Management Of Seminoma
Treatment
The initial management involves a radical inguinal orchiectomy with high ligation
In patients with life-threatening metastatic disease and a clear-cut diagnosis of germ cell malignancy, initial management should be with chemotherapy —> when completed: surgery
Important pre-treatment steps:
- Sperm testing and banking
- Fertility discussion
Surgery
- Radiacal inguinal orchiectomy with high ligation
- Both diagnostic and therapeutic
- The testicular vessels and vas deferens are mobilized
- Non-crushing clamp is placed across the cord structure —> decrease the risk of tumor spreading by manipulation.
Seminoma
Stage Distribution | % |
---|---|
I | 70% |
II | 20% |
III | 5% |
IV | 5% |
Review of treatment:
Stage I
- Options post Surgery:
- Surveillance
- RT
- Chemotherapy
Active Surveillance:
- 5-year recurrence-free survivals —> 82%
- 10-year recurrence-free survivals —> 78%
- 70% of recurrences occurred within the first 2 years post-op
- 7% of recurring cases —> after 6 years
- Follow Up:
- Tumor markers
- CXR
- Abdominal/pelvic CT
- q3–4 months for years 1–3
- q6 months for years 4–7
- Annually for 15yrs
Radiation:
- Contraindication to RT:
- Pre-op RT
- IBD
- Horseshoe kidney
- Cancer-specific survivals for stage I and II A–B —> 99%–100% & 93%–100%
- Relapse-free survivals —> 95% and 85%
- RT toxicity:
- Increased risk of late gonadal toxicity
- Secondary malignant tumors
- Increased risk of cardiovascular disease
- Ways to reduce morbidity of RT:
- Reduced dose
- Reduce volume
- Surveillance
Simulation and Field Arrangement
- Before anything make sure R/O any contraindication to Radiation
- Previous RT
- Inflammatory Bowel Dis.
- Any history of collagen vascular disease
- Horseshoe kidney
- Be aware if patient has pacemaker
- Always start with CONSENT
- Intent
- Curative / Adjuvant
- Modality
- Photon
- Energy
- 6MV
- Any Consultation
- Fertility Consult
- Sperm Banking
- Simulation
- CT Abdomen+Pelvis
- Contrast+
- Position
- Supine
- Arms folded on chest
- Aides
- knee cushion
- head rest
- Dose/Fractionation
- Phase 1 20Gy/10
- Phase 2 if Stage IIA —> 10Gy/5 boost(LN)
- Phase 2 if Stage IIB —> 16Gy/8 boost(LN)
- Technique
- 3D Conventional
- Volumes
- CTV
- Para-AO (all stages)
- Superior border —> upper level of T12
- Inferior border —> inferior level of L5
- 1.5cm around IVC and AO
- start 2cm lower than top of kidney
- Dog-Leg field (stage IIA-IIB)
- Sup —> T12
- Inf —> Ipsilateral acetabulum
- Lateral border for the lower part —> a line from the tip of the ipsilateral transverse process L5 to the superolateral border of acetabulum
- Medial border of the lower part —> a line drawn from the tip of the contralateral transverse process of L5 to medial border of ipsilateral foramen obturator
- For stage I seminoma, the volumes to be contoured depend on the laterality of the seminoma.
- PTV —> 1cm
- Para-AO (all stages)
- CTV
- Organs At Risk
- For dog-leg fields
- Kidney:
- 1st phase
- Right & left kidney —> D50% <8Gy
- Mean dose to both kidneys <9Gy
- 2nd phase:
- Both kidney —> D50% <2 Gy
- Mean dose —> 3Gy
- 1st phase
- Small Bowel
- Liver
- Kidney:
- For dog-leg fields
- Outcome
- 5yr Cancer-Free Survival —> 98%
- 5yr Overall Survival —> 96%
- Stage IIA —> 5yr DFS —> 95%
- Stage IIB —> 5yr DFS —> 89%
- Side Effects ( Toxicity from treatment )
- GI
- Nausea
- Kidney
- CVD
- Secondary Ca
- GI
Right Side:1
- Paracaval nodes = ParaAO = R Lumbar LN
- Located —> Ant to psoas major, Post to the peritoneum, lat of IVC, Med lateral border of psoas major.
- Pre-caval = Pre-aortic nodes
- Ant to the aorta/inferior vena cava, Med of their lateral boundaries, Post to the peritoneum / SMA
- Interaortocaval nodes = interaortic nodes
- The volume bounded by the anterior borders of the inferior vena cava/aorta, laterally by their lateral borders, and posteriorly by the vertebral bodies of the spine.
Left Side:
- Same + Left Renal Hilum
Stage II
- Options of treatment:(nonbulky)
- Retroperitoneal RT
- irradiation is very effective and is recommended for patients with nonbulky tumor (stage IIA to IIB),
- Bulky (>5vm)
- Chemotherapy
- In certain rare instances, RPLND can be considered.
retroperitoneal lymph node dissection (RPLND)
- for seminoma considered for post - chemo masses
- nerve sparing to have normal ejaculation
- mortality is low
- 10% bowel ileus
- 10% risk of life time bowel obstruction
Non seminoma
Stage IB
- surveillence
- chemo
- nerve sparing RPLND
- is curative
IIA
For seminoma:
Post chemo mass <3cm then observe
page revision: 27, last edited: 06 Oct 2012 04:12