This document outlines a case presentation on testicular seminoma cancers. It discusses the case presentation, investigations including imaging, tumor markers, biopsy, and staging. It then covers prognosis factors, management strategies for different stages including surveillance, chemotherapy regimens, radiotherapy fields and doses. It also discusses complications, follow up, residual disease, and special considerations for patients with conditions like horseshoe kidney.

1. By:Gebrekirstos,COR-II
Moderator:Dr Wondemagegnehu,Consultant Oncologist
AAU,CHS
December 17,2019
Case Presentation on Testicular
cancers(Seminoma)

2. Out line of presentation:
A) Case on the presentation
B) Investigation Modalities
C) Staging
D) Prognosis factors
E) Managements
F) Complications of Rx
G) Follow up
H) Case critics
I) References

3. B) Investigations
1)History –Hx undescended testis, retractile testis,
personal/family Hx of same disease, orchidopexy
& previous inguinal or scrotal surgery.
2)Physical Exam-testicular mass, Special attention
to LN bearing areas ,abdominal mass
3) Testicular U/S-helps to define the origin of the
scrotal mass as majority of extra testicular lesions
are benign
• U/S features of testicular tumors –solid mass
associated internal vasculature with &
microlitiasis.

4. B) Investigations…
• U/S is not reliable in predicting tumor
histology, but in general:
-seminomas – hypo echoic & homogeneous
-NSGCT-heterogeneity in echo texture with
calcification.
↔solid mass in the scrotum with elevated
tumor markers should be considered
malignant till proved otherwise!

5. B) Investigations…tumor markers

6. B) Investigations…
5) Biopsy
If scrotal U/S shows features of testicular tumors
with elevated tumor markers, radical
orchidectomy through an inguinal incision is
diagnostic & primary Rx of testicular tumors
• Inguinal biopsy of the contralateral testis may be
indicated during surgery if:
-atrophy
-cryptorchidism
-suspicious abnormalities are found on U/S

7. B) Investigations…
6) Imaging
-Abd-pelvic CT –for all GCT(sensitivity -40%, specificity 95% for 1cm thresh hold LAP)
-CXR-for all seminoma pts
-Chest CT-scan(has 10% higher in detecting met than CXR)
-all NSGCT
-Seminoma with abnormal Abd-pelvic CT
-seminoma with abnormal CXR
-Brain MRI:
-symptomatic pts
-choriocarcinoma
-post-orchiectomy serum beta bHCG >5000 IU/L
-Extensive lung met
-relapse with ↑ tumor markers but PE & other imaging -ve
PET – CT scan
- limited role fore initial staging (can be used if CT is questionable) Sensitivit-66%,specificity 98%
- not able to detect lesion <5mm or teratoma of any size(low metabolic actives)
-important to evaluate residual retroperitoneal disease after Chemo(sensitivity for mass >3cm is
88% with –ve predictive value of 96%) & should be done after 6-8wks of last chemo

10. D) Prognosis of GCT
• Stage of disease
• Histology (seminoma -better)
• Size(seminoma>4cm 30% risk of recurrence)
• LVI(in NSGCT LVI+ve 50% risk of recurrence with
surveillance)
• Extra pulmonary met
• Elevated tumor marker-NSGCT
• Primary site(testicular vs extra testis)-NSGCT
• Rate of tumor marker decline
• Primary or relapse disease

11. D) Prognosis of GCT

12. E) Management
• Primary treatment
• The initial management involves a radical inguinal
orchiectomy in almost all cases except for the
uncommon life threatening presentation in which
systemic treatment is initiated immediately.
• Suspicious testicle should beremoved even in pts
with disseminated GCT -chemo sanctuaries site
for cancer cells
• If desired by pt Concurrent insertion of testicular
prosthesis may be considered during radical
inguinal orchiectomy

13. E) Management…
• Conditions where Chemo can be initiated
immediately without biopsy waiting:
1) Rapidly increasing beta-HCG or AFP levels
2)Symptoms related to disseminated disease
3) A testicular mass or distribution of metastatic
disease consistent with a testicular,
retroperitoneal, or mediastinal GCT

14. E) Management…
• Further management is decided by :
-Stage of the disease
-Histology types
*Pure seminoma
*NSGCT w/c includes:
-Mixed GCTs
-Tumors pathologically described as pure
seminomas but with ↑ serum AFP

15. E) Management…
• Sperm banking
• Should be discussed with reproductive age
pts,if clinically indicated, before any
therapeutic intervention that may
compromise fertility (surgery,RT,CT)

