MANAGEMENT OF TESTICULAR

NEOPLASMS
DR.SURESH BABU
FINAL YR.PG
PROF.DR.SHANMUGAM M.S.
UNIT 3.
 TREATMENT OPTIONS
 SURVEILLANCE
 SURGERY
 - Orchidectomy
 - RPLND
 CHEMOTHERAPY
 RADIOTHERAPY
 SEMINOMA( TYPICAL)
 STAGE 1 ---------> Radiation therapy.
 RISK factors : - primary tumor > 6 cm
- vascular/ lymphatic invasion

RISK FACTORS

PRESENT ABSENT

RADIATION
CHEMOTHERAPY SURVEILLANCE
 SPERMATOCYTIC - SEMINOMA
 Age > 65 ---------> Exclude sarcoma

 Benign ---------> No adjuvant therapy.

Persistent tumor marker

No radiology evidence of tumor chemotherapy
 STAGE 2A,2B-SEMINOMA
 T (1-3) , N (0-2) , M (0) , S (0-1)

• Radiation therapy
• Chemotherapy – If lymph nodes are close to
Hilum of kidney
 STAGE 2C,3 – SEMINOMA
 Cisplatin based chemotherapy

HISTOLOGY
RESIDUAL MASS

•
Necrosis GCT
Diffuse Desmoplasia Discrete mass >3cm

• Observation Surgical resection

observation Salvage chemotherapy

(Vinblastin , Ifosfamide , Cisplatin)

 NON-SEMINOMATOUS GERM CELL
TUMOR

• LOW STAGE
Stage 1 – (T1-3,N0,M0,S0-1)
Stage 2A – (T1-3,N1,M0,S0-1)
Stage 2B – (T1-3,N2-3,M0,S0-1)

• HIGH STAGE
Stage 2C – (T1-4,N2-3,M0-2,S0-1)
Stage 3 – (T1-4,N1-3,M1-2,S1-3)
 STAGE 1 NSGCT
• RISK FACTORS – T2 (or) higher
Embryonal cell type > 40%
Vascular / lymphatic invasion
RISK FACTORS
Stage 1S
PRESENT ABSENT
(chemotherapy
Template RPLND
Chemotherapy Surveillance
BEP * 3cycles)
 STAGE 2A,2B NSGCT

 Bilateral RPLND
 Primary chemo (BEP * 3 cycles)

Node <2cm ------> No adjuvant chemo

>2cm ------> Chemo (BEP * 2 cycles)
 STAGE 2C,3 NSGCT
GOOD / LOW RISK
 Favorable outcome
 High cure rates
 Reduces treatment toxicity
 more aggressive chemotherapy
POOR / HIGH RISK
 Early possible chemotherapy
 Complete response
 tolerable side effects..
 STAGE 2C,3 - NSGCT
GOOD RISK DISEASE
 Chemotherapy [BEP * 3 Cycles]

Good risk disease

Resolution Recurrence

Observation
• RESOLUTION
• OBSERVATION
• RECURRENCE
• Salvage chemo - yes – observation
+
• High dose chemo - No elevated tumor
markers
- DESPERATION SURGERY
 CONTIND.......
 Residual retroperitoneal mass
<1cm – observation
>1cm – B/L RPLND + Tumorectomy

 Histology
Necrosis – Observation
GCT – Salvage chemo (VIC / BEC)
 CONTND.....
 Residual mets
 Tumor marker elevation - salvage chemo
{Exclude false + ve elevation}
 CONTIND..
RECURRENCE / POOR RISK
 High dose chemotherapy (HDCT) with etoposide
and carboplatin
+
Stem cell support

HDCT(under clinical trial) –

1st cycle – Gemcitabine , Docetaxel , Melphalan,
Carboplatin
2ndcycle – Ifosfamide , Carboplatin , Etoposide
• Increased Tumor markers
- Salvage chemotherapy

• Inadequate - Desperation surgery

 NON – GERM CELL TUMOR
• Radical orchidectomy is the treatment of
choice for all Non – Germ Cell Tumors
• Except for Leukemic infiltration of testis , for
which Low dose Radiotherapy(20Gy) will
suffice
• surgical treatment for Non germ cell tumor is
curative in most of the cancers.
 RADICAL ORCHIECTOMY

• High ligation of cord at internal ring

• Cord isolated
• testis and tunica delivered
• Orchiectomy
• Cord vessels tied with silk for identification
purpose.
RADICAL ORCHIECTOMY
ANATOMIC REGIONS OF RPLND
RETROPERITONEAL LYMPH NODE DISSECTION

INDICATIONS
• STAGE 1A,1B
MARKER
• STAGE 2A,2B -VE
• post chemo residual retroperitoneal mass
• Radiological evidence of tumor
 RPLND
PRE- OPERATIVE

 LOW STAGE – Uncomplicated

No bowel preparation

 POST-CHEMO – Pulmonary function

Aware of pulmonary edema
Use colloid solution.
Bowel preparation (previous RPLND)
 RPLND
 SPLIT AND ROLL TECHNIQUE

