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

  1. 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
  2. Always start with CONSENT
  3. Intent
    • Curative / Adjuvant
  4. Modality
    • Photon
  5. Energy
    • 6MV
  6. Any Consultation
    • Fertility Consult
    • Sperm Banking
  7. Simulation
    • CT Abdomen+Pelvis
    • Contrast+
  8. Position
    • Supine
    • Arms folded on chest
  9. Aides
    • knee cushion
    • head rest
  10. Dose/Fractionation
    • Phase 1 20Gy/10
    • Phase 2 if Stage IIA —> 10Gy/5 boost(LN)
    • Phase 2 if Stage IIB —> 16Gy/8 boost(LN)
  11. Technique
    • 3D Conventional
  12. 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
  1. 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
      • Small Bowel
      • Liver
  2. Outcome
    • 5yr Cancer-Free Survival —> 98%
    • 5yr Overall Survival —> 96%
    • Stage IIA —> 5yr DFS —> 95%
    • Stage IIB —> 5yr DFS —> 89%
  3. Side Effects ( Toxicity from treatment )
    • GI
      • Nausea
    • Kidney
      • CVD
    • Secondary Ca

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