testicular cancer - oncologypro.esmo.org · • testicular cancer • orchiectomy, mixed nsgct, 80%...
TRANSCRIPT
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Testicular CancerProf. Dr. Jörg BeyerPhysician-in-ChiefDepartment of Oncology, University Hospital Berne, Switzerland
Mail: [email protected]
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The menue:
• Epidemiology & Staging• Ongoing discussions & risk-adapated treatment• Focus on early stage disease• Little on advanced/poor risk disease• Little on relapsed or refractory disease• Some emphasis on survivorship care• Full presentation via the ESO webpage
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Testis cancer in Europe 2012Incidence Mortality
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All pts. treated inDenmark between
1984 - 2007
Mortensen Eur Urol 2014Daugaard J Clin Oncol 2014Kier Eur Urol 2016
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Take home message
Germ-cell cancer is the most frequent cancerin men age 20-40 years. About 3% are primaryextragonadal.
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+ H & P, physical examination including testes+ Testicular ultrasound+ Tumormarker AFP, HCG and LDH (no PLAP)+ CT thorax and abdomen+/- CT/MRI brain (only if pulmonary metastases present)
- No PET CT scans !!
Initial Staging
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• Tumor size, rete testis involvement• Seminoma vs Non-seminoma or mixed tumors• In non-seminoma: is there teratoma present• Evidence of lymphovascular invasion
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Take home message
About 70% of patients present as clinical stage I.
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Vascular invasion - must be stated in the pathology report- needs an experienced pathologist- is helped by anti CD 31 immunohistology- must be obvious in the section
Slide at the courtesy of Prof. Loy, Berlin
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Cancer Medcine 2014, doi: 10.1002/cam4.324
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Case No 1: 33 years
• Testicular cancer• Orchiectomy => pure seminoma• Size 4 cm, no infiltration rete testis or vascular invasion• AFP und HCG normal• LDH prior orchiektomy 480 U/L• LDH post orchiektomy normal• CT thorax & abdomen w/o LN metastases
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Stadium Inur im Hoden
Stadium II
N1 = abd. Lk. < 2 cmN2 = abd. Lk. 2-5 cmN3 = abd. Lk. > 5 cm
Stadium III
M1a = med. / cerv. Lk. oder pulmonale Met.M1b = extr. pulm. Met.
Stadieneinteilungnach UICC
Stage accordingto the UICC
classification
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Case No 1: 33 years
• Testicular cancer• Orchiectomy => pure seminoma• Size 4 cm, no infiltration rete testis or vascular invasion• AFP und HCG normal• LDH prior orchiektomy 480 U/L• LDH post orchiektomy normal• CT thorax & abdomen w/o LN metastases
Seminoma Stage I => Which treatment ?
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Abbildung 2: Strahlenfeld Seminom im Stadium I
Radiation treatment Seminoma Stage I
Dose 20 Gy
Pro: long experiencelow relapse rate
Con: acute & late toxicitiessecondary tumors
Abbildung 2: Strahlenfeld Seminom im Stadium I
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Upd
ate
ASC
O 2
008
Lancet 2005; 366:293-300
AUC 7cave: avoid
undertreatment, no capping
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Ann
Onc
ol M
arch
201
3
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• Safe• Relapse rate of 15-20% in seminoma• Almost all relapses can be salvaged by BEP x 3• Overall survival close to 100%• Only those who need treatment get treated• Avoids adjuvant treatment in 80-85% of patients
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all patients with metastatic seminoma (stage II & III) should receive first-line chemotherapy
with three rarely four cycles of BEP*
* four cycles BEP in patients with bulky or extrapulmonary disease
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3 Zyklen BEPevery 21 days
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No Bleomycin
• Age > 50 years• Packyears > 20 years• DLco < 60% of normal• Restrictive lung disease (e.g. COPD)• Poor renal function GFR < 80 ml/min
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3 Zyklen BEP (4 Zyklen EP)every 21 days
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PET - CT
Only in Seminomawith residual tumorpost chemotherapy
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Summary Current Treatment Strategies in Seminoma
Histologie !
• Ca. 80% of patients present as stage I
"Active Surveillance“ the new standard, alternatively one cycle adjuvantCarboplatin AUC 7. Adjuvant radiation no longer recommended.
