Germ Cell Tumours: Difference between revisions
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* '''Based on histology (seminoma vs. NSGCT) and clinical stage''' | * '''Based on histology (seminoma vs. NSGCT) and clinical stage''' | ||
==== | ==== General principles ==== | ||
* '''Newly elevated and/or rising serum tumor marker levels after orchiectomy indicate the presence of metastatic disease, and these patients should receive induction chemotherapy.''' | * '''Newly elevated and/or rising serum tumor marker levels after orchiectomy indicate the presence of metastatic disease, and these patients should receive induction chemotherapy.''' | ||
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*** Patients require serial follow-up CT imaging | *** Patients require serial follow-up CT imaging | ||
===== | ===== CS IIA and IIB Seminoma ===== | ||
* ≈15-20% of patients with seminoma have CS II disease at diagnosis; 70% of these patients have CS IIA and IIB. | * ≈15-20% of patients with seminoma have CS II disease at diagnosis; 70% of these patients have CS IIA and IIB. | ||
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* Routine surveillance CT imaging is unnecessary after complete resolution of disease. | * Routine surveillance CT imaging is unnecessary after complete resolution of disease. | ||
===== | ===== CSIIC and III seminoma ===== | ||
* '''Regimen and number of cycles are based on IGCCCG risk classification''' (see above) | * '''Regimen and number of cycles are based on IGCCCG risk classification''' (see above) | ||
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** '''Intermediate-risk: BEP×4''' | ** '''Intermediate-risk: BEP×4''' | ||
===== | ===== Special scenarios ===== | ||
====== | ====== Residual masses after radiotherapy for seminoma ====== | ||
* '''Patients should undergo biopsy and histologic confirmation of the suspected lesion before management decisions are made.''' | * '''Patients should undergo biopsy and histologic confirmation of the suspected lesion before management decisions are made.''' | ||
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** RPLND should not be performed without histologic confirmation of NSGCT pathology. | ** RPLND should not be performed without histologic confirmation of NSGCT pathology. | ||
====== | ====== Residual masses after chemotherapy for seminoma ====== | ||
* After first-line chemotherapy, 60-80% of patients have radiologically detectable residual masses. | * After first-line chemotherapy, 60-80% of patients have radiologically detectable residual masses. | ||
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** Post-chemotherapy radiotherapy has no role in the management of residual masses | ** Post-chemotherapy radiotherapy has no role in the management of residual masses | ||
====== | ====== Relapse of seminoma ====== | ||
* '''If chemo-naïve:''' | * '''If chemo-naïve:''' | ||
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**** Although primary chemotherapy is associated with the lowest risk of relapse, these relapses are less amenable to salvage therapy because they are chemoresistant, particularly if they have received a regimen other than standard dose BEP. In contrast, patients who relapse after RPLND or on surveillance are chemotherapy-naive and are cured with chemotherapy in virtually all cases. | **** Although primary chemotherapy is associated with the lowest risk of relapse, these relapses are less amenable to salvage therapy because they are chemoresistant, particularly if they have received a regimen other than standard dose BEP. In contrast, patients who relapse after RPLND or on surveillance are chemotherapy-naive and are cured with chemotherapy in virtually all cases. | ||
===== | ===== CSIS NSGCT ===== | ||
* '''Defined as the presence of elevated serum tumor markers after orchiectomy without clinical or radiographic evidence of metastatic disease.''' | * '''Defined as the presence of elevated serum tumor markers after orchiectomy without clinical or radiographic evidence of metastatic disease.''' | ||
* '''Should''' be treated similarly to patients with CS IIC and III and '''receive induction chemotherapy according to IGCCCG classification.''' | * '''Should''' be treated similarly to patients with CS IIC and III and '''receive induction chemotherapy according to IGCCCG classification.''' | ||
===== | ===== CS IIA and IIB NSGCT ===== | ||
* '''CSIIA with positive markers or CSIIB regardless of markers: primary chemotherapy (recommended by both CUA and AUA)''' | * '''CSIIA with positive markers or CSIIB regardless of markers: primary chemotherapy (recommended by both CUA and AUA)''' | ||
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***** Campbell's 11th edition, Chapter 34, page 805: Special mention is made of patients with declining or normalized serum tumor markers during first-line chemotherapy with enlarging (usually cystic) masses. These patients are considered to have growing teratoma syndrome. In these rare cases, chemotherapy is temporarily interrupted, and patients are taken for surgical resection. With complete surgical resection, the long-term prognosis for these patients is favorable | ***** Campbell's 11th edition, Chapter 34, page 805: Special mention is made of patients with declining or normalized serum tumor markers during first-line chemotherapy with enlarging (usually cystic) masses. These patients are considered to have growing teratoma syndrome. In these rare cases, chemotherapy is temporarily interrupted, and patients are taken for surgical resection. With complete surgical resection, the long-term prognosis for these patients is favorable | ||
===== | ===== CS IIC and III NSGCT ===== | ||
* '''Induction chemotherapy with cisplatin-based regimens''' | * '''Induction chemotherapy with cisplatin-based regimens''' | ||
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**** VIP×4 may be substituted for BEP×4 in patients with compromised pulmonary function and in patients in whom extensive chest surgery is likely to be performed to remove residual disease after chemotherapy | **** VIP×4 may be substituted for BEP×4 in patients with compromised pulmonary function and in patients in whom extensive chest surgery is likely to be performed to remove residual disease after chemotherapy | ||
===== | ===== Special scenarios ===== | ||
====== | ====== Residual masses after chemotherapy for NSGCT ====== | ||
* After receiving first-line cisplatin-based chemotherapy, 5-15% of patients will have partial remission with positive tumour markers or have disease progression. | * After receiving first-line cisplatin-based chemotherapy, 5-15% of patients will have partial remission with positive tumour markers or have disease progression. | ||
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**** Teratoma, then patient should undergo resection. | **** Teratoma, then patient should undergo resection. | ||
====== | ====== Relapsing NSGCT ====== | ||
* '''Treatment depends on what treatment the patient previously received and, in certain cases, the location of the relapse.''' | * '''Treatment depends on what treatment the patient previously received and, in certain cases, the location of the relapse.''' | ||
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** High-stage NSGCT: systemic therapy will be given and therefore hemiscrotectomy is not needed | ** High-stage NSGCT: systemic therapy will be given and therefore hemiscrotectomy is not needed | ||
==== | ==== Treatment related sequelae ==== | ||
* '''Early toxicity''' | * '''Early toxicity''' | ||