Genitourinary Cancer – 2
(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Thank you Chiragbhai for very interesting points about Testicular cancer: 1. One of the highest cure rates, even in stage four. 2. Very fast growth, unlike most other solid tumors. 3. Swelling in testis is an indication for urgent sonography, even if painless. If there is a suspicion of testicular mass on sonography, high inguinal orchidectomy should be done for biopsy. NO ROLE for Trans scrotal biopsy. 4. There are two main types on pathology: Seminoma, Nonseminoma. 5. Tumor markers are very important in diagnosis and follow up – AFP, HCG, LDH.
After diagnosis, what are the next important steps?
Answer: Once diagnosis is established, stage is determined. This includes CT scans, and very interestingly post biopsy repeat AFP, HCG, LDH. They should be repeated if required every 3-5 days for accurate levels, as the stage determination is based on post biopsy levels. Based on half life, about 2 weeks post biopsy may be considered adequate time line for tumor marker levels to be used for staging. Lowest level post biopsy should be used for staging. Half life for AFP is 5-7 days and for HCG it is 30 hours. If tumor markers do not normalize post orchidectomy, it is suggestive of residual disease. If there are symptoms, bone scan, MRI brain may be required to detect spread.
Stage is based on TNM classification, as for most other cancers.
However risk level is determined based on tumor markers (AFP, HCG, LDH), Site of primary tumor, and non pulmonary visceral metastases. There are three risk levels: Good (with overall 90% long term survival), Intermediate (80% long term), Poor (50% long term).
Pure seminoma has such good results that no patients are considered in poor risk with this histology.
Que: How do you treat these tumors? Is surgery the mainstay of therapy?
Ans: Surgery has a role, but limited mainly in removing testis. In some cases, retroperitoneal dissection is part of treatment. Other than that, this is primarily a disease treated by chemotherapy. And all the remarkable improvements in results in this cancer are mainly due to chemotherapy, achieved by very thorough understanding of chemotherapy drugs, and well designed clinical trials over several years.
Pure seminoma has very high cure rates. However it is important to note that if there is high AFP, it indicates presence of non seminoma component. And whatever the histology, patient must be treated as non seminoma.
Before starting chemotherapy, patients should be given option of sperm banking, as these are generally young patients. sperm banking is widely available even in India, is easy, not expensive, and takes only about 3 days. Occasional patients have extremely aggressive disease and require starting chemotherapy early, as soon as there is suspicion, even before biopsy results are available – based on radiology, tumor markers and clinical findings.
Early stage pure seminoma has cure rate of 99%. Most of the stage 1 patients are cured by orchidectomy alone. Other options in this category include either a single dose of carboplatin chemotherapy or low dose radiotherapy to retroperitoneal nodes. Stage 2 and higher seminoma need radiotherapy to retroperitoneal and same side pelvic nodes. These tumors are highly radiosensitive, hence doses needed are much less than other solid tumors. However, these are young patients, and there is a significant chance of secondary tumors in long term, in radiotherapy field, such as sarcoma. Hence clinical trials have evaluated role of chemotherapy in this setting also, with very good results. Preference is shifting towards chemotherapy instead of radiotherapy, including most guidelines.
Patients who relapse after radiotherapy, can be cured in over 90% cases by standard chemotherapy, again showing excellent efficacy of chemotherapy in this disease.
Post chemotherapy, there are occasional patients with residual mass, especially concerning are the ones with size over 3 cm. PET scan is now used to determine which one of these patients should undergo early resection versus observation. If there is no activity on PET scan, close monitoring is acceptable. Immediate retroperitoneal node dissection or other surgery is not required.
Very close monitoring is key to success after treatment, as early relapse has excellent cure rates. Monitoring mainly involves history and physical examination, CT scan, chest x ray, and HCG levels. Unlike other solid tumors, initial follow up is very frequent, generally every 2 months in first year at least. CT scan however is done every other visit or so.
November 14th 2017.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org