16. E.1) Management seminoma
• Seminoma is highly chemo & radio sensitive and
cures are routinely achieved even in advanced
disease settings.
• 5 yrs survival rate of GCT(both seminoma &
NSGCT)
-Prior to dev’t of effective CT regimens(1970s)-64%
-Currently ----------------------------------------------->95%
• Thus, the focus has shifted to minimize
treatment-related morbidity

18. E.1) Management seminoma…stage I
• DSS for stage I disease is 99% irrespective of the
management strategy used.
• So Rx decision is based on considerations of
cost, burden of therapy, and pt preference
• Options after initial orchiectomy include :
1)Active surveillance (preferred)
2)Chemo-with 1/2 cycles of single agent carboplatin
3)RT (20 Gy,preferred or 25.5 Gy)

19. E.1) Management seminoma…stage I
• Most stage I seminoma pts are cured by
orchiectomy alone with 20% will relapse if no
adjuvant therapy is offered.
• Either adjuvant RT or CT with single-agent
carboplatin is associated with:
- DFS >95%
-DSS ≈100%.

20. E.1) Management seminoma…stage I
Surveillance:
- become the management of choice
-B/n 1999-2008(population-based cohort from
British Columbia, Canada, and Oregon)
-Adjuvant RT use ↓ from 50 – 9%
-surveillance ↑ from 47-87%.
- Survey of Canadian radiation oncologists in 2006
revealed that 56% felt surveillance as the
preferred management

21. E.1) Management seminoma…stage I
• Surveillance-Kollmannsberger et al
• Retrospective study of 2,483 clinical stage I pts managed
with active surveillance(b/n 1998 -2010)
-1,139 stage I NSGCT
- 1,344 stage I seminoma
Relapse occurs 221 (19%) -NSGCT
173 (13%) -seminoma pts
Most relapse occur 2yrs (90%) NSGCT
3yrs(92%) seminoma
5 yrs diseases specific survival was 97.7%
• Conclusion-Active surveillance for CSI testis ca leads to
excellent outcomes

23. E.1) Management seminoma…stage I
• Surveillance:
• Surveillance should be conducted ONLY WITH
COMPLIANT PTS and with an understanding
that because of the risk of late relapse, they
should be monitored for at least 10 yrs

24. E.1) Management seminoma…stage I
• Adjuvant RT:
• In the past, the standard postoperative management of
pts with stage I seminoma has been adjuvant RT to the
para aortic and ipsilateral pelvic lymph nodes (“dog-
leg”/ “hockey stick” radiation field).
• This is a highly effective treatment:
-RR 1-5%
-DSS- 100%
↔without the need for ongoing abdominal imaging.

25. E.1) Management seminoma…stage I
• Adjuvant RT:
• As most of the relapses on surveillance occur in
the paraaortic region,smaller radiation target
volumes is adopted to ↓treatment toxicity.
• Pts at higher risk for RT morbidity so that RT is
contra indicated:
-IBD
-Horse shoe kidney
-Prior RT

26. E.1) Management seminoma…stage I
• Adjuvant RT:
• Optimal RT field size for seminoma
• Purpose- To compare relapse rates & toxicity associated
with para-aortic (PA) strip or PA and ipsilateral iliac lymph
node irradiation (dogleg (DL)field)
• Patients and Methods: Between July 1989 & May 1993, 478
men with testicular seminoma stage I (T1-T3; no ipsilateral
inguinoscrotal operation before orchiectomy) were
randomized
-PA-236 pts
-DL-242pts

28. E.1) Management seminoma…stage I
• Adjuvant RT:
• Results :median follow up 4.5yrs
• 18 relapse-9 in each arms(4-35 mon from RT)
-4 pelvic(all in PA RT)
• 1 pt died in the PA field
• 3 yrs relapse free survival-96% PA
-96.6% DL
• 3 yrs survival 99.3(PA) &100%(DL)
• Acute toxicities(N,V & leucopenia) less in PA
• Sperm count higher after PA at 18 mo follow up
• Conclusion -PA radiotherapy is recommended as standard
treatment in these patients(T1-T3,undisturbed lymphatic )

30. E.1) Management seminoma…stage I
• Adjuvant RT:Dose 20 vs 30 Gy
• MRC TE18,EORTC 30942
• From 1995 to 1998 625 stage I post orchiedectomy pts
randomly assigned either to 20 or 30 GY in 2Gy/ ≠ RT
• Median follow up 61mo, 95% pts followed for 2yrs & 70% pts
followed for 5 yrs

