1. The document discusses testicular cancer including risk factors, staging, markers, treatment protocols, relapse, and follow up. 2. Treatment for testicular cancer often involves chemotherapy with BEP protocol for good risk patients and other protocols for intermediate/poor risk. 3. Surgery may be used for residual tumors after chemotherapy and follow up monitoring is important due to risk of relapse.

1. Dr CK Das MD,DM,MRCP(UK)
Assistant Professor Medical Oncology
Regional Cancer Center, PGIMER, Chandigarh

2. International variation in estimates of national
agestandardised testicular cancer (a) incidence rates
and (b) mortality rates, all ages.

3. Histology WHO 2017

4. Risk Factors of GCT

5. Development
of germ cell
tumours

6. Location of GCT

7. GCT Work up

8. Marker in GCT

9. AJCC 8TH 2017 Testicular Cancer Staging

10. STAGE 1 (disease confined to the testis)

11. CLINICAL STAGE 1 SEMINOMA
(70-75% of all seminoma)

13. Relapse rate in Stage 1 seminoma:
Active surveillance in 1822 patients

14. CLINICAL STAGE 1 NON-SEMINOMA
:SWENOTECA Model
LVI/
SPERMATIC CORD/
SCROTAL INVOLVEMENT

15. International Germ Cell Consensus Classification
Prognostic category Nonseminoma Seminoma
Good risk
Testicular tumor or primary extragonadal retroperitoneal tumor,
and low serum tumor-marker levels:
AFP <1,000 ng/ml
hCG <1,000 ng/ml or <5,000 IU/l)
LDH <1.5 times normal level
Absence of extrapulmonary visceral metastasesa
Any primary site
Any serum tumor-marker level
Absence of extrapulmonary visceral metastasesa
Intermediate risk
Testicular site or primary extragonadal retroperitoneal site,
and intermediate serum tumor-marker levels:
AFP 1,000–10,000 ng/ml
hCG 5,000–50.000 IU/l
LDH 1.5–10 times normal level
Absence of extrapulmonary visceral metastasesa
Any primary site
Any serum tumor marker level
Presence of extrapulmonary visceral metastasesa
Poor risk
Primary mediastinal germ-cell tumor or testicular tumor,
or primary retroperitoneal tumor with high serum tumor-marker levels:
AFP >10,000 ng/ml
hCG >50,000 IU/l
LDH >10 times normal level
Presence of extrapulmonary visceral metastasesa
NA

16. Seminoma

17. Seminoma

18. PET CT in GCT

19. NON-SEMINOMA

20. Randomized trials in good-risk

21. Randomized trials in intermediate and poor-risk

22. BEP Improvements

23. BEP ProtocolPREMED:
1) CAP NUTEPITANT 300 MG+ PALONOSETRON 0.5 MG 1 CAP BEFORE CHEMOTHERAPY D1
2) INJ DEXAMETHASONE 12 MG/100 ML OF NS OVER 30 MIN D1
3) INJ PALONOSETRON 0.25 MG IVP D4 ONLY
4) INJ DEXAMETHASONE 8 MG IVP D2,D3,D4,D5
CHEMOTHERAPY
1) INJ CISPLATIN 20 MG/M2 /500 ML OF NS IV OVER 60 MIN D1,D2,D3 ,D4,D5
2) INJ ETOPOSIDE 100MG/M2 IN 500 ML OF 5% DEXTROSE IV OVER D1, D2, D3,D4,D5
3) INJ MGSO4 1 AMP+KCL 20 MEQ IN 100 ML OF NS IV OVER 60 MIN D1,D2,D3,D4,D5
4) INJ MANNITOL 100 ML IV OVER 10 MIN D1,D2.D3,D4.D5
5) INJ HYDROCORT 100 MG IVP D1,D8,D15 BEFORE BLEOMYCIN
6) INJ BLEOMYCIN 30 IN IN IVP OVER 30 MIN D1, D8 D15
7) 10 IV SET, 1 20 G CANNULLA, 5 10 ML SYRINGE,2 16G NEEDLE, 1 PAIR OF GLOVES
POST CHEMOTHERAPY
1) INJ PEG GCSF 6 MG SC D5
2) TAB RABEPRAZOLE -D ONCE A DAY BEFORE FOOD FOR 5 DAY
3) SYP LACTULOSE/LACTITOL 20 ML AT NIGHT FOR 3 DAY
4) If fever 100.3F over 1hr tab Augmentin 625 mg TDS+tab Levofloxacin 500 mg od and consult PGI Emergency
>90% CINV
Risk
3 DAY NEPA
CINV Protection
dRTA
Mg/K Loss
Compensation
Diuresis
Loop
Diuretics+Mannitol
Bleomycin
infusion
reaction
Prevention
Peg-GCSF
>20% FN Risk

24. BEP Protocol

25. Post Chemotherapy

26. Surgery for Residual GCT

27. Growing Teratoma Syndrome

28. RPLND Evidence in Teratoma

29. Follow up

30. Relapse GCT
IGCCCC-2 Lorch-Bayer Score
• Late >2year
Risk Group Score
Very Low Risk -1
Low Risk 0
Intermediate
Risk
1-2
High Risk 3-4
Very High Risk >5

31. Second Line

32. Third Line

33. Semen Preservation

34. When to do Semen Preservation

36. When can orchiectomy be postponed?
Extensive visceral metastases, in those with very elevated hCG or AFP
(thus establishing the diagnosis of TGCC with no need for histological
confirmation
patient conditions related to metastatic dissemination require
immediate chemotherapy

37. CNS+/Bone Metastasis GCT
Chemotherapy according to the IGCCCG classification for poor
prognosis TGCC is recommended as standard of care for patients with
upfront brain and/or bone metastases
There are no high-quality data governing routine use of post-
chemotherapy local treatment (surgery or radiation) for the brain or
bone.
Primary whole-brain radiotherapy is not recommended
single residual lesions after chemotherapy and normal or normalised
tumour markers should be considered for additional surgery or
stereotactic radiation

38. Take home message