Germ cell tumor

Germ Cell Tumors

Germ Cell Tumor Part 1

What is the treatment for stage I seminoma ?

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Radical orchiectomy with or without adjuvant carboplatinum or radiotherapy to the pelvic lymph nodes

Germ Cell Tumor Part 1
Germ Cell Tumor

What defiance poor risk in seminoma?

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Nothing

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Germ Cell Tumor

What defines intermediate risk in non-seminoma?

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Testes, retroperitoneal primary disease
No pulmonary metastases
S2

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Germ Cell Tumor

Which germ cell tumor is highly sensitive to radiotherapy?

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Seminoma

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Germ Cell Tumor

What is the diagnosis of a nonseminomatous mass that grows during chemotherapy?

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Growing teratoma syndrome – chemotherapy resistant disease

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Germ Cell Tumor

What is the only feature that makes a seminoma intermediate risk?

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Non-pulmonary visceral metastases

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Germ Cell Tumor

What is the definition of platinum-refractory testicular germ cell tumor ?

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Relapsed after second line treatment
Refractory – growth within one month of platinum based chemotherapy

Germ Cell Tumor
Germ Cell Tumor

What is known about the alpha and beta subunits of hCG?

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Alpha has high homology with TSH, LH, and FSH
Beta subunit is used for diagnosis
Very high levels of beta-hCG can be seen in hyperthyroid cases

Germ Cell Tumor
Germ Cell Tumor

Which histology for germ cell tumors looks like a fried egg?

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Seminoma

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Germ Cell Tumor

What size cut off is used on PET scan for posttreatment masses in seminoma?

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3 cm

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Germ Cell Tumor

What is recommended for posttreatment masses in seminomas?

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PET scan to determine if they should be resected if any residual disease is seen on biopsy – if so, give 2 more cycles of chemotherapy

Germ Cell Tumor
Germ Cell Tumor

What diagnosis should you consider for late relapse nonseminomatous germ cell tumor or primary platinum-refractory tumors that grow during chemo for nonseminomatous germ cell tumor with low tumor markers ?

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Teratoma

Germ Cell Tumor
Germ Cell Tumor

Which chemotherapy agents are active in relapsed / refractory testicular germ cell tumors?

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Cis-platinum, ifosfamide, vinblastine, paclitaxel, gemcitabine, oxaliplatin, bleomycin

Germ Cell Tumor
Germ Cell Tumor

What are ways to quickly stage germ cell tumors?

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Stage I testes only and S0
Stage II retroperitoneal lymph nodes or S1
Stage III non-retroperitoneal lymph nodes or extra lymph node metastases or S2 / S3

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Germ Cell Tumor

What are the 4 different histologic subtypes of nonseminomatous germ cell tumor ?

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Yolks act tumor, choriocarcinoma, embryonal carcinoma, teratoma

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Germ Cell Tumor

What is the pattern of metastatic spread for seminomas?

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Lymphatic

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Germ Cell Tumor

What should be avoided for primary mediastinal germ cell tumor?

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Bleomycin, consider the VIP regimen

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Germ Cell Tumor

For testicular germ cell tumor patients treated with VIP, what second line chemotherapy can be offered?

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Autologous stem cell transplant or cisplatin / vinblastine / bleomycin (PVB regimen)

Chemotherapy with gemcitabine or oxaliplatin

Germ Cell Tumor
Germ Cell Tumor

What are germ cell tumors in women called?

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Dysgerminoma

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Germ Cell Tumor

Which histologic subtypes of testicular germ cell tumor are brain metastases most common with?

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Choriocarcinoma

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Germ Cell Tumor

What is the difference in treatment between seminoma and nonseminomatous metastatic germ cell tumors?

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No difference

Germ Cell Tumor
Germ Cell Tumor

What is the management recommendation for posttreatment residual masses in nonseminomatous germ cell tumors?

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Retroperitoneal lymph node dissection if the lesion is larger than 1 cm

Germ Cell Tumor
Germ Cell Tumor

How will salvage treatment be different for relapsed testicular germ cell tumors that are early versus late?

