SEMINOMA

Mayur Mayank

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• INTRODUCTION• DIAGNOSIS AND EVALUATION• STAGING AND PROGNOSTIC FACTORS• MANAGEMENT– STAGE I SEMINOMA– STAGE II SEMINOMA– STAGE III SEMINOMA

• CONCLUSION• REFERENCES

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INTRODUCTION

• Most common Germ cell tumor (~50%)• Types :– Classical– Anaplastic– Spermatocytic • Older age group

• Confined to testis• Very good prognosis• Orchidectomy is the cure• No role of Radiation therapyRADIOSENSITIVITY +++

CHEMOSENSITIVITY +++

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Anatomy of Testis Lymphatic drainage of Testis

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• Lymph node drainage (Regional LN’s):– Right testis : • Inter aorto caval • pre caval • pre aortic lymph nodes

– Left testis : • Pre aortic • para aortic • left renal hilar • inter aorto caval lymph nodes.

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DIAGNOSIS AND EVALUATION

• Mass in the testicular region• Mostly presents as a painless lump• NO BIOPSY / FNAC• Trans scrotal ultrasound• Tumor markers– bHCG Can be Positive in 15-30% patients– AFP Always NEGATIVE– PLAP Positive in about 90% patients – LDH

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• History of prior inguinal or scrotal surgery, cryptorchidism, retractite testis or orchidopexy.

• Examination of the contralateral testis• CT scan of the abdomen and pelvis• CT Thorax (in cases of Stage II and onwards)• Ultrasound of the contralateral testis

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STAGE GROUPING AND PROGNOSTIC GROUPING

9Ref : Pure Seminoma : A review and update, Boujelbene et al, Radiation Oncology 2011, 6:90

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PROGNOSTIC GROUPING

• Good prognosis– Normal AFP– Any LDH– Any HCG– No Non Pulmonary

metastases

• Intermediate prognosis– Normal AFP– Any LDH– Any HCG– Non pulmonary visceral

metastasis present

NO BAD PROGNOSIS GROUP PRESENT

As per International Germ Cell Cancer Collaborative Group (IGCCCG)

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• Other prognostic factors :– Tumor size > 4 cms– Presence of rete testis invasion

Associated with high risk of relapse

32 % risk of relapse in the presence of both15 % risk of relapse in the presence of either factors

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MANAGEMENT

• Surgery is the main stay of management : Radical inguinal orchidectomy with high ligation of the cord.

• Retro peritoneal lymph node dissection (RPLND) is no longer regarded as a therapeutic option in management of seminomas.

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STAGE I SEMINOMA

• Adjuvant treatment options :

ACTIVE SURVEILLANCE

ADJUVANT RADIATION THERAPY

ADJUVANT CHEMOTHERAPY

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ACTIVE SURVILLANCE

• Valid option for patients with stage I seminoma with no poor prognostic factors and with no factors for relapse.

• Patients followed up with regular interval CT scans

• MRC TE24 - Trial of Imaging and Schedule in Seminoma Testis (TRISST)– addressing the issue of regular CT scans and

radiation dose delivered due to it.– MRI for regular screening

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ADJUVANT RADIATION THERAPY

• Has been the standard of care for management of stage I seminomas

• Used in cases where active surveillance is not an option

• Techniques of radiation therapy :– Para Aortic Radiation – DOG LEG technique (para aortic + ipsilateral pelvic

fields)– Inverted Y technique (para aortic + bilateral pelvic

fields)

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• Initially Dog leg field was the radiation therapy field which was used in all cases

• MRC TE 10 : Showed that para aortic field is non inferior for the treatment of patients with stage I seminoma with no adverse factors

• Radiation therapy dose used : 30 Gy in 15 fractions

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• MRC TE 18 : Radiation therapy dose was reduced from 30 Gy in 15 fractions to 20 Gy in 10 fractions

• No significant difference in rates of relapse

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• MRC TE 19 : Compared Radiation therapy (20 Gy in 10 fractions or 30 Gy in 15 fractions) to Carboplatin (1 cycle, 7 AUC)

• No significant difference in rates of relapse

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PARA AORTIC RADIATION

Superior : Lower Border of T 10 vertebra

Inferior : Lower border of L 5 vertebra

Laterals : to borders of transverse processes of vertebrae with inclusion of ipsilateral renal hilum on the left side.

