Management of Non

Seminomatous Germ Cell

Tumors of Testis

Dr. Akhil Kapoor

Acharya Tulsi Regional Cancer

Treatment & Research Center, Bikaner

Post Orchiectomy Tests

• Post Orchiectomy Serum Marker Status:

Decides Staging

• Usually performed after 3 weeks of Surgery

• Discuss Sperm Banking in young patients,

preferably before surgery.

• CE CT Abdomen & Pelvis

• A Chest CT is indicated if :

the abdominopelvic CT shows retroperitoneal

adenopathy or,

the CXR shows abnormal results.

• Brain MRI and Bone Scan. If clinically indicated.

• No role of PET-CT

Treatment options

Stage dependent treatment options after inguinal

orchiectomy include

• Surveillance,

• Chemotherapy, and

• RPLND.

• Although the timing of the RPLND may vary, most

patients will undergo an RPLND at some point during

treatment.

• Major morbidity with bilateral dissection : Retrograde

ejaculation, resulting in infertility.

• Nerve dissection techniques preserve antegrade

ejaculation in 90% of cases.

Bilateral RPLND

Involves removal of lymphatic tissue extending from:

• Lateral: between both ureters,

• Superior: diaphragmatic crus

• Inferior: bifurcation of the common iliac arteries.

Stage IA, IB (T2 only)

(1) Surveillance,

(2) Nerve-sparing RPLND.

• Cure rate with either approach exceeds 95%.

• With surveillance, up to 30% patients will develop

relapse which must be identified early.

• RPLND is recommended within 4 weeks of a CT

scan and within 7 to 10 days of repeat serum

marker testing to ensure accurate presurgical

staging.

Stage IB (T2 only)

• Vascular invasion is a significant predictor of

relapse when orchiectomy is followed by

surveillance alone.

• Surveillance generally not recommended for T2

disease with vascular invasion due to 50% chance

of relapse.

Post RPLND

• pN0: Surveillance

• pN1: Surveillance (preferred) vs. BEP- 2Cycles

• pN2: BEP- 2Cycles

• pN3: BEP- 3Cycles

F/U during Surveillance

Stage IB

1. Nerve-sparing RPLND, or

2. Primary chemotherapy: BEP for 2 cycles

After primary Chemo,

• Residual mass of 1 cm or greater : Nerve-sparing

RPLND

• Residual mass <1cm: Surveillance vs. RPLND

F/U for Stage IB

Stage IS

Elevated levels of AFP and beta-HCG after

orchiectomy :

• Disseminated nonseminoma

• hepatobiliary disease,

• marijuana use, and

• Hypogonadism.

• After excluding other causes, 3 cycles of BEP

Stage IIA with Normal Markers

1. Nerve-sparing RPLND (Preferred), or

2. BEP 3 Cycles.

• For patients with persistently elevated AFP or HCG

levels, induction chemotherapy.

Post Treatment in Stage IIA

After primary Chemo,

• Residual mass of 1 cm or greater : Nerve-sparing

RPLND

• Residual mass <1cm: Surveillance vs. RPLND

After primary RPLND,

• pN0: Surveillance

• pN1: Surveillance (preferred) vs. BEP- 2Cycles

• pN2: BEP- 2Cycles

• pN3: BEP- 3Cycles

IGCCCG Risk Grouping

For Good Risk Stage IIA-S1, IIB, IIC, IIIA

BEP for 3 cycles

• If CR: Surveillance vs. RPLND

• If Partial response (residual mass with normal

AFP & hCG levels) :

• If Incomplete Response, 2nd line CT

For Intermediate & Poor Risk IIIB & IIIC

BEP 4 Cycles

• If CR: Surveillance vs. RPLND

• If Partial response (residual mass with normal

AFP & hCG levels) :

• If Incomplete Response, 2nd line CT

F/U in Stage II, III Non Seminoma

Comparison of F/U Schedules

Second Line Therapy for Metastatic

Germ Cell Tumors

• Prognostic factors to decide whether patient is a

candidate for conventional dose therapy or high-

dose therapy with stem cell support as a second-

line option.

Favorable prognostic factors to conventional dose

second-line chemotherapy include:

• testicular primary site,

• prior complete response to first-line therapy,

• low levels of post- orchiectomy serum tumor

markers, and

• low-volume disease

Conventional Dose CT

High Dose CT

Resistance to High Dose CT

• For patients who do not experience CR to second-

line high-dose therapy, the disease is nearly always

incurable;

• Only exception is the rare patient with elevated

serum tumor markers and a solitary site of

metastasis (usually retroperitoneal) that undergoes

surgical resection.

• Other options are participation in a clinical trial or

best supportive care.

Palliative Chemotherapy

• Gemcitabine with paclitaxel

• Gemcitabine with oxaliplatin

• Gemcitabine with paclitaxel and oxaliplatin

• Oral Etoposide (50mg/sqm)

Summary

Stage IA, IB (T2 only)

(1) Surveillance,

(2) Nerve-sparing RPLND.

Stage IB

1. Nerve-sparing RPLND, or

2. Primary chemotherapy: BEP for 2 cycles

Stage IS

3 cycles of BEP

Stage IIA with Normal Markers

1. Nerve-sparing RPLND (Preferred), or

2. BEP 3 Cycles.

For Good Risk Stage IIA-S1, IIB, IIC, IIIA

BEP 3 Cycles

For Intermediate & Poor Risk IIIB & IIIC

BEP 4 Cycles

After primary Chemo,

• Residual mass of 1 cm or greater : Nerve-sparing

RPLND

• Residual mass <1cm: Surveillance vs. RPLND

After primary RPLND,

• pN0: Surveillance

• pN1: Surveillance (preferred) vs. BEP- 2Cycles

• pN2: BEP- 2Cycles

• pN3: BEP- 3Cycles

THANKS