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.

Testicular Cancer


Published on

Testicular Cancer chemotherapy offers a cure rate of at least 85 percent.

Testicular Cancer

  1. 1. Testicular Cancer Ryan Mills Pharm D. candidate May 3, 2007
  2. 2. <ul><li>H&P: A.M is a 23-year-old Mexican American male who has a 1-year history of a right testis mass. He recently presented with right flank pain. Work up showed several pulmonary metastases as well as retroperitoneal metastasis and right hydronephrosis. His scrotal ultrasound revealed several lesions. </li></ul><ul><li>PMH/Medications: Noncontributory. </li></ul><ul><li>Allergies: NKDA </li></ul>
  3. 3. <ul><li>February 28, 2007: </li></ul><ul><li>U/S scrotum: right testicular multiple masses compatible with primary malignancy of the testes. </li></ul><ul><li>CT scan abdomen, pelvis and chest: metastatic disease to the lungs and invasion of the tumor into the inferior vena cava and right kidney. </li></ul><ul><li>U/S kidney: massive retroperitoneal lymphadenopathy. </li></ul>
  4. 4. <ul><li>March 1, 2007: </li></ul><ul><li>Right inguinal orchiectomy: Right testis and spermatic cord were sent to pathology to determine prognosis. </li></ul>
  5. 5. <ul><li>March 2, 2007 </li></ul><ul><li>Patient D/C pending pathology results. </li></ul><ul><li>Results </li></ul><ul><li>Right orchiectomy showed, Nonseminomatous germ cell tumor of testis, T2 N3 M1, S2, (AFP 427, LDH 1853), stage III. </li></ul>
  6. 6. <ul><li>IMPRESSION AND PLAN: Available data support diagnosis of primary right testis nonseminomatous cancer, predominantly seminoma but possibly with other histologic components, with high LDH and AFP, metastatic to periaortic nodes, right inguinal region and lungs. The patient is &quot;intermediate risk&quot; based on his markers and metastases. Plan to start BEP chemotherapy. </li></ul>
  7. 7. <ul><li>Delbes G, Hales BF, Robaire B. Effects of the chemotherapy cocktail used to treat testicular cancer on sperm chromatin integrity. J Androl. 2007 Mar-Apr;28(2):241-9; discussion 250-1. Epub 2006 Oct 4. </li></ul>
  8. 8. <ul><li>March 5, 2007: </li></ul><ul><li>Patient readmitted: surgical site pain, SOB & pain radiating down his right leg. </li></ul><ul><li>CT chest: PE with multiple lesions of varying sizes. </li></ul><ul><li>Nasal Cannula-SOB </li></ul>
  9. 9. <ul><li>March 6, 2007: </li></ul><ul><li>CT right leg: Mass extending into right inguinal canal. </li></ul><ul><li>March 9, 2007: CT brain negative. </li></ul><ul><li>March 16, 2007 :   </li></ul><ul><li>Endoscopy duodenem: extrinsic gastric compression and upper esophageal injury. </li></ul>
  10. 10. <ul><li>March 23,2007: Febrile Neutropenia: ID recommendations </li></ul><ul><li>Vancomycin </li></ul><ul><li>Merepenem </li></ul><ul><li>Levofloxacin (ARF contraindicates AMG) </li></ul><ul><li>Caspofungin </li></ul>
  11. 11. <ul><li>April 04, 2007: </li></ul><ul><li>Bronchoscopy: bilateral pulmonary infiltrate. </li></ul><ul><li>April 09,2007: </li></ul><ul><li>Culture: Candida species present. Rare large yeast with broad-based budding form. </li></ul>
  12. 12. <ul><li>April 10, 2007: Started Itraconazole x 6 months. Indication: Blastomyces per ID </li></ul><ul><li>April 19, 2007: Febrile Neutropenia (Standard Protocol) </li></ul><ul><li>Cefepime </li></ul><ul><li>Vancomycin </li></ul><ul><li>Levofloxacin </li></ul>
