Part ii management of testicular carcinoma - dr vandana

2,067 views

Published on

management of testicular carcinoma-
Dr vandana,kgmc,
kgmu,lucknow,
radiotherapy

Published in: Health & Medicine
0 Comments
3 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,067
On SlideShare
0
From Embeds
0
Number of Embeds
4
Actions
Shares
0
Downloads
164
Comments
0
Likes
3
Embeds 0
No embeds

No notes for slide

Part ii management of testicular carcinoma - dr vandana

  1. 1. Management of Testicular Tumor Presented By: Dr. Vandana Dept. of Radiotherapy, CSMMU, Lucknow
  2. 2. 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%.
  3. 3. 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.
  4. 4. WHO classification Germ cell tumors- Intratubular germ cell neoplasia ( precursor lesion ) Seminoma  Classic  Spermatocytic  Anaplastic Nonseminoma  Embryonal carcinoma  Yolk sac  Teratoma  Choriocarcinoma.  Mixed germ cell tumor.
  5. 5. Cont… Non Germ Cell Tumor  Sex cord stromal tumors 2. Leydig cell 3. Sertoli cell 4. Granulosa cell 5. Fibroma Thecoma 6. Gonadoblastoma Others:  Lymphoma, rhabdomyoma, melanoma
  6. 6. SEMINOMA
  7. 7. Stage wise management of seminoma Stage I Surgery surveillance radiotherapy chemotherapy
  8. 8. Surveillance Indication: Pts. who can comply. Sites for relapses  Retroperitoneum- 76-94%  Mediastinum- 5-15%  Inguinal-3-11%
  9. 9. Cont….
  10. 10. Adjuvant RT Indications  High risk feature o Tumor size>4 cm o Presence of rete testis invasion o LVSI UKMRC & EORTC Trial  625 pts,  20 Gy in 10 # in 2 wks Vs 30 Gy in 15 # in 3 wks  result  Almost comparable 5 yr RFS  Toxicity was less in 20 Gy arm.
  11. 11.  inclusion of pelvic nodes was controversial. If pelvic nodes not involved then surveillance with ct pelvis. UK medical research council study(1999) TRADITIONAL RT REDUCED FIELD RT 3YR RELAPSE FREE 96.6% 96% SURVIVAL OS 99.3% 100% PELVIC RELAPSE FREE 100% 98.3% SURVIVAL
  12. 12. Adjuvant CT Single agent carboplatin 1 or 2 cycles used ( 2 better than 1) UK medical research council study(2005) ADJUVANT RT ADJUVANT CT 3 YR RELAPSE 95.9% 94.8% FREE SURVIVAL RELAPSE DISTANT 57 % 74 % PARA PELVIC 31 % AORTIC GROUP Long term toxicity is unknown but regime is well tolerated acutly with only mild myelotoxicity
  13. 13. Adjuvant CT Multiple nonrandomized trials have been published using either a single or 2 cycles of carboplatin. These trials have demonstrated the safety of this approach and have yielded low rates of relapses.
  14. 14. SURVEILLANCE ADJUVANT RT ADJUVANT CT% OF PTS 20 % 4% 1 ×CARBO - 5 -9 %RELAPSING 2×CARBO - 0 – 3 %MEDIAN TIME TO 14 MONTHS 4% @ 5 yrs -RELAPSEMC RELAPSE RETRO PERITONEAL DISTANT METS PARA AORTIC NODES NODES 74 -94%5YR CAUSE 99.3% 99 – 100% 99- 100%SPECIFIC SURVIVAL
  15. 15. Cont… Survival approaches 100 % what ever is the treatment strategy. The goal is minimal treatment morbidity with out compromising chance of cure. If pt is complaint then surveillance is the choice if not ADJUVANT CT/ ADJUVANT RT
  16. 16. SEMINOMA STAGE 2 Depends on bulk of retroperitoneal nodes Radiotherapy treatment of choice in stage 2a & 2b (node < 5cm), 25 to 35 Gy Disease specific survival rate 97 – 100% Reoccurance rate < 10% ,MC site SCF & mediastinum. Ct + rt = rt alone (patterson et al, 2001)
  17. 17. STAGE 2C Stage 2c ( node > 5cm) Systemic chemo is the treatment of choice, Rt is a option but relapse rate is 30%. RT to be used as primarymodality if mass is centrally located & doesn’t over lie most of one kidney or significantly overlap liver. If not suitable then CT is the choice BEP/EP IF nodes > 10 cm RT relapse rate is 40 % hence CT
