Testis carcinoma- management- seminoma

Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
Management of Seminoma Testis
1

Moderators:
Professors:
 Prof. Dr. G. Sivasankar, M.S., M.Ch.,
 Prof. Dr.A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr. J. Sivabalan, M.S., M.Ch.,
 Dr. R. Bhargavi, M.S., M.Ch.,
 Dr. S. Raju, M.S., M.Ch.,
 Dr. K. Muthurathinam, M.S., M.Ch.,
 Dr. D.Tamilselvan, M.S., M.Ch.,
 Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai.
2

SEMINOMA
 75 % confined to testis alone.
 10-15 % to retroperitoneal LN.
 5-10% to distant mets.
 Goal of treatment is to achieve cure with
minimal morbidity.
3 Dept of Urology, GRH and KMC, Chennai.

AJCC STAGING SYSTEM
CLINICAL STAGE
DESCRIPTION
I
Is
II
III
Confined to testis
Confined to testis with post
orchiectomy elevation of
tumor markers.
Retroperitoneal metastases
Supra diaphragmatic or visceral
metastases

TNM STAGING
PrimaryTumor (T)
 TX: Primary tumor cannot be
assessed
 T0: No evidence of primary tumor
 Tis: Intratubular germ cell
neoplasia (carcinoma in situ)
 T1:Tumor limited to the testis and
epididymis and no
vascular/lymphatic invasion
 T2: Tumor limited to the testis
and epididymis with
vascular/lymphatic invasion or
tumor extending through the
tunica albuginea with
involvement of tunica vaginalis
 T3: Tumor invades the
spermatic cord with or without
 T4: Tumor invades the scrotum
with or without

TNM STAGING
Regional Lymph Nodes (N)
 NX Regional lymph nodes cannot be assessed
 N0: No regional lymph node metastasis
 N1: Lymph node mass 2 cm or less in greatest dimension or
multiple lymph node masses, none more than 2 cm in greatest
dimension
 N2: Lymph node mass, more than 2 cm but not more than 5 cm
in greatest dimension, or multiple lymph node masses, any one
mass greater than 2 cm but not more than 5 cm in greatest
dimension
 N3: Lymph node mass more than 5 cm in greatest dimension

TNM STAGING
 Distant Metastasis (M)
 M0: No evidence of distant metastasis
 M1a: Nonregional nodal or pulmonary metastasis
 M1b: Nonpulmonary visceral metastasis

TNM STAGING
 SerumTumor Markers (S)
LDH HCG(mIU/L) AFP(ng/ml)
S0 N N N
S1 < 1.5 X N <5000 <1000
S2 1.5-10 X N 5000-50000 1000-10000
S3 >10XN > 50000 > 10000

PRINCIPLES OF TREATMENT
 Radical inguinal orchidectomy is standard first line of
therapy
 Lymphatic spread initially goes to RETRO-
PERITONEAL NODES
 Early hematogenous spread RARE
 Bulky RetroperitonealTumours or MetastaticTumors
CHEMOTHERAPY

RADICAL ORCHIECTOMY
 A radical orchiectomy with high ligation of the spermatic
cord at the level of the internal ring is the first step
 This procedure provides histopathologic diagnosis andT
categorization
 Associated with minimal morbidity and no mortality
 Provides local control of the tumor in the vast majority of
patients

RADICAL ORCHIDECTOMY

EARLY CLAMPING

Organ Sparing Surgery
 Indications:
 In synchronous, bilateral testicular tumours
 In metachronous, contralateral tumours, with normal
preoperative testosterone levels
 In a tumour in a solitary testis, with normal preoperative
testosterone levels
 The tumour volume in these cases should be less than about 30%
of the testicular volume

Organ Sparing Surgery
 Inguinal exploration of the testis, gentle occlusion of the spermatic
cord vessels, and tumor identification by palpation or intraoperative
USG.
 Incision of the tunica albuginea is performed above the tumor,
which is enucleated with a small margin of the adjacent
parenchyma.
 The tumor and additional biopsies from the tumor bed are sent for
frozen section analysis to exclude tumor infiltration.
 Majority of tumor enucleation procedures were performed under
cold ischemia .