31. E.1) Management seminoma…stage I
• Carboplatin Vs RT for Stage I Seminoma:MRC TE19/EORTC
30982
• Purpose:to compare adjuvant RT & CT(single agent
carboplatin) for stage I seminoma-updated result of 6.5 yrs
follow up
• Pts & methods –1447 pts randomly assignment
• RT-904 pts
• Chemo(carboplatin AUC*7)-573 pts
• Results

33. E.1) Management seminoma…stage I
• Observation vs CT vs RT (Clinical Outcomes & Prognostic
Factors for Relapse in a Large US Cohort)
• This analysis defines the experience at Kaiser Permanente
Southern California from 1990 to 2010
• Retrospective study 502 pts post orchiectomy
• Outcome evaluated RFS(relapse free survival),OS &CSS
• Risk factors for recurrence evaluated were(age, preoperative
hCG ↑, preoperative LDH ↑, tumor size, LVI, RTI,epididymis
invasion, and invasion through the tunica albuginea)
• RT -329 pts (117 DL,205 PA,&7 unknown field)
• Chemo-79 pts(33-1×carboplatin, 36-2×carboplatin 10 –other
agents)
• Surveillance -94 pts

34. E.1) Management seminoma…stage I
• Observation vs CT vs RT(Clinical Outcomes & Prognostic
Factors for Relapse in a Large US Cohort)

35. E.1) Management seminoma…stage II
• Rx depends on size of retroperitoneal LAP:
-Stage IIA(≤2cm) RT preferable
-Stage IIB(2-5cm) CT preferable, RT for non bulky
disease(<3cm)
-Stage IIC(>5CM) –CT is indicated
• RT is curative in 80-90% of pts, with recurrence
largely due to occult disease outside the radiation
field.
• There is an excellent success rate with
combination CT in pts who do relapse after RT

36. E.1) Management seminoma…stage II
• If chemotherapy is given, both EP and BEP are
preferred regimens in this setting.
• However, a bleomycin-free regimen should be
considered in pts with :
-↓/borderline GFR
-pts> 50 yrs age
-significant lung met
-pts with underlying lung diseases
-Hx of active smoking
• D/t studies have reported d/t outcomes with regard to
whether CT or RT is more effective in this setting

37. E.1) Management seminoma…stage I
• The NCCN Guidelines recommend either RT or
CT as primary treatment for both stage IIA
and IIB seminoma.
• However, CT is preferred for stage IIB
seminoma, with RT being reserved for select
patients with non-bulky (≤3 cm) disease

38. E.1) Management seminoma…stage II
• Stage II survival by Rx strategy (S.M. Glaser et al)
• Purpose –to compare RT vs CT in stage II seminoma in randomized
manner.
• Methods- 2437 stage II seminoma pts treated with orchiectomy & either
RT/MACT from 1998 -2012.
-IIA=960 pts (39.4%)
-IIB=812 pts (33.3%)
- IIC=665 pts (27.3%)
Median follow up-65 months (ranges 34-106)
• Rates of RT utilization were:
IIA -78.1%
IIB -54.4%
IIC -4.2%.
• Rates of MACT utilization were:
IIA-21.9%
IIB-45.6%
IIC-95.8%.

39. E.1) Management seminoma…stage I
• Stage II survival by Rx strategy (S.M. Glaser et al)
• Results:
• For stage IIA pts at 5 yrs survival improved
with RT compared MACT(99% vs 93%)
• For stage IIB pts at 5 yrs survival was :
-95.2%-RT P=.041,no significant d/ce
-92.4-MACT multivariable analysis.

40. Stage II survival by Rx strategy (S.M. Glaser et al)

41. Stage IIC& III seminoma
• Patients with stage IIC or stage III seminomas are
classified as either good or intermediate risk.
• Intermediate risk in seminoma is based on metastases
to organs other than the lungs.
• Standard chemotherapy is used for both groups of
patients.
• Good risk -3BEP/ 4EP (both preferred)
• Intermediate -4BEP/(preferred) or 4VIP (etoposide,
mesna, ifosfamide ,and cisplatin)
• VIP reserved for pts with bleomycin contraindication