• Ca. 20% of patients present with metastastic disease
Standard treatment with three (rarely four) cycles BEP
Careful with bleomycin in poor pulmonary & renal function & older age
No residual tumor resection after chemotherapy !
Residual tumors after chemotherapy „rare“ indication for PET-CT scans
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Case No 2: 36 years
• Testicular cancer• Orchiectomy, mixed NSGCT, 80% EC.• Size 4 cm, no vascular invasion • CT thorax and abdomen w/o metastases• AFP 1.480 U/L, HCG 10 U/L prior orchiectomy
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Case No 2: 36 years
• Testicular cancer• Orchiectomy, Mixed NSGCT, 80% EC.• Size 4 cm, no vascular invasion • CT thorax and abdomen w/o metastases• AFP 1.480 U/L, HCG 10 U/L prior orchiectomy• AFP 560 U/L, HCG normal post orchiectomy
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Case No 2: 36 years
• Testicular cancer• Orchiectomy, Mixed NSGCT, 80% EC.• Size 4 cm, no vascular invasion • CT thorax and abdomen w/o metastases• AFP 1.480 U/L, HCG 10 U/L prior orchiectomy• AFP 560 U/L, HCG normal post orchiectomy• AFP 140 U/L, HCG normal after 2 weeks• AFP 64 U/L, HCG normal after 3 weeks• AFP normal, HCG normal after 35 days
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Case No 2: 36 years
• Testicular cancer• Orchiectomy, mixed NSGCT, 80% EC.• Size 4 cm, no vascular invasion • CT thorax and abdomen w/o metastases• AFP 1.480 U/L, HCG 10 U/L prior orchiectomy• Normalization of tumor markers post orchiectomy
Non-Seminoma CS I => Which treatment ?
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Stadium Inur im Hoden
Stadium II
N1 = abd. Lk. < 2 cmN2 = abd. Lk. 2-5 cmN3 = abd. Lk. > 5 cm
Stadium III
M1a = med. / cerv. Lk. oder pulmonale Met.M1b = extr. pulm. Met.
Stadieneinteilungnach UICC
Stage accordingto the UICC
classification
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Eur U
rol 2
015
14%Relapses
48%Relapses
1 cycle1 cycle
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• Safe• Relapse rate of 15-50% in non-seminoma• Almost all relapses can be salvaged by BEP x 3 (-4)• Overall survival close to 100%• Only those who need treatment get treated• Avoids adjuvant treatment in 80-85% of patients
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Summary Current Strategies inNon-Seminoma
• Ca. 60% of patients present as clinical stage I
"Surveillance“ in "low risk" patients without vascular invasion in theprimary tumor, one cycle adjuvant BEP in "high risk" patients withevidence of vascular invasion in the primary tumor
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Case No 3: 36 years
• Lumberjack• Increasing shortness of breath at work• Went to the A & E of his local hospital• Pleural mass and multiple pulmonary metastases
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Case No 3: 36 years
• Increasing shortness of breath at work• Pleural mass and multiple pulmonary metastases
• Admitted to pulmonary service of the local hospital• Thoracic CT scan and bronchoscopy• Undifferentiated cancer compatible with NSCLC
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Case No 3: 36 years
• Increasing shortness of breath at work• Pleural mass and multiple pulmonary metastases
• Admitted to pulmonary service of the local hospital• Thoracic CT scan and bronchoscopy• Undifferentiated cancer compatible with NSCLC
• Carboplatin, gemcitabine & bevacizumab• Staging PET CT scan after first cycle
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Case No 3: 36 years
• Increasing shortness of breath at work• Pleural mass and multiple pulmonary metastases
• Admitted to pulmonary service of the local hospital• Thoracic CT scan and bronchoscopy• Undifferentiated cancer compatible with NSCLC
• Carboplatin, gemcitabine & bevacizumab• Staging PET CT scan after first cycle
• AFP 138.000 ng/ml, LDH 834 U/l, HCG normal
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Overall Survival> 90 %
Overall Survival~ 78 %
Overall Survival~ 45 %
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Case No 3: 36 years
• Patient with extensive disease germ-cell cancer
• High risk of first-line failure & treatment related death
- poor performance status- poor pulmonary & renal function- high risk of sepsis and multiorgan failure- high incidence of cns metastases- fatal bleeding from ruptured metastases- fatal pulmonary embolism
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Influence of center experience on "failure-free survival" in poor prognosis germ-cell tumor
< 5 Pat.
