Testicular Tumours Part 2 Vinod Jain 16.09.2014

Clinical Staging (Boden and Gibbs – 1971) Stage I (A) – confined to testis with no spread through capsule or spermatic cord Stage II (B) – Clinical or radiological evidence of spread beyond testis but with in regional L.N. B1 -<2cm B2 -2-5cm B3 - >5cm Stage III (C) - Disseminated above diaphragm / visceral disease

Treatment Modalities Stage wise protocol Care of fertility Surgery Radiotherapy Chemotherapy Stage wise protocol Care of fertility

Treatment Modalities – Surgery Radical orchiectomy Organ sparing orchiectomy Hemiscrotectomy RPLND (retroperitoneal lymph node dissection - Boundaries) Modified RPLND with surveillance - modification Testicular implants (Silicon or saline)

Treatment Modalities – Radiotherapy Tele-Cobalt RT – 2500 cGy within 3 weeks to paraortic, precaval, bilateral common iliac and external iliac Inguinal – depending on indication

Treatment Modalities – Chemotherapy First line – BEP – Bleomycin, Etoposide and cis-Platinum Second line – Ifosfamide + BEP = Salvage CT Third line – High dose CT with autologous Bone Marrow transplantation

Stage wise protocol – Seminoma (SGCT) Stage I- Radical orchiectomy + 2500 cGy RT in para aortic area Stage II/ B1, B2 – Radical orchiectomy + RT – para aortic + paracaval + Bilat common iliac + ipsilateral ext. iliac. If previous opn/orchiopexy – contralateral inguinal LN with testicular shield Stage II/B3 and stage III – CT x 4 cycles (contd.)

Residual retroperitoneal LN CT x 4 cycles Residual retroperitoneal LN Complete Remission Follow up <3 cm >3 cm Follow up CT Surgical excision / RT

Stage wise protocol – Non Seminoma (NSGCT) Stage I- Radical orchiectomy + RPLND or modified RPLND with surveillance Stage II/B1, B2 – Radical orchiectomy + RPLND (Boundaries) II/B1 – No CT II/B2 – CT x 2 cycles Stage II/B3 and III – CT (BEP) x 4 cycles

CT (BEP) x 4 cycles Always Excision Tumour marker increased Tumour marker normalizes Salvage CT (BEP) + ifosfamide Residual mass No residual Mass Remission No remission Always Excision Follow up Follow up Autologous BM transplant + high dose CT or stem cell support

Follow Up schedule 3 monthly x 2 years – then Yearly Look for Other testis Abdomen / L.N. Haematological Examination Tumour markers Chest X-ray CT scan

(Partial orchiectomy is done) Organ sparing surgery Younger age with organ confined tumour of <2 cm size Polar tumours occurring in solitary testis or with contra-lateral tumour (Partial orchiectomy is done)

Let us revise Classification Incidence Etiology Spread of tumour Clinical Staging Clinical features Differential Diagnosis Investigations ---------------------------------------------------------------------------------- Treatment Follow up schedule