part ii management of testicular carcinoma - dr vandana
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management of testicular carcinoma-Dr vandana,kgmc,kgmu,lucknow,radiotherapyTRANSCRIPT
Management of Testicular TumorPresented 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.
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.
Cont… Non Germ Cell Tumor
Sex cord stromal tumors1. Leydig cell2. Sertoli cell3. Granulosa cell4. Fibroma Thecoma5. Gonadoblastoma
Others: Lymphoma, rhabdomyoma, melanoma
SEMINOMA
Stage wise management of seminoma
Surgery surveillance
radiotherapy chemotherapy
Stage I
Surveillance Indication: Pts. who can comply. Sites for relapses
Retroperitoneum- 76-94% Mediastinum- 5-15% Inguinal-3-11%
Cont….
Indications High risk feature
o Tumor size>4 cmo Presence of rete testis invasiono 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.
Adjuvant RT
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 SURVIVAL
96.6% 96%
OS 99.3% 100%
PELVIC RELAPSE FREE SURVIVAL
100% 98.3%
Adjuvant CT
Single agent carboplatin 1 or 2 cycles used ( 2 better than 1)
UK medical research council study(2005)
Long term toxicity is unknown but regime is well tolerated acutly with only mild myelotoxicity
ADJUVANT RT ADJUVANT CT
3 YR RELAPSE FREE SURVIVAL
95.9% 94.8%
RELAPSE DISTANT 57 %PELVIC 31 %
74 % PARA AORTIC GROUP
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.
SURVEILLANCE
ADJUVANT RT
ADJUVANT CT
% OF PTS RELAPSING
20 % 4% 1 ×CARBO - 5 -9 %2×CARBO - 0 – 3 %
MEDIAN TIME TO RELAPSE
14 MONTHS 4% @ 5 yrs -
MC RELAPSE RETRO PERITONEAL NODES 74 -94%
DISTANT METS PARA AORTIC NODES
5YR CAUSE SPECIFIC SURVIVAL
99.3% 99 – 100% 99- 100%
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 options1. 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 / III BEP 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
Non-seminoma
Stage wise management of Non-seminoma
STAGE I
Surveillance RPLND Chemotherapy
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)
SURVEILLANCE RPLND ADJ CT(BEP *2)
RELAPSE RATE 28% 11% 2%
DISEASE SPECIFIC SURVIVAL
98% 98 – 99% 99%
Recurrence 50 % retroperitoneal nodes, 25% lung
Distant sites RETROPERITONEAL NODES
Median time to relapse is 6 month with almost all relapse < 2 yrs.
STAGE II (A/B)
< 2 cm > 2 cm
surveillance CT x 3 cycles
relapse residual disease
chemotherapy salvage
surgery
STAGE IIc /III
Chemotherapy
residual disease
salvage surgery
Note: - 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.
Thank You