Part 1 management of testicular carcinoma - dr vandana
Management of Testicular Tumor Presented By: Dr. Vandana Dept. of Radiotherapy, CSMMU, Lucknow
Introduction Relatively rare. 1-2 % of all male malignancies. Malignancy in 20-34 yrs of age. Most curable solid neoplasm. 90-95% of testicular tumors are germ cell tumors, either seminoma or non-seminoma. Improvement in diagnostic techniques, tumor markers, improved surgical techniques, advanced radiotherapy machines and multidrug chemotherapy , decrease the mortality from 50% to <10%.
Lymphatic Drainage Right testis: along the IVC inter-aortocaval region pre-aortic & para-aortic lymph nodes, with possible cross- over within the retroperitoneum Left testis: Preaortic and para-aortic lymph nodes around the left renal hilum inter-aortocaval nodes mostly without cross-over Retroperitoneal lymph nodes are located anterior to the T11 to L4 vertebral bodies concentrated at the L1–L3 level Nodal spread to iliac chain is ipsilaterally but infrequent (~3%) Scrotal skin: lymphatics drain into the inguinal and external iliac nodes.
Royal Marsden staging system STAGE I Limited to testis IIA Nodes <2 cm IIB Nodes 2–5 cm IIC Nodes 5–10 cm IID Nodes >10 cm III Nodes above and below diaphragm IV Extralymphatic mets
Cont… Regional lymph nodes (N) clinical Nx Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastasis with a lymph node mass ≤2 cm in greatest dimension; or multiple lymph nodes ≤2 cm in greatest dimension N2 Metastasis with a lymph node mass > 2 cm but ≤5 cm in greatest dimension; or multiple lymph nodes, any one mass > 2 cm but ≤5 cm in greatest dimension N3 Metastasis with a lymph node mass > 5 cm in greatest dimension
Nb: indicates the upper limit of normal for the LDH assay
GENERAL MANAGMENT After obtaining serum AFP & B-Hcg levels in suspected case of malignant germ cell tumour Radical inguinal orchietectomy with high ligation of spermatic cord is done, it is both diagnostic & therapeutic Further management depends on, pathology & stage of disease.Note: - Considering of sperm banking must be discussed with the patients before undergoing any therapeutic intervention that may compromise fertility including RT ,Surgery and CT.
Management of testicular tumor is combined modality treatment. Various treatment modalities are: Surgery Surveillance Radiotherapy Chemotherapy
SurgeryRadical orchidectomy: all patients done via an inguinal incision, with cross clamping of spermatic cord vasculature and delivery of testis into the surgical field. Scrotal violation, increased local/regional recurrence, but no difference in distant recurrence rate or overall survival.
Retro peritoneal lymph node dissection(RPLND): Indication: preferred treatment for low stage NSGCT Include the precaval, retrocaval, paracaval, interaortocaval, retroaortic, preaortic, para-aortic, and common iliac lymph nodes bilaterally. Disadv.: sympathetic nerve fibers are disrupted, resulting in loss of seminal emission. A modified RPLND developed that preserves ejaculation in up to 90%.
Surveillance An option, as potentially 80-85% of patients will not develop recurrence Rationale -With availability of highly effective salvage rt /ct for relapse disease & low risk of occult disease in nodes in stage 1 pts. Indications Seminoma Stage I NSGCT Stage I Disadvantage Costly and inconvenient
Radiation therapy Indications Adjuvant therapy for stages I–IIb diseases Salvage of loco-regional failure after surgery or chemotherapy Palliative treatment to loco-regional or distant metastatic sites Techniques EBRT to lymph nodes High-energy radiation (6 – 18 MV) Seminoma is extremely radiosensitive. Radiation therapy is often used for adjuvant therapy for early-stage seminoma, and its use in non-seminoma germ cell tumors (GCT) is limited.
Position and immobilization Supine, arms placed by the pt. side and legs straight, with feet stabilized with a foam wedge underneath the knees. Position penis out of field Shielding Contra-lateral testis is shielded with a lead clamshell device. Mean dose values to the contralateral testicle. PA PA + IL iliac Without shield 1.86 cGy 3.89 cGy With shield 0.65 cGy 1.48 cGy
Stage I: Field margins Superior: T11–T12 interspace Inferior: L5–S1 interspace Lateral: transverse process For left testis: cover renal hilum Dose 20 Gy in 10# to para-aortic ± pelivic lymph node by ap-pa field Elective para-aortic field for stage I seminoma
Stage II Superior: T11–T12 interspace Inferior: mid-obturator foramen Lateral: transverse process down to L5–S1 interspace then diagonally to the lateral edge of the acetabulum, then vertically downward to the median border of the obturator foramen For left testis: cover renal hilum Paraaortic and ipsilateral inguinal field for stage II left testicular seminoms, with inclusion of the rental hilus.
Stage II a- 25Gy in 20 # by AP-PA Stage II b & IIc 25 Gy in 20 # 10 Gy in 5 #
Chemotherapy Indications As an alternative to adjuvant RT for stages I–II seminoma Adjuvant therapy for stages II–IV seminoma Regimens Single-agent carboplatin become an alternative for stage I seminoma Regimens including BEP, EP, PVB, and VIP for stages II–IV diseases
Conclusion Most common curable malignancy of young adults. Most common- germ cell tumors Seminoma > nonseminoma Nonseminoma occurs a decade earlier. Surgery is the main modality of treartment followed by Radiotherapy & or chemotherapy for seminoma and chemotherapy & RPLND for nonseminoma. Surveillance generally for patients who are compliant.
Radical inguinal orchiectomy with initial high ligation of the spermatic cord is the standard procedure for diagnosis and treatment. Biopsy prior to orchiectomy is usually not recommended. Follow-up is recommended to detect second primary tumors, local or distant recurrences, and to monitor for potential long- term side eff ects.