Systemic Management of Testis Cancer

Educational Objectives

The goal of this program is to improve management and risk stratification of testis cancer. After hearing and assimilating this program, the clinician will be better able to:

1. Select a management strategy for testis cancer based on risk factors.
2. Utilize serum tumor markers to risk-stratify disseminated testicular cancer and assess response to treatment.

Summary

Stages of testicular cancer: 7th edition of American Joint Committee on Cancer (AJCC) Tumor-Node-Metastasis (TNM) Staging — T1 corresponded to cancer in testis or epididymis and T2 corresponded to lymphovascular invasion or invasion beyond tunica albuginea into tunica vaginalis; 8th edition of AJCC TNM Staging — T2 stage corresponds to invasion of epididymis or hilar soft tissue; stratified T1 for seminomas into T1a and T1b based on size; predicts likelihood of having metastases at time of diagnosis, rather than likelihood of relapse with stage 1 disease

Risk factors for relapse: lymphovascular invasion main factor for nonseminomas; pure or predominant embryonal tumors associated with higher risk; invasion into epididymis not associated with increased risk

Management of early-stage disease: if chemotherapy used, one cycle recommended over 2 cycles, although surveillance preferred for most patients; retroperitoneal lymph node dissection (RPLND) may prevent late complications from chemotherapy; trial from United Kingdom — after follow-up of ≥3 yr, 4 malignant recurrences occurred in 246 patients who received one cycle of chemotherapy, and 3 of 4 were cured with additional treatment; 3 recurrences of teratomas were cured with surgery; overall survival >99%

Risk factors with seminomas: review showed that size >4 cm increases risk for relapse; rete testis invasion increased risk for relapse by ≈50% in systematic review; series from Denmark showed that lymphovascular invasion was associated with worse prognosis for given tumor size

Carboplatin: 2 cycles recommended to reduce risk for relapse; has low short-term toxicity; 2 cycles associated with relapse rate of ≤3%, whereas trials show relapse rate of ≈5% and ≈10% with single cycle for patients with tumor size >4 cm; pooled international analysis showed one cycle yielded relapse rate of 15% and 5-yr disease-free and overall survival of 82% and 98%, respectively

Measuring glomerular filtration rate (GFR): inotrope methodology often unavailable; cystatin C test provides accurate estimated GFR when used with creatinine

Serum tumor markers: for staging of disseminated testicular cancer, use values on first day of first-line chemotherapy; ignore levels of alpha fetoprotein (AFP) <20 ng/mL that are relatively stable; mild elevations in β-human chorionic gonadotropin (hCG) may be caused by manufacturing of β-hCG by pituitary gland in response to hypogonadism; rate of decrease — AFP should decrease by ≈50% per wk; β-hCG should decrease by ≈50% every 3 days; lactate dehydrogenase (LDH) should only be used on first day of chemotherapy for risk stratification

Chemotherapy regimens: good risk — 3 cycles of BEP chemotherapy (bleomycin, etoposide, and cisplatin) or 4 cycles of EP chemotherapy (etoposide and cisplatin); intermediate or poor risk — 4 cycles of BEP or VIP chemotherapy (etoposide or vinblastine, ifosfamide, and cisplatin); criteria for 4 cycles of BEP are AFP >1000 ng/mL, β-hCG >5000 mIU/mL, and LDH ≥1.5 upper limit of normal (although most clinicians use ≥3 times in practice) on first day of chemotherapy; any metastasis to organs other than lung (eg, liver or bone) and primary mediastinal nonseminomas considered poor risk

Residual masses: positron emission tomography (PET) yields false positive in 75%; if fluorodeoxyglucose is positive, repeat in ≈2 mo to confirm; however, no reason to perform PET for testis cancer; resection recommended for nonseminomas

Second-line chemotherapy: options include TIP chemotherapy (paclitaxel, ifosfamide, and cisplatin), VIP, and high-dose carboplatin plus etoposide

Readings

Ng K et al: Dose intense chemotherapy in the management of poor prognosis and relapsed testicular cancer: experiences and controversies. Expert Rev Anticancer Ther. 2018 May;18(5):431-436; Paner GP et al: Updates in the eighth edition of the tumor-node-metastasis staging classification for urologic cancers. Eur Urol. 2018 Apr;73(4):560-569; Smith ZL et al: Testicular Cancer: Epidemiology, Diagnosis, and Management. Med Clin North Am. 2018 Mar;102(2):251-264.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose. In his lecture, Dr. Gilligan presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Gilligan was recorded at the 17th Annual Multidisciplinary Genitourinary Oncology Course, held December 14, 2017, in Cleveland, OH, and presented by the Cleveland Clinic Foundation. For information on future CME activities from this sponsor, please visit clevelandclinicmeded.com. The Audio Digest Foundation thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

ON091702

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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