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