42. F) GCT in pts with horseshoe kidney
• Horseshoe kidney (pelvic kidney) occurs in 1/400 persons in
the general population.
• There are 2 problems in management of these pts:
1) technical problem in delivery of RT as major part of renal
parenchyma lies on the radiation field associated with
radiation nephritis.
2) Abnormalities in the lymphatic drainage of testis resulting
in unusual patterns of relapse when standard RT field is
used.
For this reason preferred management in this types of pts is:
-stage I-surveillance
-stage II-Chemotherapy

43. G) Bilateral testicular GCT/tumor
arising in a single testis
• Men who have Hx testicle ca are at ↑ risk of contralateral
disease(metachronous or synchronous,1-5%)
• Recommended treatment-bilateral orchiectomy with its complications:
- infertility
-lifelong dependence on androgen replacement
-psychological morbidity(castration at young age)
• To preserve endogenous hormonal function, organ-sparing surgery
followed by low-dose RT (16-20 Gy in 2-Gy/≠using a direct field with
electrons) to the remnant testis to eradicate residual CIS and prevent
future invasive disease is an option with a high likelihood of cure in
selected pts.
• This procedure is contraindicated ;
- large tumors (>30% of the testis volume)
- clinical evidence of metastatic disease a

44. H) Residual disease
• For patients with stage II or III disease treated
with primary chemotherapy, residual masses
are present at 1 month in up to 80% of
patients.
• Most of these then gradually regress over a
period of several months.
• observation alone is adequate for a residual
mass <3 cm in size.

45. H) Residual disease…
• if the tumor is well defined on CT and measures
>3 cm in greatest dimension, positive histology
can be found in 50%.
→ It is reasonable to resect these masses.
• If the mass is poorly defined, even if >3 cm, the
chance of finding positive histology is <10%.
Resecting such a mass is hazardous, with risk of
great vessel, ureteric, and small bowel injury.
→ These should be observed

46. H) Residual disease…
• FDG-PET scans can reliably predict the
presence of viable disease in retroperitoneal
masses post CT in seminomas.
• It should be performed 6 wks after the last
cycle of CT , as earlier imaging has a higher
risk of false +ve results.

47. H) RT techniques
• Modern RT uses smaller field & dose than
used previously
• Should be started as soon as the orchiectomy
wound healed
• Location of kidneys vary with in PA field from
pts to pts & for relatively medial kidney small
renal block can placed at T12
• Rt & Lt kidney D50% should be ≤8Gy & for
single kidney D15% should be 20 Gy.

48. H) RT techniques
• Pt supine arm on his side with
• knee support for comfort
immobilization can use
• Penis out of field
• Use scrotal shield (Clamshell)
• Use PA/AP with >6MV photon
• Dose
PA-field

49. H) RT techniques
Dog leg/Modified dog leg
• Second phase(cone
down) contains daily 1.8-
2Gy to LN (gross tumor)
to total dose of:
-30Gy-IIA
-36Gy-IIB
• Dose

51. I) Testicular shielding
• During retroperitoneal & ipsilateral iliac lymph
nodes RT , the dose to the remaining testis
ranges between 0.3 and 1.5 Gy.
• Dose received depends on distance of the
testicle from field edge.
• Effective shielding devices reduce dose
received by the testicle to <1% of the mid
plane dose

52. J) Complications of treatments
J.1)RT:
• Impaired fertilities
• PUD(5-10%)
• Second malignancies
-stomach -RR 4.0
-pancreas -RR 3.6
-bladder RR 2.7
- lung, esophagus, colon, and pleura
• Cardiac disease(due to increase DM post RT)

53. J) Complications of treatments
J.2) Chemotherapy
• Alopecia
• Nausea & vomiting
• Myelosupression(Cisplatin)
• Raynaud phenomenon(24-49%)
• Atrophy of the remaining testis(Cisplatin)
• pulmonary fibrosis(Bleomycin)
• secondary malignancy(etoposide)
• high-tone hearing loss
• Neurotoxicity
• BEP causes immediate azoospermia but Long-term fertility
impaired little(paternity rate after 2-4c of BEP is 70-85%.)

55. K) Follow up
• Abdomino-pelvic CT scan should done 8 wks
after chemo
• If with complete response ---put on follow up
• Post chemo residual mass <3 cm—follow up
• Post chemo >3 cm do PECT/CT(at least 2mon
from chemo)-negative predictive value->90%
but high false +ve, so repeat PET/CT & do
RPLND

56. k) Follow up…

58. Thank you!
• Take of message!
• GCT is highly treatment sensitive & curative
• “Appropriate staging work up & Rx
choosing paramount as subsequent
Rx modalities can be difficult in our
set up”

59. Thank you!
• y