Editing Germ Cell Tumours (section)

==== General principles ====

* '''<span style="color:#ff0000">Newly elevated and/or rising serum tumor marker levels after orchiectomy indicate the presence of metastatic disease</span>, and these patients should receive induction chemotherapy.'''
* '''In the setting of a negative metastatic evaluation and slowly declining markers (i.e., not according to half-life), patients should be monitored closely and have levels checked periodically until the levels normalize or begin to rise.'''
* '''Surveillance for clinical stage I disease'''
** '''Advantages (1):'''
*** '''Potentially reducing treatment-related toxicity''' by restricting treatment to patients with a proven need for it.
**** '''Radical orchiectomy alone has high cure rate in patients with CSI GCT (80-85% for CS I seminoma and 70-80% for CSI NSGCT)'''
***** '''Patients that relapse on surveillance have excellent outcomes with salvage therapy'''.
** '''Disadvantages (4):'''
**# Highest risk of relapse (compared to adjuvant treatment)
**# Need for long-term (>5 years) surveillance
**# Risk of second malignant neoplasms owing to intensive surveillance CT imaging
**# More intensive therapy required to treat patients at the time of relapse than if they had received treatment at diagnosis
* '''<span style="color:#ff0000">Radiotherapy</span>'''
** '''<span style="color:#ff0000">Seminoma are sensitive to radiation therapy</span>'''
** '''<span style="color:#ff0000">Radiation therapy has no role in NSGCT with the exception of treatment for brain metastases.</span>'''
* '''<span style="color:#ff0000">Chemotherapy</span>'''
** '''<span style="color:#ff0000">International Germ Cell Cancer Collaborative Group (IGCCCG) risk classification</span>'''
*** '''<span style="color:#ff0000">Used</span>''' over the TNM system '''<span style="color:#ff0000">to select the chemotherapy regimen and number of cycles in patients receiving chemotherapy for advanced disease</span>'''
**** '''<span style="color:#ff0000">Developed in patients with metastatic GCT at the time of diagnosis and is NOT applicable to patients with relapsed GCT</span>'''
*** '''<span style="color:#ff0000">Classified into (3): good, intermediate, and poor prognosis</span>'''
***'''<span style="color:#ff0000">Classification based on:</span>'''
****'''<span style="color:#ff0000">NSGCT (3):</span>'''
****# '''<span style="color:#ff0000">Presence of non-pulmonary visceral metastasis</span>'''
****# '''<span style="color:#ff0000">Primary mediastinal NSGCT</span>'''
****# '''<span style="color:#ff0000">TMs at the initiation of chemotherapy (not levels measured before orchiectomy)</span>'''
**** '''<span style="color:#ff0000">Seminoma (1):</span>'''
****# '''<span style="color:#ff0000">Presence of non-pulmonary visceral metastasis</span>'''
****#* '''<span style="color:#ff0000">No poor prognosis category</span>'''

{| class="wikitable"
|'''Histology'''
|'''Good prognosis'''
|'''Intermediate prognosis'''
|'''Poor prognosis''' (II or greater)
|-
|'''Non-seminoma'''
|
* '''Testis/retroperitoneal primary AND'''
* '''No non-pulmonary visceral metastases AND'''
* '''Good markers'''
** AFP < 1000 ng/mL AND
** hCG < 5,000 IU/L (1,000 ng/mL) AND
** LDH < 1.5 x upper limit of normal
** (CSI-IIIa)
|
* '''Testis/retroperitoneal primary AND'''
* '''No non-pulmonary visceral metastases AND'''
* '''Intermediate markers:'''
** AFP≥ 1,000 and ≤ 10,000 ng/mL OR
** hCG ≥ 5,000 IU/L and ≤ 50,000 IU/L OR
** LDH ≥ 1.5 x N and ≤ 10 x N
** (CSIIIb)
|
* '''Mediastinal primary OR'''
* '''Non-pulmonary visceral metastases OR'''
* '''Poor markers:'''
** AFP > 10,000 ng/mL OR
** hCG > 50,000 IU/L (10,000 ng/mL) OR
** LDH > 10 x upper limit of normal
** (CSII or greater)
|-
|'''Seminoma'''
|
* Any primary site AND
* '''No non-pulmonary visceral metastases''' AND
* Normal AFP, any hCG, any LDH
|
* Any primary site AND
* '''Non-pulmonary visceral metastases AND'''
* Normal AFP, any hCG, any LDH
| 
|}

** During chemotherapy, patients need to be monitored on a regular basis with serial tumour marker estimation.
** Post-chemotherapy, radiological restaging should be performed in all patients.
*** If the expected tumour marker decline is seen, all residual masses should be treated appropriately.
*** If the tumour markers plateau and are at a low level, they should be followed closely.
*** If there is a persistent plateau or tumour marker decline, residual masses should be treated appropriately.
** Markedly elevated HCG prior to treatment may take longer to normalize or plateau at the end of chemotherapy
* '''RPLND'''
** See [[Retroperitoneal Lymph Node Dissection|RPLND]] Chapter Notes