Testicular

Question 1

pathophysiology -4

Answer 1

>95% germ cell

---seminoma (45%)
#most frequent 4th decade(30s), secrete beta-hCG only

---nonseminoma (50%)
#most frequent 3rd decade(20s), secrete beta-hCG, alpha fetoprotein

Question 2

presentation by stage -5

Answer 2

I: 70%

II: 17%

III: 11%

no stage IV

1st site of dissemination is retroperitoneal LN - need to remove

Question 3

tumor markers - AFP -3

Answer 3

nonseminoma only

elevated in 40-60%

half-life 4-6 days (IMPT WHEN FOLLOWING TX)

Question 4

tumor markers - beta-hCG -3

Answer 4

10-20% seminoma

40-60% nonseminoma

half life 1 d (easier to monitor b/c shorter)

Question 5

tumor markers - LDH -3

Answer 5

nonspecific

80% seminoma

60% nonseminoma

Question 6

seminoma prognosis -3

HOW MANY RISK STRATIFICATION GROUPS?

Answer 6

better than nonseminoma

good: no nonpulmonary visceral mets
intermediate: nonpulmonary mets

Question 7

nonseminoma prognosis - POOR -5

Answer 7

afp >10,000

bhCG >50,000

LDH >10 xULN

other mets BESIDES lung

primary TUMOR mediastinal

Question 8

treatment - seminoma - stage IA or IB -4

three tx options

Answer 8

radical inguinal orchiectomy

all cat 1
1. XRT to RPLN and ipsilateral pelvic LN

2. may use carbo 7 x1-2 cycles in place of XRT
3. surveillance an option

Question 9

treatment - seminoma - stage IIA or IIB -2 tx options

IIA = N1
IIB = N2

Answer 9

1. XRT

2. if IIB may receive EP x4cycles

Question 10

treatment - seminoma - stage IIC or III -2 tx algorithms - 3 tx choices

WHAT IS RISK STRATIFICATION?

Answer 10

use risk stratification

all cat 1 recs

good: EP x4 or BEP x3 cycles
int: BEP x4 cycles

Question 11

treatment - nonseminoma - stage IA or IB -2

IA = tumor limited to testis, NOT tunica vaginalis
IB = everything else

Answer 11

1. observation vs nerve sparing RPLND, if LN (+) give systemic tx
2. IB can receive BEP x2 cycles instead of LN dissection

Question 12

treatment - radical inguinal orchiectomy -1

Answer 12

ALL pts have this surgery

Question 13

treatment - nonseminoma - stage IIA -2 algorithms 3 tx choices

WHAT DOES TX CHOICE DEPEND ON?

Answer 13

depends on tumor markers

IF normal:

1. BEP x3 or EP x4 (cat 2B)
2. RPLND

IF elevated:
1. BEP x3 or EP x4 FOLLOWED BY RPLND OR SURVEILLANCE

Question 14

treatment - nonseminoma - stage IIB -3

DOES TX CHOICE DEPEND ON ANYTHING?

Answer 14

DOES NOT DEPEND ON TUMOR MARKERS

EP x4 or BEP x3

+/- RPLND as in IIA elevated (outcomes equal if tumor markers nml)

Question 15

treatment - nonseminoma - stage III - good or int prognosis -2

PAY ATTENTION TO PROGNOSIS

Answer 15

good: EP x4 or BEP x3 FOLLOWED BY RPLND OR SURVEILLANCE
int: BEP x4

Question 16

EP 3 vs 4 cycles -1

Answer 16

OS decreases if only 3 cycles - give 4

Question 17

cisplatin vs carboplatin -2

IS ONE BETTER THAN THE OTHER?

Answer 17

cis is significantly better than carbo in both EP and BEP designs

4x relapses, 3x deaths with carbo in EP

Question 18

treatment - nonseminoma - stage III - poor prognosis -3 tx choices

PAY ATTENTION TO PROGNOSIS

IS HIGH DOSE CIS BETTER THAN STD DOSE = 20 daily x5d q21d?

Answer 18

1. BEP x4 is TOC

high dose cis NOT better than std dose (20 qd x5d q21d)

2. VIP x4 is no better than BEP (which is better tolerated) but is also cat 1.
3. clinical trial - current study looking at front line autoSCT

Question 19

relapsed dz tx with prior chemo- stage I or II -2 choices

Answer 19

EP x4

BEP x3

Question 20

relapsed dz tx with prior chemo- stage III -3 choices

Answer 20

1. VIP(etoposide=VP-16) or VeIP(vinblastine) - long term remission 25%
2. TIP(taxol) - 63% remain in CR
3. high dose chemo (usually carbo based) prior to autoSCT -20-90% long term remission, (90% in seminoma)

Question 21

nonseminoma prognosis - INTERMEDIATE

Answer 21

afp 1,000-10,000

bhCG 5,000-50,000

LDH 1.5-10 xULN

ONLY lung METS

primary TUMOR testis

Question 22

nonseminoma prognosis - GOOD

Answer 22

afp <1.5 xULN

ONLY lung METS

primary TUMOR testis

Question 23

staging

Answer 23

I: not node (+), IS: = S1-3 serum markers

II: node (+); S0 = serum markers wnl

III: M, S1-3

serum markers 1 good, 2 int, 3 poor