Kidneys should be identified prior by IVU and a horse shoe kidney should be ruled out.

As much as possible, the normal kidney should be protected by sheilding.

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Virtual simulation film of a Para Aortic field

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DOG LEG TECHNIQUE

• Includes the para aortic field with ipsilateral pelvis nodal field

• Used in cases of stage I seminoma with history of scrotal violation, prior inguinal or scrotal surgeries or history of distorted lymphatics

• Used in all cases if stage II A and II B seminomas treated with radiation therapy

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Superior : T10-T11 interspace

Inferior : Lower border of Obturator foramen

Lateral : 2-3 cms lateral to vertebral bodies including the transverse process bilaterallyTo include Left renal hilum in case of Left testis

Testicular shielding for the other testisRenal shielding

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Testicular shield

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Virtual Simulation film of a Dog Leg technique

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INVERTED Y TECHNIQUE

• Para aortic fields with bilateral pelvic nodes• Used in special situations like bilateral

seminoma

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STAGE II SEMINOMA

• Treatment depends on the bulk of retroperitoneal nodal disease present.

• Radiation therapy and chemotherapy, both can be used for the management.

• No role of active surveillance.

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Stage II A (lymph nodes 1-2 cms)

Borderline Stage II B(lymph nodes 2-2.5

cms)

Stage II B(lymph nodes 2.5-5

cms)

• Radiation therapy is the standard of management• Para aortic and ipsilateral pelvic lymph nodes (DOG LEG TECHNIQUE)• Dose : 30 Gy in 15 fractions• Chemotherapy with BEP (3 cycles) or EP (4 cycles) is equivalent to radiation therapy in efficacy• Less chances of secondary malignancies and toxicity with systemic chemotherapy

Stage II C(lymph nodes >5 cms)

Managed as per protocol of Stage III

• Chemotherapy with BEP (3 cycles) or EP (4 cycles) is the standard of care• Radiation therapy can be given if the patient is unfit for chemotherapy or denies chemotherapy• Fields as in Stage II A• Dose : 36 Gy in 18 fractions

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STAGE III SEMINOMA

• Chemotherapy is the standard of care• Role of radiation therapy is very limited and is

used only in cases of – Relapse

• Chemotherapy used is :– BEP x 3 cycles or EP x 4 cycles for patients with

good prognosis– BEP X 4 cycles for patients with intermediate

prognosis

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CONCLUSION

• Seminomas are highly radio and chemo sensitive tumors with a very good prognosis.

• The management protocol presently is centered to reduce the toxicity to the minimum levels.

• Radiation therapy induced second cancers can be prevented by judicious use of other modalities like active surveillance and chemotherapy in stage I disease.

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REFERENCES• Fosså SD, Horwich A, Russell JM et al. (1999) Optimal planning target volume for stage I

testicular seminoma: a Medical Research Council randomised trial. Medical Research Council Testicular Tumour Working Group, TE10. J Clin Oncol 17: 1146.

• Jones WG, Fosså SD, Mead GM et al. (2005) Randomised trial of 30 versus 20 Gy in the adjuvant treatment of stage I testicular seminoma: a report on Medical Research Council Trial TE18, European Organisation for the Research and Treatment of Cancer Trial 30942 (ISRCTN18525328). J Clin Oncol 23: 1200–8.

• Oliver RT, Mason MD, Mead GM et al. (2005) MRC TE19 collaborators and the EORTC 30982 collaborators. Radiotherapy versus single-dose carboplatin in adjuvant treatment of stage I seminoma: a randomised trial. Lancet 366: 293–300.

• Principles and practices of Radiation Oncology 5th edition, Edward C Halper, Carlos A Perez, Luther W Brandy

• Practical radiotherapy planning 4th edition, Ann Barrett, Jane Dobbs, Stephen Morris, Tom Roques

• Pure Seminoma : A review and update, Boujelbene et al, Radiation Oncology 2011, 6:90• Testicular seminoma: ESMO Clinical Recommendations for diagnosis, treatment and follow-

up ,H.-J. Schmoll, K. Jordan, R. Huddart, M. P. Laguna, A. Horwich, K. Fizazi & V. Kataja, Annals of Oncology 20 (Supplement 4): iv83–iv88, 2009