Pathological examination of the testis
 Macroscopic features: testis size
 Tumor maximum size
 Macroscopic features of
epididymis, spermatic cord and
tunica vaginalis.
 Sampling:1 cm2 section for every
centimetre of maximal tumor
diameter, including normal
macroscopic parenchyma (if
present), albuginea and epididymis
and selection of suspected areas.
 At least one proximal and one distal
section of spermatic cord plus any
suspected area.
 Presence or absence of peri-
tumor venous and/or lymphatic
invasion
 Presence or absence of
albuginea,tunica vaginalis, rete
testis, epididymis or spermatic
cord invasion
 Presence or absence of ITGCN
in adjacent parenchyma
 pT category
 IHC studies: in seminoma and
mixed germ cell tumour.

Intra-tubular Germ Cell Neoplasia
 Diagnosed by:
 Testicular biopsy performed
for the investigation of
infertility.
 By biopsy of the contralateral
testis in a patient with GCT.
 By biopsy within the affected
testis in a patient undergoing
testis sparing surgery.
 Radical orchiectomy is the
most definitive.
 Low-dose radiotherapy (20
Gy) is associated with
similar rates of local
control.
 Testosterone replacement
therapy is ultimately
required in 15% to 25% of
patients

Stage I Seminoma
 15-20% of stage I seminoma patients have subclinical
metastatic disease.
 Usually in the retroperitoneum.
 Will relapse after orchidectomy alone.
 The management of these patients includes
 Surveillance
 Primary radiotherapy
 Primary chemotherapy with single-agent
carboplatin

Stage Grouping
Stage I pT1-4 N0 M0 S0
Stage I S
Any pT/Tx N0 M0 S1-3

Stage I Seminoma
 Surveillance:
 Surveillance for CS I seminoma is complicated by the
limited utility of serum tumor markers to detect relapse
 10% to 20% of relapses occur 4 years or more after diagnosis

 History and physical examination ,TM,USG
 1st yr Every 3-6 month,
 2nd yr Every 6-12 monthly
 3rd yr Every 6-12 monthly
 4th yr Anually
 5th yr Annually
 CECT Abdomen and pelvis 1st yr 3, 6 &12 month,
 2nd yr Every 6-12 monthly
 3rd yr Every 6-12 monthly
 From 4th yr onwards 12-24 monthly
 CXRAs clinically indicated,CT chest in symptomatic patients

Stage I Seminoma
 Primary Radiotherapy
 mainstay of treatment for CS I seminoma
 Radiotherapy is given to the retroperitoneum and ipsilateral
pelvis, termed dogleg configuration
 The optimal radiation dose : 20 to 25.5 Gy in 10 to 17 daily
fractions

 No prophylactic RT to
mediastinum
 Shielding of opposite testis
 Local control- 100%
Dog leg port –
top of T11 through L5 to
ipsilateral iliac nodes up to
mid-obturator foramen

Stage I Seminoma
 Primary chemotherapy
 A single agent course of
carboplatin
 Low myelotoxicity and
gonadal toxicity
 Recurrence rate 9%.
 Primary chemotherapy
 Two courses of carboplatin
were associated with no
relapses .
 The optimal dosing of
carboplatin is calculated by
the formula 7 ×
(glomerular filtration rate
[GFR, mL/min] + 25) mg

Stage IIA and IIB Seminoma
 The standard treatment of stage II A/B seminoma is radiotherapy
 The radiation dose delivered in stage IIA and IIB is 30 Gy and 36
Gy, respectively
 The standard radiation field –dog leg

Stage II
II A Any pT/Tx N1 M0 S0 or S1
II B Any pT/Tx N2 M0 S0 or S1

 In stage IIB, the lateral borders should include the metastatic
lymph nodes with a safety margin of 1.0-1.5 cm
 Induction chemotherapy (BEP×3 or EP×4) is preferentially
given to patients with bulky (>3 cm) and/or multiple
retroperitoneal masses .

 The retroperitoneal lymph node groups included in radiation
treatment fields for stage II seminoma are :
1. Ipsilateral external iliac
2. Bilateral common iliac
3. Paracaval
4. Para-aortic nodes superiorly.

 Retroperitoneal disease in close relation to the kidney,
chemotherapy is usually preferred to avoid exposing the
kidney to radiation
 In patients with a history of herniorrhaphy or prior
orchiopexy, field includes the contralateral inguinal region.
 The contralateral testis shielded .
 Patients treated with postorchiectomy radiation therapy 5-
year survival rates of approximately 80%(70% to 92% ).

