Testicular Cancer Part 1

Fahad A. Al-MashatR5-Part II !!!

Intro•Most common malignancy in males (20-40 yrs)

•2nd MC Ca after leukemia in males (15-19 yrs)

•2 % bilat.

•Majority of tumors in males > 50 yrs Lymphoma

•10-30 % of men will present with distant mets.

•Localized Seminoma:

•Most common GCT presentation

•50% of all men with GCT

Risk Factors•Cryptorchidism

•4-6 fold increase in risk

•RR goes down 2.0 to 3.0 if orchiopexy before puberty

•Family Hx of testicular cancer

•RR is 8-12 brother.

•RR is 2-4 Father.

•Personal Hx of testicular cancer

•ITGCN:

•Present in adjacent testicular parenchyma in 80-90 % of invasive GCT cases.

•Risk of invasive GCT:

•50% @ 5 yrs

•70% @ 7 yrs

•Present in 5-9% of contralateral testes.

•Contralateral incidence increases to 36% with atrophy/cryptorchidism!

Clinical Presentation

•Painless Testicular Mass

•Pain is less common (rapid expansion, due to intreatumor hemorrhage, & infarction).

•Trauma (brings testis to attention)!

•Vague Scrotal Discomfort

•Regional/Distant mets:

•15% pure seminomas

•85% NSGCT

•Gynecomastia 2% (↑HCG, ↓ Test., or ↑ estrogen), mostly seen in Leydig cells.

•Infertility (2/3 of patients).

•Symptoms related to mets 10-20 % of pts

CS 1

•80% of seminoma pts

•Options: long term cancer control with each approaches 100%

•Surveillance

•1ry RadioRx

•1ry ChemoRx

•Surveillance:

•Limited utility of tumor markers to detect relapse.

•Need for long term CT surveillance (10-20% relapses occurring 4 yrs or more post Dx).

•5yr relapse-free survival 80-86%.

•Cancer specific survival approaches 100%.

•80-100% of relapses occur in retroperitoneum.

•18-24% of recurring pt will have bulky retro/distant mets

•Follow up:

•Clinical

•CXR

•Tumor Markers

•Abdominopelvic CT

•First 3 yrs every 2-4 months

•Yrs 4-7 every 6 months

•Annually thereafter

•Prognostic Factors for occult mets:

•Tumor size > 4cm

•Invasion of rete testes

•LVI is not identified as a significant predictor of relapse in CS1 seminoma.

•1ry RadioRx:

•retroperitoneal + ipsilateral (Dog-Leg Configuration)

•25-30 Gy in 15-20 daily fractions

•In-field recurrence < 1%

•Most common recurrence sites:

•Thorax & Lt supraclavicular fossa

•1st line Chemo cures almost all recurrences

•Post Dog-Leg RadioRx Surveillance:

•Clinical

•CXR

•Tumor Markers

•Side Effects:

•GI (acute and self limiting)

•Oligospermia in contralateral gonad

•Late cardiac toxicity

•18% chance of developing 2ndry malignancy @25 yrs post RadioRx

•MRC & EORTC trial(2005):

•20Gy = 30 Gy in 5-yr relapse free survival

•Less side effects with 20 Gy

•1ry ChemoRx:

•1-2 cycles of single-agent carboplatin

•Needs accurate GFR calculation

•2 cycles better in terms of risk of relapse.

•Surveillance is the preferred approach in CSI seminoma due to:

•low overall risk of relapse

•lack of validated makers identifying high risk pts

•late toxicity with RadioRx & ChemoRx

•Non-compliant pts/unwilling to be surveyed:

•1ry RadioRx

CS IIA & IIB•15-20% of seminoma pts have CS II

•70% of those have CS IIA-B

•RadioRx

•25-35Gy(+5-10 Gy boost to involved areas)

•Long-term disease-free survival:

• IIA(92-100%) up to 100 %

•IIB (87-90%) up to 90 %

•Relapses are cured in almost all cases with 1st line ChemoRx

•Routine Surveillance CT not needed after complete resolution of disease.

•Induction ChemoRx with 1st line

•BEP X3/ EP X4

•Acceptable alternative to Dog-Leg Radio Rx.

•Pts with bulky retroperitoneal masses >3cm & or multiple retroperitoneal masses

•Risk of relapse lower than with Dog-Leg RadioRx

CS IIC & III•Pts Rx with induction ChemoRx

•Regimen and no of cycles as per IGCCCG risk:

•Good Risk (90% of advanced seminoma)

•BEP X3 or EP X4

•70-90% complete radiographic response

•91% 5-year overall survival

•Intermediate risk (10%)

•BEP X4

•5-yr overall survival 79%

•5-yr progression free survival 75%

Post Chemo Residual Masses•58-80% of pts will have radiologically

detectable masses post 1st line chemo

•90% necrosis, 10% viable tumor

•Spontaneous resolution in 50-60% of them, median time 13-18 months

•Discrete masses >3cm , do PET if +ve then PCS

•< 3cm or -ve PET, observe

•PET: >3cm Sensitive 80% , Specific 100%

Relapsing Seminoma•Chemo-Naive:

•CS 1 on surveillance, give Dog-Leg RadioRx

•CS 1-I1B post 1ry RadioRx, give 1ry ChemoRx especially bulky >3cm retroperitoneal masses/systemic relapses

•1st line Chemo will cure almost all pts with disease outside retroperitoneum post 1ry Radio

•Early post Chemo relapse:

•15-20% pf advanced seminomas will relapse post induction chemo including 10% who had initial complete response

•Such pts have poor prognosis

•Long-term survival 20-50%

•Make sure you’re not dealing with a teratoma, if markers -ve get a Bx before committing to 2nd line Chemo

•Late post Chemo Relapse:

•<8%

•Favorable prognosis especially in those who didn't receive prior cisplatin