Part ii 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.
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.
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
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
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.
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
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)
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
SEMINOMA STAGE 3 Stage 3 or relapse after RT standard treatment is BEP × 3 cycles or EP × 4 cycles Followed by salvage surgery
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)
Stage II IIa II b IIc II d(< 2 cm) ( 2-5 cm) ( 5 -10 cm) ( >10 cm) RT CT/RT CT
Stage IId / IIIBEP x 3 or EP x 4 Post Chemotherapy residual Mass < 3 cm >3 cm observe well diff poorly diff Resect observe
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
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
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
STAGE II (A/B)< 2 cm > 2 cmsurveillance CT x 3 cycles relapse residual diseasechemotherapy salvage surgery
STAGE IIc /III Chemotherapy residual disease salvage surgeryNote: - Radiation therapy only for palliation in metastatic disease.
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
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
Complications : Chemotherapy Chemo side effects alopecia, nausea, myelosuppression, pulmonary fibrosis, Ototoxicity BEP causes immediate azospermia, but >50% recover sperm count
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.