1. Testicular Cancer Part 1
Fahad A. Al-Mashat
R5-Part II !!!

2. 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

3. 10-30 % of men will present with distant mets.
Localized Seminoma:
Most common GCT presentation
50% of all men with GCT

4. 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

5. ITGCN:
Present in adjacent testicular parenchyma in % of invasive GCT cases.
Risk of invasive GCT:
5 yrs
7 yrs
Present in 5-9% of contralateral testes.
Contralateral incidence increases to 36% with atrophy/cryptorchidism!

6. 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

7. Gynecomastia 2% (↑HCG, ↓ Test
Gynecomastia 2% (↑HCG, ↓ Test., or ↑ estrogen), mostly seen in Leydig cells.
Infertility (2/3 of patients).
Symptoms related to mets % of pts

10. CS 1
80% of seminoma pts
Options: long term cancer control with each approaches 100%
Surveillance
1ry RadioRx
1ry ChemoRx

11. 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

12. Follow up:
Clinical
CXR
Tumor Markers
Abdominopelvic CT
First 3 yrs every 2-4 months
Yrs 4-7 every 6 months
Annually thereafter

13. 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.

14. 1ry RadioRx:
retroperitoneal + ipsilateral (Dog-Leg Configuration)
25-30 Gy in daily fractions
In-field recurrence < 1%
Most common recurrence sites:
Thorax & Lt supraclavicular fossa
1st line Chemo cures almost all recurrences

15. Post Dog-Leg RadioRx Surveillance:
Clinical
CXR
Tumor Markers

16. 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

17. 1ry ChemoRx:
1-2 cycles of single-agent carboplatin
Needs accurate GFR calculation
2 cycles better in terms of risk of relapse.

18. 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

19. 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 %

20. Relapses are cured in almost all cases with 1st line ChemoRx
Routine Surveillance CT not needed after complete resolution of disease.

21. 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

22. 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

23. Intermediate risk (10%)
BEP X4
5-yr overall survival 79%
5-yr progression free survival 75%

25. 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 months
Discrete masses >3cm , do PET if +ve then PCS
< 3cm or -ve PET, observe
PET: >3cm Sensitive 80% , Specific 100%

26. 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

27. 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

28. Late post Chemo Relapse:
<8%
Favorable prognosis especially in those who didn't receive prior cisplatin