Chapter 092. Testicular Cancer (Part 4)

Stages I and II Seminoma Inguinal orchiectomy followed by retroperitoneal radiation therapy cures ~98% of patients with stage I seminoma. The dose of radiation therapy (2500– 3000 cGy) is low and well tolerated, and the in-field recurrence rate is negligible. About 2% of patients relapse with supradiaphragmatic or systemic disease. Surveillance has been proposed as an option, and studies have shown that about 15% of patients relapse. The median time to relapse is 12–15 months, and late relapses (5 years) may be more frequent than with nonseminoma. The relapse is usually treated with chemotherapy. Surveillance for clinical stage I...
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Chapter 092. Testicular Cancer (Part 4) Chapter 092. Testicular Cancer (Part 4) Stages I and II Seminoma Inguinal orchiectomy followed by retroperitoneal radiation therapy cures~98% of patients with stage I seminoma. The dose of radiation therapy (2500–3000 cGy) is low and well tolerated, and the in-field recurrence rate is negligible.About 2% of patients relapse with supradiaphragmatic or systemic disease.Surveillance has been proposed as an option, and studies have shown that about15% of patients relapse. The median time to relapse is 12–15 months, and laterelapses (>5 years) may be more frequent than with nonseminoma. The relapse isusually treated with chemotherapy. Surveillance for clinical stage I seminoma isnot recommended. Nonbulky retroperitoneal disease (stage IIA and IIB) is also treated withradiation therapy. Prophylactic supradiaphragmatic fields are not used. Relapses inthe anterior mediastinum are unusual. Approximately 90% of patients achieverelapse-free survival with retroperitoneal masses neutropenia with septicemia or bleomycin-induced pulmonary failure occurs in 1–3% of patients. Dose reductions for myelosuppression are rarely indicated. Long-term permanent toxicities include nephrotoxicity (reduced glomerular filtrationand persistent magnesium wasting), ototoxicity, and peripheral neuropathy. Whenbleomycin is administered by weekly bolus injection, Raynauds phenomenonappears in 5–10% of patients. Other evidence of small blood vessel damage is seenless often, including transient ischemic attacks and myocardial infarction. Risk-Directed Chemotherapy Because not all patients are cured and treatment may cause significanttoxicities, patients are stratified into good-risk and poor-risk groups accordingto pretreatment clinical features. For good-risk patients, the goal is to achievemaximum efficacy with minimal toxicity. For poor-risk patients, the goal is toidentify more effective therapy with tolerable toxicity. The International Germ Cell Cancer Consensus Group developed criteria toassign patients to three risk groups (good, intermediate, poor) (Table 92-2). Themarker cut-offs have been incorporated into the revised TNM (primary tumor,regional nodes, metastasis) staging of GCT. Hence, TNM stage groupings are nowbased on both anatomy (site and extent of disease) and biology (marker status andhistology). Seminoma is either good or intermediate risk, based on the absence orpresence of nonpulmonary visceral metastases. No poor-risk category exists forseminoma. Marker levels play no role in defining risk for seminoma.Nonseminomas have good-, intermediate-, and poor-risk categories based on thesite of the primary tumor, the presence or absence of nonpulmonary visceralmetastases, and marker levels. Table 92-2 IGCCCG Risk Classification for Advanced Germ CellTumors Risk Nonseminoma Seminoma Good Gonadal or Any primary site retroperitoneal primary site Absent nonpulmonary Absent nonpulmonary visceral metastases visceral metastases AFP < 1000 ng/mL Any LDH, hCG Beta-hCG < 5000 mIU/mL LDH < 1.5 x upper limit or normal (ULN)Intermediate Gonadal or Any primary site retroperitoneal primary site Absent nonpulmonary Presence of visceral metastases nonpulmonary visceral metastases AFP 1000–10,000 ng/mL Any LDH, hCG Beta-hCG 5000–50,000 mIU/mL LDH 1.5–10 x ULNPoor Mediastinal primary site No patients classified as poor prognosis Presence of nonpulmonary visceral metastases AFP ≥10,000 ng/ML Beta-hCG > 50,000 mIU/mL LDH > 10 x ULN Note: AFP, αfetoprotein; hCG, human chorionic gonadotropin; LDH,lactate dehydrogenase. Source: From International Germ Cell Cancer Consensus Group. For ~90% of patients with good-risk GCTs, four cycles of etoposide pluscisplatin (EP) or three cycles of BEP produce durable complete res ...