  18. 18. SEMINOMA STAGE 3 Stage 3 or relapse after RT standard treatment is BEP × 3 cycles or EP × 4 cycles Followed by salvage surgery
  19. 19. SALVAGE AFTER CT Stage 2 & 3 treated primarily by Chemo-Therapy. Residual mass present in up to 80% cases for about a month and most of them gradually regress. 3 options 1. radiotherapy( controversial) 2. surgery(if node >3cm,with discrete & well defined borders ) 3. observation( node < 3 cm, diffuse margins)
  20. 20. Stage II IIa II b IIc II d(< 2 cm) ( 2-5 cm) ( 5 -10 cm) ( >10 cm) RT CT/RT CT
  21. 21. Stage IId / IIIBEP x 3 or EP x 4 Post Chemotherapy residual Mass < 3 cm >3 cm observe well diff poorly diff Resect observe
  22. 22. Follow up schedule for seminoma After RT for stage I seminoma  H&P, labs (AFP, b-HCG, LDH), and CXR every 3–4 months for year 1,  every 6 months for year 2,  then annually,  Pelvic CT annually for 3 years for patients treated with PA-only RT (not needed if PA and pelvic RT) Stage I surveillance  H&P, labs every 3–4 months for years 1–3,  every 6 months for years 4–7,  then annually.,  CT abdomen and pelvis at each visit. CXR at alternate visits up to 10 years
  23. 23. Non-seminoma
  24. 24. Stage wise management of Non-seminoma STAGE I Surveillance RPLND Chemotherapy
  25. 25. Stage I STAGE1 (50%) Survival close to 100% Risk factors for relapse  Venous invasion  Presence of undifferentiated elements  Absence of yolk sac elements Elevated tumor markers in 2/3 cases of relapse Surveillance  Follow up tumor markers, phy examination, cxr monthly 1 yr, 2m – 2 yr, 3m – 3 yr, 6m – 4&5 yr.  CT abd & pelvis monthly 1 yr, 4m – 2 yr , 6m – 3 yr, yearly 4- 5 yr
  26. 26. NSGCT(STAGE 1) Median time to relapse is 6 month with almost all relapse < 2 yrs. SURVEILLANCE RPLND ADJ CT(BEP *2)RELAPSE RATE 28% 11% 2%DISEASE 98% 98 – 99% 99%SPECIFICSURVIVALRecurrence 50 % Distant sites RETROPERITON retroperitoneal EAL NODES nodes, 25% lung
  27. 27. STAGE II (A/B)< 2 cm > 2 cmsurveillance CT x 3 cycles relapse residual diseasechemotherapy salvage surgery
  28. 28. STAGE IIc /III Chemotherapy residual disease salvage surgeryNote: - Radiation therapy only for palliation in metastatic disease.
  29. 29. Complications : Radiotherapy Acute nausea, vomiting, diarrhea Late small bowel obstruction, chronic diarrhea, peptic ulcer disease (<2% with <35 Gy) Second cancers: 5–10% increased risk vs. general population after RT With testicular shielding, most patients will have oligospermia by 4 months that lasts ~1 year Infertility: 50% of patients have subfertile counts on presentation or after surgery. After RT, 30% able to have children
  30. 30.  50 cGy causes transient azospermia with recovery at 1 year, but only 50% of patients reach their baseline 80–100 cGy causes total azospermia with recovery 1–2 year later for some patients 200 cGy causes sterilization Testicular shield reduces testicle dose by 2–3x Kidneys: limit at least 70% <20 Gy
  31. 31. Complications : Chemotherapy Chemo side effects  alopecia,  nausea,  myelosuppression,  pulmonary fibrosis,  Ototoxicity BEP causes immediate azospermia, but >50% recover sperm count
  32. 32. 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.
  33. 33.  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.
  34. 34. Thank You

×