9 1 0 2 s Germ-cell cancer s a l c r e t s a M R B E E Prof. Dr. Jörg Beyer O Physician-in-Chief M Medical Oncology S E Inselspital, Bern University Hospital - O University of Bern S E Mail: joerg.beyer@insel.ch
9 The menue: 1 0 2 s s a • Epidemiology & Staging l c r e t • Focus on early stage disease s a M • Ongoing discussions & risk-adapated treatment R B E • Little on advanced/poor risk disease E O • Little on relapsed or refractory disease M S E • Some emphasis on survivorship care - O S • Full presentation via the ESO webpage E
Incidence and Death Rates Testis Cancer 9 1 in Europe 0 2 www.rki.de (Krebs in Deutschland Februar 2010) s s a l c r e t s a M Incidence R B E E O M S E - O Mortality S E
Germ-cell cancer in Europe 2012 9 1 http://eco.iarc.fr/eucan 0 2 Incidence Mortality s s a l c r e t s a M R B E E O M S E - O S E
Stage according to 9 1 0 UICC 2 s s a l c r e t s a M R B E E O M S E - O S E
9 Initial Staging 1 0 2 s s a l c r + H & P, physical examination including testes e t s + Testicular ultrasound a M + Tumormarker AFP, HCG and LDH (no PLAP) R B + CT thorax and abdomen E E +/- CT/MRI brain (only if pulmonary metastases present) O M S E - O - No PET CT scans !! S expert patholgy E assessment
9 1 0 2 s s a l c r e t s a M R B E Cave E O M • ca. 3% primary extragonadal S E germ-cell cancers - O • no upfront orchiectomy in S E widely metastatic disease
9 1 0 2 s s a l c r e t s a M R B E E O M S • Seminoma vs Non-seminoma or mixed tumors E - O • In Non-seminoma: is there teratoma present S E • Tumor size, rete testis involvement • Evidence of lymphovascular invasion
9 1 0 2 s s a l c r e t s a M R B E E O M S E - O S E Cancer Medcine 2014, doi: 10.1002/cam4.324
9 1 0 2 s s a l c r e t s a M R B E E Slide at the courtesy of Prof. Loy, Berlin O M S Vascular invasion - must be stated in the pathology report E - O - needs an experienced pathologist S E - is helped by anti CD 31 immunohistology - must be obvious in the section
9 1 Case No 1: 33 years 0 2 s s a • Testicular cancer l c r e • Orchiectomy => pure seminoma t s a • Size 4 cm, no infiltration rete testis M R • AFP und HCG normal B E • LDH prior orchiectomy 480 U/L E O • LDH post orchiectomy normal M S • CT thorax & abdomen w/o LN metastases E - O S E
9 1 Case No 1: 33 years 0 2 s s a • Testicular cancer l c r e • Orchiectomy => pure seminoma t s a • Size 4 cm, no infiltration rete testis or vascular invasion M R • AFP und HCG normal B E • LDH prior orchiektomy 480 U/L E O • LDH post orchiektomy normal M S • CT thorax & abdomen w/o LN metastases E - O S E Seminoma Stage I => Which treatment ?
9 1 0 2 s s Ann Oncol March 2013 a l c r e t s a M R B E E O M S E - O S E
9 1 0 2 s s a l c r e t s a M R B • Safe E E • Relapse rate of 15-20% in seminoma O M • Almost all relapses can be salvaged by BEP x 3 S E • Overall survival close to 100% - O • Only those who need treatment get treated S E • Avoids adjuvant treatment in 80-85% of patients
9 1 0 Stage I 2 s s a l c r e t s a M All pts. treated in R B Denmark between E E 1984 - 2007 with O M active surveillance S E - O S E Daugaard personal communication
Why worry about giving 3 x BEP? 9 1 0 2 s s • Lousy life during chemotherapy a l c r e • Look like a zombie t s a M • Nothing is normal any more: fatigue, R B nausea, vomitting, tinnitus, polyneuropathy, E E abnormal taste, Raynaud´s phenomenon O M S • Rare, but life-threatening risks E - O bleomycin lung, thrombosis/pulmonary emboli S E • Off work for several months
E S O - E S M O E E B R M a s t e r c l a s s 2 0 1 9 de Haas et al. Ann Oncol 2013
9 1 0 2 s s Ann Oncol March 2013 a l c r e t s a M R B E E O M S E - O S E
9 1 0 2 s s a l c all patients with metastatic seminoma (stage II & III) r e t s should receive first-line chemotherapy a M * with three rarely four cycles of BEP R B E E O M S E - O S E * four cycles BEP in patients with bulky or extrapulmonary disease
9 1 0 2 s s a l c r e t s a M R B E E O M 3 Zyklen BEP (4 Zyklen EP) S E - O every 21 days S E