  13. 13. <ul><li>CHEMOTHERAPY: Bleomycin/Etoposide/Cisplatin x 4 cycles (21 day intervals) </li></ul><ul><li>Weekly CBC, Plt, lytes, Mg++, Phos, LDH, AFP </li></ul><ul><li>NOTE: Before chemotherapy. ANC <1000, Hemoglobin <8.5, platelets <100,000, abnormal creatinine or liver function tests. </li></ul><ul><li>Day 21 with CT-chest, abdomen, CBC, Plt, lytes, Mg++, Phos, LDH, AFP. </li></ul><ul><li>Hydrate with NS 150ml/hr during treatment </li></ul>
  14. 14. <ul><li>CHEMORX </li></ul><ul><li>Etoposide: QD x 5d </li></ul><ul><li>Cisplatin: QD x 5d </li></ul><ul><li>Bleomycin: Days 2,9,16 </li></ul><ul><li>March 10 Cycle # 1 </li></ul><ul><li>April 4 Cycle # 2 </li></ul><ul><li>April 30 Cycle # 3 </li></ul><ul><li>Note: 21d intervals extended b/c not meeting criteria. i.e afbrile/neutropenic </li></ul>
  15. 15. Epidemiology <ul><li>Most frequently occuring malignancies in young men. </li></ul><ul><li>Most common in males ages 20-35 </li></ul><ul><li>Uncommon after the age of 40. Therefore accounts for only 1% of malignancies in males. </li></ul><ul><li>Whites are at a higher risk than African Americans </li></ul>
  16. 16. Risk Factors <ul><ul><li>Cryptorchidism (Undescended Testicle: intraabdominal higher risk vs. inguinal) </li></ul></ul><ul><ul><li>Caucasian (4-5 x risk) </li></ul></ul><ul><ul><li>Testicular cancer contralateral testis </li></ul></ul><ul><li>Klinefelters syndrome </li></ul><ul><li>HIV pos. </li></ul>
  17. 17. Symptoms <ul><li>Asymptomatic nodule or swelling </li></ul><ul><li>Testicular mass, feeling of heaviness, pain and/or hardness </li></ul><ul><li>Advance Disease may experience </li></ul><ul><li>Abdominal pain: RP adenopathy </li></ul><ul><li>Gynecomastia: elevated b-HCG </li></ul><ul><li>Dyspnea: pulmonary metastases </li></ul><ul><li>HA/seizure: brain metastases </li></ul>
  18. 18. Differential Diagnosis <ul><li>Metastasis from prostate, lung, or melanoma. </li></ul><ul><li>Epididymitis </li></ul><ul><li>Lymphoma </li></ul><ul><li>Spermatocele </li></ul><ul><li>TB, gumma </li></ul><ul><li>Leukemia </li></ul>
  19. 19. Diagnostic <ul><li>Goal: Highly curable (85% of cases) </li></ul><ul><li>Physical Exam </li></ul><ul><li>U/S: detects parenchymal abnormality </li></ul><ul><li>CT abdomen, chest, pelvis : extent of dissemination </li></ul><ul><li>MRI: Used when results don’t match or brain if pt. has CNS sx. </li></ul>
  20. 20. Labs: Tumor Markers <ul><li>Alpha fetoprotein (aFP) </li></ul><ul><li>half-life 5-7 days </li></ul><ul><li>commonly excreted by embryonal and yolk sac </li></ul><ul><li>Indicates nonseminoma </li></ul><ul><li>Human Chorionic Gonadotropin (bHCG) </li></ul><ul><li>Half-life 24hrs </li></ul><ul><li>Enhanced estrogen production of testes-Gynecomasta </li></ul><ul><li>Modestly elevated in pure seminomas </li></ul>
  21. 21. Tumor Markers <ul><li>Lactate Dehydrogenase (LDH) </li></ul><ul><li>Nonspecific tumor marker but is a useful prognostic indicator </li></ul><ul><li>Indicator of tumor burden </li></ul>
  22. 22. Primary Testicular Cancer <ul><li>GERM CELL (95%) </li></ul><ul><li>Single cell-type 60% </li></ul><ul><li>Mixed 40% </li></ul><ul><li>NONGERM CELL (5%) </li></ul><ul><li>Leydig 1-3% </li></ul><ul><li>Sertoli <1% </li></ul><ul><li>Gonadoblastoma 0.5% </li></ul><ul><li>GCT 2 MAIN TYPES </li></ul><ul><li>Seminoma (40-50%) Primoridal germ cell </li></ul><ul><li>Nonseminomas (50-60%) </li></ul><ul><li>Embryonal cell </li></ul><ul><li>Yolk sac </li></ul><ul><li>Teratomas </li></ul><ul><li>Chorlocarcinomas </li></ul>
  23. 23. Therapy <ul><li>Seminomas are highly sensitive to XRT </li></ul><ul><li>Tumors with seminoma histology with elevated AFP treat as nonseminoma </li></ul><ul><li>Brain metastasis should receive WBR </li></ul><ul><li>U/S testes shows malignancy, check lab markers and proceed w/orchiectomy. </li></ul><ul><li>Exception: Benign </li></ul>
