Stage IA, IB (T2 only)
(1) Surveillance,
(2) Nerve-sparing RPLND.
Stage IB
1. Nerve-sparing RPLND, or
2. Primary chemotherapy: BEP for 2 cycles
Stage IS
3 cycles of BEP

26. Stage IIA with Normal Markers
1. Nerve-sparing RPLND (Preferred), or
2. BEP 3 Cycles.
For Good Risk Stage IIA-S1, IIB, IIC, IIIA
BEP 3 Cycles
For Intermediate & Poor Risk IIIB & IIIC
BEP 4 Cycles

27. After primary Chemo,
• Residual mass of 1 cm or greater : Nerve-sparing
RPLND
• Residual mass <1cm: Surveillance vs. RPLND
After primary RPLND,
• pN0: Surveillance
• pN1: Surveillance (preferred) vs. BEP- 2Cycles
• pN2: BEP- 2Cycles
• pN3: BEP- 3Cycles

28. THANK
S