Testicular Cancer

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Testicular CancerDr. AADITYA PRAKASHDNB Resident, Radiation OncologyBMCHRC, JaipurINTRODUCTION Testicular cancers constitute 1% of all cancers. GCTs are the most common solid tumors in men between the ages of 15 and 35 years. In a man age 50 or older, a solid testicular mass is usually a lymphoma. Approximately 90 % of GCTs originate in the testis, and 10 % are extragonadal. Most curable solid neoplasm.LYMPHATICSRight testis: along the IVC inter-aortocaval region pre-aortic & para-aortic lymph nodes, with possible cross-over within the retroperitoneumLeft testis: Preaortic and para-aortic lymph nodes around the left renal hilum inter-aortocaval nodes mostly without cross-overRetroperitoneal lymph nodes are located anterior to the T11 to L4 vertebral bodies concentrated at the L1L3 levelNodal spread to iliac chain is ipsilaterally but infrequent (~3%)Scrotal skin: lymphatics drain into the inguinal and external iliac nodes.

HISTOLOGIC CLASSIFICATION OF TESTIS TUMORS Germ cell tumors (demonstrating one or more of the following components) Seminoma Embryonal carcinoma Teratoma Choriocarcinoma Yolk sac tumor (endodermal sinus tumor: embryonal adenocarcinoma of the prepubertal testis)Sex cord stromal tumors (gonadal stromal tumors) Leydig cell tumor Sertoli cell tumor Granulosa cell tumor (adult and juvenile types)Tumor with both germ cell and gonadal stromal elements GonadoblastomaAdnexal and para-testicular tumors Mesothelioma Tumors of soft tissue origin (e.g., sarcomas) Adnexal tumor (e.g., adenocarcinoma) of the rete testisMiscellaneous neoplasms Carcinoid Lymphoma CystMetastatic neoplasms

CLASSIFICATIONS OF GERM CELL TUMORS

STAGING OF TESTIS TUMORS BY THE AMERICAN JOINT COMMITTEE ON CANCER (AJCC)Primary TumorThe extent of primary tumor is classified after radical orchiectomypTX Primary tumor cannot be assessed. (If no radical orchiectomy has been performed, TX is used.)pT0 No evidence of primary tumor (e.g., histologic scar in testis)pTis Intratubular germ cell neoplasia (carcinoma in situ)pT1Tumor limited to the testis and epididymis without vascular/lymphatic invasion. Tumor may invade into the tunica albuginea but not the tunica vaginalis.pT2Tumor limited to the testis and epididymis with vascular/lymphatic invasion, or tumor extending through the tunica albuginea with involvement of the tunica vaginalispT3Tumor invades the spermatic cord with or without vascular/lymphatic invasionpT4Tumor invades the scrotum with or without vascular/lymphatic invasion

STAGING OF TESTIS TUMORS BY THE AMERICAN JOINT COMMITTEE ON CANCER (AJCC)Regional Lymph Nodes (N) ClinicalNX Regional lymph nodes cannot be assessedN0No regional lymph node metastasisN1Metastasis with a lymph node mass 2 cm or less in greatest dimension; or multiple lymph nodes, none more than 2 cm in greatest dimensionN2Metastasis with a lymph node mass, more than 2 cm but not more than 5 cm in greatest dimension; or multiple lymph nodes, any one mass greater than 2 cm but not more than 5 cm in greatest dimensionN3Metastasis with a lymph node mass more than 5 cm in greatest dimensionPathologic Lymph Nodes (pN)pNX Regional lymph nodes cannot be assessedpN0No regional lymph node metastasispN1Metastasis with a lymph node mass 2 cm or less in greatest dimension and five or fewer nodes positive, none more than 2 cm in greatest dimensionpN2Metastasis with a lymph node mass more than 2 cm but not more than 5 cm in greatest dimension; or more than five nodes positive, none more than 5 cm; or evidence of extranodal extension of tumorpN3Metastasis with a lymph node mass more than 5 cm in greatest dimensionSTAGING OF TESTIS TUMORS BY THE AMERICAN JOINT COMMITTEE ON CANCER (AJCC)Distant Metastasis (M)MX Distant metastasis cannot be assessedM0 No distant metastasisM1 Distant metastasisM1a Nonregional nodal or pulmonary metastasisM1b Nonpulmonary visceral metastasisSerum Tumor Markers (S)SXMarker studies not available or not performedS0Marker study levels within normal limitsS1LDH 10,000N indicates the upper limit of normal for the LDH assaySTAGE GROUPING