  24. 24. Radical Orchiectomy <ul><li>Inguinal approach </li></ul><ul><li>Testicle and spermatic cord are then sent to a pathologist for staging. </li></ul>
  25. 25. Staging Metastases above the diaphragm or to visceral organs III Metastases to retroperitoneal nodes; sometimes catergorized as nonbulky or bulky dependant on size and number of nodes involved II Confined to testicles I
  26. 26. Abnormal tumor marker levels <ul><ul><li>AFP value of greater than 9 ng/mL is considered abnormal. </li></ul></ul><ul><ul><li>HCG level of greater than 4 mIU/mL is considered abnormal. </li></ul></ul><ul><ul><li>LDH value of more than 1.5 times the reference range is considered abnormal. </li></ul></ul>
  27. 27. Tumor Markers <ul><li>Serum tumor markers are routinely used for diagnosis, staging and follow-up. </li></ul><ul><li>Absence of elevated levels of HCG, AFP and LDH in a patient with a testicular mass does not rule out the presence of a tumor. </li></ul><ul><li>These markers can signal an incomplete cure or relapse long before it is evidenced by physical or radiologic examination. </li></ul>
  28. 28. Prognosis <ul><li>Seminoma (at 5 years) </li></ul><ul><li>I: 98% </li></ul><ul><li>IIA: 92-94% </li></ul><ul><li>IIB-III: 33-75% </li></ul><ul><li>NSGT (at 5 years) </li></ul><ul><li>I: 96-100% </li></ul><ul><li>IIA: >90% </li></ul><ul><li>IIB-III: 55-80% </li></ul>
  29. 29. Treatment Overview <ul><li>Chemo +/- resection of residual mass </li></ul>Seminoma Nonseminoma Stage III <ul><li>XRT or chemo </li></ul><ul><li>chemo followed by resection </li></ul>Seminoma Nonseminoma Stage IIB (bulky) <ul><li>XRT </li></ul><ul><li>RPLND +/- chemo </li></ul>Seminoma Nonseminoma Stage IIA(nonbbulky) <ul><li>XRT to retroperitoneal/ inguinal nodes </li></ul><ul><li>RPLND or surveillance </li></ul>Seminoma Nonseminoma Stage I
  30. 30. retroperitoneal lymph node dissection <ul><li>RPLND primary treatment (NSGCTs) </li></ul><ul><li>Remove abdominal lymph nodes </li></ul><ul><li>Problems mainly occur with the nerve: infertility, ejaculation problems </li></ul>
  31. 31. Chemotherapy <ul><li>BEP: (Bleomycin, Etoposide, Cisplatin) 2-4 cycles 21d intervals (4 most common) </li></ul><ul><li>EP: (Etoposide, Platinol) 4 cycles 21d intervals </li></ul>
  32. 32. Salvage Thearpy <ul><li>No initial complete response </li></ul><ul><li>VIP: (Etoposide, Ifosamide,Mesna, Platinol) 3-4 cycles 21d intervals </li></ul><ul><li>High-dose chemotherapy with autologous bone marrow transplantation in selected patients with bulky disease </li></ul>
  33. 33. Follow up <ul><ul><li>physical examinations, chest radiographs and serum tumor markers </li></ul></ul><ul><ul><li>CT scans detect recurrence in the retroperitoneum and chest </li></ul></ul><ul><ul><li>Follow-up protocols vary by institution, type, stage and treatment </li></ul></ul>
  34. 34. Recommended Exams <ul><li>Every 2-3 months 1 st yr. </li></ul><ul><li>Every 3-6 month 2 nd yr. </li></ul><ul><li>Every 6 month remainder 5 yrs. </li></ul><ul><li>CTscans: 3-6 months 1 st yr. then annually </li></ul><ul><li>Men at high risk: Annually with self-exam monthly </li></ul>
  35. 35. Complications <ul><li>Pulmonary toxicity: Bleomycin keep total dose under 400 units. </li></ul><ul><li>Nephrotoxicity: Cisplatin- decreased Cr: Dosed based on CrCl </li></ul><ul><li>Neurologic: Cisplatin- Ototoxicity </li></ul><ul><li>Cardiovascular: HTN, MI, Angina </li></ul><ul><li>Secondary Malignancies: Etoposide characterized by 11q23 translocation </li></ul>