> 19 Pat. 10-19 Pat.
5-9 Pat.
p < 0.018
EORTC/MRC trial
Impact of Center Expertise on Surivalin Patients with "poor prognosis" Germ-cell Cancer
Collette et. al J Natl. Cancer Inst. 1999
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All patients with metastastic Non-Seminoma shouldreceive first-line chemo with three to four cycles BEP
No dose reduction or treatment delay for uncomplicated cytopenias.No routine G-CSF or other growth factors. In patients with dyspnoeor pneumonia check for bleomycin toxicity, before continuation with BEP
Standard first-line treatment regimens
days
days
days
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R
PEB
RPEB PEB PEB
PEIPEI PEI PEI
Randomized trials using upfront HDCT
„Intergroup trial“ USAStarted 1997Published 2007
No benefit from upfront HDCT
„EORTC GU“ EuropeStarted 1999Published 2011
No benefit from upfront HDCT
n=219, JCO 2007, Motzer et al.
n=131, Ann Oncol 2011, Daugaard et al.
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Fizazi et al. Lancet 2014
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Do resect all residual lesions > 1 cm afterchemotherapy in non-seminoma !
• may contain vital cancer (more frequent than in seminoma)• may contain teratoma (does not exist in seminoma)
PET scans are useless in non-seminoma !Do not resect resdiual lesions in seminoma !
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Pre BEP x 3 Post BEP x 3
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Summary Current Strategies inNon-Seminoma
Histologie !
• Ca. 60% of patients present as clinical stage I
"Surveillance“ in "low risk" patients without vascular invasion in theprimary tumor, one cycle adjuvant BEP in "high risk" patients withevidence of vascular invasion in the primary tumor
• Ca. 40% of patients present with metastatic disease
Standard chemotherapy three to four cycles PEB according to risk.Resection of all residual tumor post chemotherapy. No role for PET-CTscans
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Prognostic factors in relapsed/refractory GCC
Histologie !
poor good• Primary Tumor mediastinal gonadal
• Histology non-seminoma seminoma
• Respone 1° Line no CR/NED/PRm- CR/NED
• Response duration short long
• Marker Level high low
• Metastatic location brain, bone, liver lymphnodes or lung
• Salvage attempt second or subsequent first-salvage
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OhneRisikofaktoren
Patienten mitProgress oder Rezidivnach Chemotherapie
KonventionelldosierteTherapie
MitRisikofaktoren
Hoch dosisierteTherapie
Indication for salvage surgery?
- Progression mature teratoma- late relapse > 2 years- resectable relapse after HDCT
Risk factors
- extragonadal primary tumor- no CR / PRm- after first-line- early relapse- extrapulmonary metastases- high AFP or HCG levels- any second or subsequentrelapse
Strategy for first-salvagePatients
with relapse or progressionafter chemotherapy
Withoutrisk factors
Withrisk factors
Conventionaldose treatment
Highdose treatment
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Travis/Fosså JNCI 2005
Second solid non-germ cell cancer
Diagnosis at 20y at age 70: 40% vs. 20%
No of solidtumors
RR (95%CI)
Radiotherapy alone 892 2.0 (1.9-2.2)Chemotherapy alone 35 1.8 (1.3-2.5)
Radioth. + Chemoth. 25 2.9 (1.9-4.2)
Modern radiotherapy:Reduced dose & field
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Metabolic syndrome in will develop in 20-30 % of testicular cancer survivors
de H
aas
et a
l,Ann
Onc
ol 2
013
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• Details on histology & intial stage
• Details on treatment delivered (drugs, schedules, modalities)
• Recommendation for a follow-up schedule (10 years)
• Risk of relapse only in the first 2-3 years
• Identify main individual long-term toxicities that might occur
• Give life-style recommendations
• Identify possible additional resources (e.g. support groups)
• Identify the person in charge for follow-up including contactinformation!
Basi
cs o
f a s
urvi
vors
hip
plan
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Summary testicular cancer
Histologie !
• Get exact histological information
• Get exact staging information
• Follow the correct management algorithmus meticulously
• High cure rates even in metastatic tumor stages
• Manage patients only in interdisciplinary teams specificallydedicated to the management of testicular cancers !
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German/Swiss/Austrian Grouphttp://www.hodenkrebs.de
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