Summary Current Treatment Strategies in 9 Seminoma 1 0 2 s s a • Ca. 80% of patients present as stage I l c r e t "Active Surveillance“ the new standard, alternatively one cycle adjuvant s a M Carboplatin AUC 7. Adjuvant radiation no longer recommended. R B Histologie ! E • Ca. 20% of patients present with metastastic disease E O M Standard treatment with three (rarely four) cycles BEP S E Careful with bleomycin in poor pulmonary & renal function & older age - O S No residual tumor resection after chemotherapy ! E Residual tumors after chemotherapy „rare“ indication for PET-CT scans
9 1 Case No 2: 36 years 0 2 s s a • Testicular cancer l c r e • Orchiectomy, mixed NSGCT, 80% EC. t s a M • Size 4 cm, no vascular invasion R • CT thorax and abdomen w/o metastases B E • AFP 1.480 U/L, HCG 10 U/L prior orchiectomy E O M S E - O S E
9 1 Case No 2: 36 years 0 2 s s a • Testicular cancer l c r e • Orchiectomy, Mixed NSGCT, 80% EC. t s a • Size 4 cm, no vascular invasion M R • CT thorax and abdomen w/o metastases B E • AFP 1.480 U/L, HCG 10 U/L prior orchiectomy E O • AFP 560 U/L, HCG normal post orchiectomy M S E - O S E
9 1 Case No 2: 36 years 0 2 s s a • Testicular cancer l c r e • Orchiectomy, Mixed NSGCT, 80% EC. t s a • Size 4 cm, no vascular invasion M R • CT thorax and abdomen w/o metastases B E • AFP 1.480 U/L, HCG 10 U/L prior orchiectomy E O • AFP 560 U/L, HCG normal post orchiectomy M • AFP 140 U/L, HCG normal after 2 weeks S E - • AFP 64 U/L, HCG normal after 3 weeks O S • AFP normal, HCG normal after 35 days E
9 1 Case No 2: 36 years 0 2 s s a • Testicular cancer l c r e • Orchiectomy, mixed NSGCT, 80% EC. t s a • Size 4 cm, no vascular invasion M R • CT thorax and abdomen w/o metastases B E • AFP 1.480 U/L, HCG 10 U/L prior orchiectomy E O • Normalization of tumor markers post orchiectomy M S E - O Non-Seminoma CS I => Which treatment ? S E
48% 14% 9 1 Relapses Relapses 0 2 s s a l c Ann Oncol 2017 r e t s a M R B E E O M S E - O 1 cycle 1 cycle S E
9 1 0 2 s s a l c r e t s a M R B • Safe E E • Relapse rate of 15-50% in non-seminoma O M • Almost all relapses can be salvaged by BEP x 3 (-4) S E • Overall survival close to 100% - O • Only those who need treatment get treated S E • Avoids adjuvant treatment in 80-85% of patients
9 1 0 Stage I 2 s s a l c r e t s a M All pts. treated in R B Denmark between E E 1984 - 2007 with O M active surveillance S E - O S E Daugaard personal communication
Summery Current Strategy in 9 1 Non-Seminoma 0 2 s s a l c • Ca. 60% of patients present as clinical stage I r e t s a "Surveillance“ in "low risk" patients without vascular invasion in the M primary tumor, one cycle adjuvant BEP in "high risk" patients with R B evidence of vascular invasion in the primary tumor Histologie ! E E O M S E - O S E
Case No 3: 36 years 9 1 0 2 • Lumberjack s s a • Increasing shortness of breath at work l c r e • Went to the A & E of his local hospital t s a • Pleural mass and multiple pulmonary metastases M R B E E O M S E - O S E
9 1 0 2 s s a l c r e t s a M R B E E O M S E - O S E
Case No 3: 36 years 9 1 0 2 s • Increasing shortness of breath at work s a l c • Pleural mass and multiple pulmonary metastases r e t s a M • Admitted to pulmonary service of the local hospital R B • Thoracic CT scan and bronchoscopy E E • Undifferentiated cancer compatible with NSCLC O M S E - O S E
Case No 3: 36 years 9 1 0 2 s • Increasing shortness of breath at work s a l c • Pleural mass and multiple pulmonary metastases r e t s a M • Admitted to pulmonary service of the local hospital R B • Thoracic CT scan and bronchoscopy E E • Undifferentiated cancer compatible with NSCLC O M S E • Carboplatin, gemcitabine & bevacizumab - O • Staging PET CT scan after first cycle S E
9 1 0 2 s s a l c r e t s a M R B E E O M S E - O S E
9 1 0 2 s s a l c r e t s a M R B E E O M S E - O S E
9 1 0 2 s s a l c r e t s a M R B E E O M S E - O S E
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