STAGE IIC AND STAGE III SEMINOMA
IIC Any pT/Tx N3 M0 S0 or S1
III A Any pT/Tx Any N M1a S0 or S1
III B
Any pT/Tx Any N M0 S 2
Any pT/Tx Any N M1a S2
III C
Any pT/Tx Any N M0 S3
Any pT/Tx Any N M1 b Any S

Stage IIc and Stage III Disease:
Advanced Seminoma
 Cisplatin-based chemotherapy.
 More than 90% of patients who present with stage
III disease achieve a complete response to
chemotherapy alone.
 Extensive prior irradiation can have an impact on the
amount of chemotherapy received as well as the
response rate.
 Response rates better when cisplatin-based
chemotherapy is given as the primary treatment with
no prior radiation.

RISK CLASSIFICATION
RISK STATUS SEMINOMA
GOOD RISK Any primary site and No non pulmonary visceral metastases and
Normal AFP ,Any HCG or LDH
INTERMEDIATE Any primary site and Non pulmonary visceral metastases and
Normal AFP , Any HCG or LDH
POOR RISK No patients classified as poor prognosis

Stage IIc and Stage III Disease:
Advanced Seminoma
 The regimen and number of cycles of chemotherapy is
determined by the IGCCCG risk
 Good risk group (90% Cases): BEP×3 or EP×4
chemotherapy
 Intermediate risk group (10% cases): BEP×4

RESIDUAL MASS
 The approach to the patient with pure seminoma and
a residual mass after chemotherapy is controversial
 Two important differences between seminoma and
NSGCT in this setting
 First, teratoma in the residual mass is very rare.
 Second, a complete RPLND is often not technically
possible owing to obliteration of tissue planes secondary to
the severe desmoplastic reaction of these tumors after
chemotherapy

RESIDUAL MASS
 Patients with residual masses smaller than 3 cm after
chemotherapy may be observed
 An FDG PET scan should be done for masses 3 cm or larger.
 A negative PET scan usually implies freedom from disease

RESIDUAL MASS
 A positive PET scan is often associated with residual viable
seminoma and additional therapy should be considered.
 If surgical resection appears feasible, it should be done
 Second line chemotherapy(vinblastine, ifosfamide,cisplatin)

Relapse Seminoma
 Chemotherapy-Naive Seminoma Relapse:
 Occurs in men with CS I seminoma on surveillance and in
those with CS I-IIB seminoma treated with primary
radiotherapy
 Patients with CSI on surveillance- Dog-leg radiotherapy is
employed cure rates of 70% to 90% are reported
 Patients with bulky (>3 cm) retroperitoneal masses and
systemic relapse should receive first-line chemotherapy,and
salvage rates approach 100%

Relapse Seminoma
 Postchemotherapy Seminoma Relapse—Early:
 15% to 20% of patients with advanced seminoma will
experience relapse after induction chemotherapy.
 Includes 10% who achieve an initial complete response
 Regimen:4 cycles of PEI (cisplatin, etoposide, ifosfamide)
 4 cycles ofVIP (Vinblastine, ifosfamide, cisplatin)

Relapse Seminoma
 Postchemotherapy Seminoma Relapse—Late:
 Definition:-
 Initial diagnosis of testicular GCT
 Recurrence of GCT established by biopsy, marker elevation, or
growth at a previously stable GCT site.
 Interval of more than 2 years since successful treatment of the
initial GCT.

Relapse Seminoma
 Postchemotherapy Seminoma Relapse—Late:
 Surgery is the preferred treatment modality for resectable
tumors at late relapse.
 In a selected group of patients referred to the MSKCC for
salvage chemotherapy at late relapse, only a regimen of
paclitaxel, ifosfamide, and cisplatin followed by surgery was
found to be effective.

FERTILITY
 Approximately 25% of
patient defects in
spermatogenesis at the
time of presentation.
• Higher concentrations of
anti-sperm antibodies are
present in patients with
testicular cancer.
 Approximately 50% of
patients are at least
temporarily hypofertile
after orchiectomy before
adjuvant therapy.

FERTILITY
 Fertility can be further impaired by adjuvant therapy
(RPLND, radiation therapy, and chemotherapy)
• 50% of patients who receive chemotherapy experience
return of normal sperm counts by 2 years.
25% continue to remain azoospermic after chemotherapy.
• Cryopreservation of semen is applicable to patients who
undergo chemotherapy.

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