 Interaortocaval nodes
 Rt.paracaval nodes
 L.periaortic nodes
 Interiliac nodes
 COMPLICATIONS

MAJOR
Hemorrhage
Ureteral injury MINOR
Chylous ascites Prolonged ileus
Pulmonary embolus Wound infection
Wound dehiscence lymphocele
Bowel obstruction
Retrograde ejaculation
 CHEMOTHERAPY
INDICATIONS

 Stage - 1A,1B/2A,2B/3
 Post RPLND
 Marker +ve
 Relapse
 Metastasis
 DRUGS
BEP
Bleomycin 30 units IV (on days 1,8,15)
Etoposide 100 mg/ m2 IV (days 1-5)
Cisplatin 20 mg/m2 IV (days 1-5)
Repeat every 21 days
 COMPLICATIONS
• Nausea , vomiting
• Alopecia
• Myelo-suppression
• Pulmonary fibrosis
• Infertility
 CHEMOTHERAPY
SIDE EFFECTS
Cisplatin , Ifosfamide – kidney damage
(plenty of fluids given)
Cisplatin, Etoposide , Vinblastin – neuropathy
(better to stop the
treatment)
Cisplatin - Ototoxity
Bleomycin - Pulmonary fibrosis
 RADIOTHERAPY
• RETROPERITONEAL LYMPH NODES
Ipsilateral external iliac
Bilateral common iliac DOG-LEG FIELD
Paracaval
Para aortic nodes.
• Chemo preferred to retroperitoneal disease
close to kidney hilum.
• PELVIC SEGMENT
- stretches from L4 – inguinal ligament
- includes orchiectomy scar.
- 150 cgy/day ( 5 days /week )
- anterior & posterior fields on
daily basis.
 RECENT ADVANCES
TUMOR MARKERS

 NEED FOR BIOMARKERS

 Absence of seminoma marker

 For prognosis
 Guide chemotherapy
 Post chemo prediction of residual mass
histology.
 TISSUE/LIQUID MARKERS
 Different technique
 Different approaches
 Adressing genetic mechanism

LIQUID MARKERS
 Non - invasive
 Continuous evaluation of disease
 Reflects heterogeneity profile
(tissue marker x)
 LIQUID MARKERS
 Placental alkaline phosphatase (PLAP)
 TRA -1-60
 Neuron specific enolase (NSE)
 Lectin-reactive AFP
 N-glycans
 Circulating tumor DNA (ct DNA)
 Circulating free DNA ( cf DNA)
 Circulating tumor cells (CTCs)
 PLAP
• fetal germ cells
• Sensitivity,accuracy,spec
ificity
• EAU – 50% increased in
seminomas.
• false + (1.6%)
TRA -1-60
• Cell surface antigen
• embryonal CA (80%),
CA in situ
• decreased during
chemo
• Increased 1 month
before radiology sign of
recurrence
 Lectin-reactive AFP
NSE
• Useful for pts who fail in
• Isoenzyme of 2 PGH primary therapy
• Neuroendocrine tumors
• Useful in Metastatic N- Glycans
stages of seminoma
with normal HCG,LDH • Diagnostic / prognostic
• Diagnosis , surveillance • Increased levels
• not for follow up independent of histology
• 83% of pts increased with
negative inconventional
markers
 Ct DNA
 Escape of tumor DNA into circulation from primary
tumor
 Metastatic loci.
 Assessed for DNA integrity
methylation
mutational status
aberrations
 USES - more easily collected at different time parts
primary tumor of origin
metastatic phenotype clone.
 LIMITATIONS

 Rapidly cleared from circulation following

surgery
 Systemic therapy
 High sensitive technique required
 Usually low / challenging to determine origin
 CTC
• Liquid biopsy
• Live info. Disease status
• metastasis in action
• Study - 18% GCT s,
41% metastasis,
100% chemo refractory disease
• Correlates aggressive disease
• poor prognosis
 SERUM micro RNA
• Described by LEE
• Stable in different body fluids
• Deregulated in cancer cells
• miR 371-373 - Adult testicular cancer
• miR 302- 367 - malignant GCTs
• Treatment monitoring and prognosis
• Deceased in CS after orchiectomy,
• chemo response in advanced disease
• miR 371 - Correlates active GCT in post
chemo RPLND
Decision making in advanced NSGCTs

Limitations - Doesnt detect mature teratoma

Different groups , methods.
Needs standard methodology.
 ESMO
EUROPEAN SOCIETY FOR MEDICAL ONCOLOGY
(AUG,2018)
 > 10 Mhz high frequency probe
 confirm mass before orchiectomy
 exploration of contralateral testis

Contrast enhanced CT - Staging for all patients before

Orchiectomy
MRI NOT routine
PET CT
MARKER -VE - Contrast CT shows lymph nodes,
No PET CT
Repeat CT after 6-8 wks.
 FDG-PET-CT - Recurrent disease
Residual mass >3 cm in
patients with seminoma 8 wks after
chemotherapy

 Follow up with contrast CT should be done for

abdomen only.
SURVIVOR OF CA TESTES