Stage 0 pTis N0 M0 S0Stage I pT1-4 N0 M0 SXStage IA pT1 N0 M0 S0Stage IB pT2 N0 M0 S0 pT3 N0 M0 S0 pT4 N0 M0 S0Stage IS Any T N0 M0 S1-3Stage II Any T N1-3 M0 SXStage IIA Any T N1 M0 S0 Any T N1 M0 S1Stage IIB Any T N2 M0 S0 Any T N2 M0 S1Stage IIC Any T N3 M0 S0 Any T N3 M0 S1Stage III Any T Any N M1 SXStage IIIA Any T Any N M1a S0 Any T Any N M1a S1Stage IIIB Any T N1 M0 S2 Any T Any N M1a S2Stage IIIC Any T N1-3 M0 S3 Any T Any N M1a S3 Any T Any N M1B Any S

STAGING WORK UPGeneralHistory (document cryptorchidism and previous inguinal or scrotal surgery)Physical examinationLaboratory StudiesCBC, LFT, RFTSerum assaysAlpha fetoprotein (AFP)Beta human chorionic gonadotropinLDH

Diagnostic RadiologyChest x-ray films, posterior/anterior and lateral views

Computed tomography (CT) scan of abdomen and pelvis

CT scan of chest for non seminomas and stage II seminomas

Ultrasound of contralateral testisSurgeryRadical inguinal orchiectomy

Special StudiesSemen analysis

STAGING WORK UPSerum tumor marker levels should be measured prior to orchiectomy for assignment of S category.

The only exception is for Stage IS: Persistent elevation of serum tumor markers following orchiectomy is required.The Serum Tumor Markers (S) category comprises the following:Alpha fetoprotein (AFP) [ 3 cm)EP4 CYCLES OR, BEP3 CYCLESpost-chemo follow up

Or,STAGE IIB

RT to include para-aortic and ipsilateral iliac lymph nodes to a dose of 30-36 Gy (pref.)

1. H&P,AFP,LDH,beta-HCG every 3 mth for year 1 every 6 mth for years 2-5 annually FOR 6-10 YEARS2. CXR every 6 mth for years 1-23. abd./pelvic CT every 6-12 mths for years 1-2 then annually for year 3

Recurrence, treat according to extent of disease at relapse

STAGE IIC,IIIGOOD RISK primary chemotherapy :-EP4 CYCLES OR, BEP3 CYCLESINTERMEDIATE RISK primary chemotherapy:-BEP4 CYCLES

post-chemo follow up

STRATEGIES TO REDUCE RADIOTHERAPY MORBIDITY(pure seminoma)SURVEILLANCE:-Warde et al. (2002):-638 patients with stage I seminoma followed with surveillance with 7-year follow-up. Increased relapse with tumors >4 cm, LVSI, and rete testis involvement. Relapses:-0 risk factors = 12%, 1 risk factor = 16%, 2 risk factors = 30%.Prior study showed age 3 cm in diameter

STAGE II SEMINOMA DOSE:-Daily 2 Gy /fr to cumulative total dose of 30 Gy for stage IIA and 36 Gy for stage IIIB.TARGET:-Nodal mass(GTV) must be contoured and a uniform 2 cm margin from GTV to block edge should be provided for AP-PA cone down fields.

CONE DOWN

DOSE/FRACTIONATION20 Gy in 2 Gy/fx is preferred or 25.5 Gy in 1.7 Gy/fx 20 Gy vs. 30 Gy in 2 Gy fractions demonstrates similar efficacy with reduced side effects in a randomized trial for stage I seminoma . Stage II or recurrent cancer after observation should be treated with an initial dogleg field, and then a boost should be delivered to the nodal GTV. Lymph nodes 2 cm: boost to 30 Gy.Lymph nodes between 2 and 5 cm: boost to 36 Gy.Lymph nodes >5 cm: bleomycin , etoposide , cisplatin (BEP) chemotherapy is the preferred treatment. DOSE CONSTRAINTS Kidneys: D50 8, mean dose 9 Gy. If patient has only one kidney, then D15 20. Boost constraints: Kidneys: D50 2, mean dose 3 Gy.Treatment planning goal of D95 100 for PTV coverage with 3D volume based planning.

SHIELDINGContra-lateral testis is shielded with a lead clamshell device, which consists of a cup that is 1 cm thick. This shields the testicle from low-energy scattered photons and effectively reduces the testicular dose by a factor of 4.If scrotal irradiation is necessary because of previous scrotal surgery or tumour involvement of the tunica vaginalis, a scrotal field using electron therapy is used to treat the scrotal sac and lower inguinal nodes on the affected side.

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