Diapositiva 1

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TUMORI DEL TESTICOLO
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Pathology Seminoma
Pure seminoma accounts for 47 of all testis
cancer patients (50 of patients with
cryptorchidism have seminoma). More than 90 of
the cases of pure seminoma are of the subtype
called classic. These patients usually present
with disease in the fourth or fifth decade.
Approximately 75 of them present with stage I
disease. Such patients may have modest elevations
of serum beta -human chorionic gonadotropin
(beta -HCG). It is worth noting that any
elevation of alpha-fetoprotein connotes the
presence of nonseminomatous germ cell
tumor. Spermatocytic seminoma accounts for 7 of
all seminomas. The median age of presentation is
in the sixth and seventh decade of life. Because
metastases are extraordinarily rare, orchiectomy
is the only required treatment.
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Pathology Non seminomatous Germ Cell Tumors
Embryonal carcinoma
Yolk sac carcinoma
Choriocarcinoma
Teratoma
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Staging of GCTs

• Stage I Testis only, T1
• Stage II T2-4, vascular or lymphatic invasion
  present
• Stage IIA nodes lt2 cm
• Stage IIB nodes 2-5 cm
• Stage IIC nodes gt5 cm
• Stage III Distant metastases

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Primary Germ Cell Tumors of the testis

• Usually present with painless testicular mass
• Retroperitoneal mets can cause back pain
• Pulmonary mets can cause dyspnea
• Initial test if suspicious for malignancy
• - testicular ultrasound
• Staging CT of abd/pelvis, chest if X-ray abnormal

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Diagnosis- Ultrasound. Most patients with
testicular cancer present with a painless
scrotal mass. This mass may be confused with
epididymitis, particularly when pain is noted.
Careful attention on physical examination, should
generally discern a testicular mass from
epididymitis. Testicular ultrasound will confirm
the findings. Translumination of the testis may
determine if the patient has a hydrocele
however, about 20 of patients with germ cell
tumors of the testis will have a hydrocele.
Testicular ultrasound is one of the most useful
tools to evaluate a testicular mass. Findings
reveal solitary or multiple hyperechoic lesions.
Small areas of speckled calcifications suggest
carcinoma in situ. Over 95 of patients with
testicular mass will have malignant pathology.
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Presenting signs of testicular cancer.
Patients with retroperitoneal spread of tumor may
present with back pain, usually in the lumbar
region. Further lymphatic spread to
supraclavicular lymph nodes (Virchows node) have
also be seen. Patients with advanced pulmonary
disease may have cough, shortness of breath, and
hemoptysis. Disease spread to the central
nervous system and bone is rare thus, routine
screening by radiograph or radionuclide scans is
unnecessary in the absence of symptoms. Some
patients present with gynecomastia. Although
common in adolescents, new onset of gynecomastia
in young adults should suggest germ cell
malignancy or other endocrine abnormalities
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Diagnosis and treatment are closely tied. The
preferred approach in a patient with a testicular
mass is a radical orchiectomy using the inguinal
approach. Fine-needle aspiration or
trans-scrotal biopsy is contraindicated because
they can cause aberrant spread of tumor to
inguinal and iliac lymph node chains. Chest
radiography should be performed to rule out the
possibility of pulmonary disease. If negative,
CT of the chest should be performed. An
abdominal CT scan should be done to evaluate the
retroperitoneal lymph nodes.
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Serum beta -human chorionic gonadotropin (
beta-HCG) and alpha-fetoprotein (AFP) levels
are elevated in about 85 of the patients with
disseminated germ cell tumor. These markers are
useful diagnostically and therapeutically. In a
patient with pathologic stage I testicular
cancer, an orchiectomy should result in the
reduction of serum HCG and AFP levels according
to their half lives (1 day and 5 days,
respectively). During treatment with
chemotherapy, at least a one log reduction of
serum beta-HCG should occur every 3 weeks.
Patients with elevated AFP have a less
predictable decline.
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EARLY STAGE DISEASE Radiation therapy
Radiation therapy is usually used in patients
with seminoma who have stage I or early stage II
disease. Most patients with stage I seminoma can
be successfully treated with the total dose of
2500 to 3500 cGy to a target area, which includes
the periaortic region from approximately the 11th
thoracic vertebrae to the lumbar region and
extends to the ipsilateral hemipelvis to include
external iliac lymph nodes. Routine radiation to
the orchiectomy scar or to the testis is not
routinely performed. Bulky stage II disease is
usually treated with moderately higher dosages of
35 to 40 cGy or alternatively with systemic
chemotherapy.
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EARLY STAGE DISEASE Surgery
Retroperitoneal lymphadenectomy. Retroperitoneal
surgery for metastatic testis cancer consists of
two primary operations. In low stage disease, a
modified template of dissection is used
contingent upon the side of the primary tumor.
Hence, the field of dissection for a
right-sided testicular tumor includes the right
paracaval and interaortocaval regions. For a
left testicular primary, the field includes the
left periaortic and preaortic lymphatics. The
ipsilateral sympathetics are preserved to
guarantee maintenance of emission and
ejaculation postoperatively
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EARLY STAGE DISEASE Surgery
For early-stage (clinical stage I, IIa or IIb)
nonseminomatous germ cell tumor, retroperitoneal
lymphadenectomy has been the mainstay of
treatment for most of the past century. The
success of surgery has been predicated on the
observation that testis cancer travels at a
predictable pattern from the testis to the
retroperitoneum before developing systemic
metastases. Surgical operations have evolved from
a variety of templates to minimize complications
of retrograde ejaculation.
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Surveillance Schedule
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For patients with low-volume disease (3 cm in
cross-sectional diameter) and normal (or within
predicted half life) serum markers, the primary
retroperitoneal lymph node dissection (RPLND) is
preferred treatment. In such patients, RPLND will
result in cures of approximately 70, without
additional therapy. In patients with completely
resected disease but with metastasis to lymph
nodes, adjuvant chemotherapy can be considered.
Two cycles of BEP (bleomycin, etoposide,
Platinol) in such patients should reduce the
relapse rate to around 1. If observed without
adjuvant therapy, approximately 30 of patients
have recurrence, but three cycles of BEP should
produce virtually a 100 cure rate for those with
relapsing disease. For patients with rising
markers following orchiectomy or with
retroperitoneal disease greater than 3 cm in
cross-sectional diameter (clinical stage B2
disease), primary chemotherapy is indicated. In
the absence of disease above the diaphragm and
with serum beta-human chorionic gonadotropin and
alpha-fetoprotein below 5000 IU/L and 1000 ng/mL,
respectively, three cycles of BEP or four cycles
of EP (etoposide, Platinol) are standard therapy.
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BEP (bleomycin, etoposide, Platinol) for
treatment of stage C disease
Patients with disseminated disease are treated
with cisplatin-based combination chemotherapy. As
mentioned earlier, various staging systems have
been used over the years to categorize patients
with disseminated germ cell tumors. Patients with
good-risk disease can be treated with three
cycles of BEP or four cycles of EP (etoposide,
Platinol). In a recent randomized, prospective
trial, no therapeutic differences were observed
between the two regimens, with slightly greater
hematologic toxicity associated with the four
cycles of EP. For patients with intermediate
and advanced disease, the cure rate is lower. As
such, these patients are candidates for
potentially more aggressive therapy. The standard
treatment approach is four cycles of BEP. For
patients with underlying pulmonary disease,
substitution of ifosfamide for bleomycin (VIP) is
reasonable. VIP therapy has an equivalent
therapeutic outcome to BEP, but has slightly
greater hematologic toxicity.
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Postchemotherapy retroperitoneal lymph node
dissection (RPLND). RPLND is another operation
for metastatic testicular tumors. This procedure
is performed for residual retroperitoneal tumor
after administration of chemotherapy for
metastatic testis cancer. The metastatic tumor
can be very adherent to the great vessels and
other structures thus, proper tissue planes are
difficult to determine. Specialized vascular
techniques are sometimes necessary to completely
resect the retroperitoneal tumor, but complete
resection of all tumor is essential to ensure a
good outcome.
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Results of studies on salvage therapy
Salvage therapy is indicated for patients who
relapse from complete remission or who have an
incomplete partial response to primary
chemotherapy. Ifosfamide salvage therapy. VeIP
(vinblastine, ifosfamide, and cisplatin) produces
durable complete remissions in about 25 to 30
of patients with recurrent nonseminomatous germ
cell tumor (NSGCT) treated with second-line
therapy. In patients with recurrent seminoma,
VeIP chemotherapy will produce durable complete
remissions in approximately 50 of patients.
High-dose chemotherapy with carboplatin and
etoposide with peripheral stem cell rescue will
produce durable complete remissions in
approximately 50 of patients as second-line
therapy. For patients with relapsing NSGCT, this
is preferred in salvage therapy. Patients who are
candidates for salvage therapy have mixed
prognostic factors. Patients with pure seminoma
or longer relapse-free intervals (but lt 2 years)
have better prognosis than those patients whose
tumors progress on cisplatin, multiple regimens,
or mediastinal primary tumors.
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