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Early recommend autologous stem cell transplant
Late VIP regimen versus autologous stem cell transplant

Germ Cell Tumor
Germ Cell Tumor

Where are the 3 most common extragonadal sites for germ cell tumor?

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Mediastinum, retroperitoneum, suprasellar pineal gland

Germ Cell Tumor
Germ Cell Tumor

What is the only time we consider PET scan surveillance for testicular germ cell tumor ?

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Men with seminoma
PET scan not recommended for nonseminomatous germ cell tumor because any positive mass must be resected whether or not it is PET avid

Germ Cell Tumor
Germ Cell Tumor

What time course distinguishes early versus late relapse testicular germ cell tumor?

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6 months

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Germ Cell Tumor

What is a treatment option for a patient with mediastinal seminoma, good and intermediate risk?

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Good risk- BEP for 3 cycles or EP for 4 cycles
Intermediate and poor risk – BEP for 4 cycles or VIP
Radiotherapy can be considered if patient is not a good chemotherapy candidate

Germ Cell Tumor
Germ Cell Tumor

Does left or right sided testicle cancer drain to the para-aortic lymph nodes?

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Left-sided

Germ Cell Tumor
Germ Cell Tumor

Which germ cell tumor is more common in HIV?

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Seminoma

Germ Cell Tumor
Germ Cell Tumor

Which patients with mediastinal seminoma should avoid bleomycin / etoposide / cisplatin ?

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Patients older than 50, underlying lung disease, history of radiotherapy to the chest

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germ Cell Tumor

What defines intermediate risk in non-seminoma?

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Testes, retroperitoneal primary disease
No pulmonary metastases
S2

germ Cell Tumor
Germ Cell Tumor

What are 3 high-risk features of nonseminomatous germ cell tumor?

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Lymphovascular invasion or embryonal carcinoma components, T3 primary tumor, T4 primary tumor

Germ Cell Tumor
Germ Cell Tumor

What is a treatment for stage II seminoma ?

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Platinum based chemotherapy or radiotherapy

Germ Cell Tumor
Germ Cell Tumor

What is the adjuvant carboplatin dose for stage I seminoma?

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Carboplatinum AUC = 7

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Germ Cell Tumor

What are the treatment options for stage I nonseminomatous germ cell tumor with high-risk features?

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Retroperitoneal lymph node dissection and bleomycin / etoposide / cis-platinum

Germ Cell Tumor
Germ Cell Tumor

What are 2 main contraindications for adjuvant radiotherapy in stage I seminoma?

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Horseshoe kidney and inflammatory bowel disease

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Germ Cell Tumor

What defines poor risk nonseminomatous germ cell tumor?

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Primary mediastinal disease, the presence of non-pulmonary metastases, S3 disease

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Germ Cell Tumor

Which germ cell tumors are more indolent?

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Seminoma

Germ Cell Tumor
Germ Cell Tumor

When is the only time you give carboplatinum for germ cell tumors?

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Seminoma stage I

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Germ Cell Tumor

Which nonseminomatous germ cell tumor histology is most concerning ?

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Embryonal components , need adjuvant treatment such as retroperitoneal lymph node dissection versus chemotherapy with BEP

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Germ Cell Tumor

When is the only time you give 4 cycles of BEP?

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Intermediate or poor risk disease

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Germ Cell Tumor

What are the treatment options for good versus intermediate or poor risk germ cell tumor ?

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BEP for 3 cycles good risk
BEP for 4 cycles intermediate and poor risk

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Germ Cell Tumor

Where is the most common location for a late relapse in testicular cancer?

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Retroperitoneum

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Germ Cell Tumor

What defines bulky disease for stage II seminoma?

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Lymph nodes greater than or equal to 3 cm

Germ Cell Tumor
Germ Cell Tumor

What can you offer after relapsed refractory testicular germ cell tumor that are platinum refractory?

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Autologous stem cell transplant

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Germ Cell Tumor

What are the 2 most important features on histology for germ cell tumor?

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Presence of lymphovascular invasion or embryonal components

Germ Cell Tumor
Germ Cell Tumor

List of primary differences between adjuvant treatment for seminomatous versus nonseminomatous germ cell tumor?

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Seminoma radiotherapy or carboplatinum
Nonseminomatous germ cell tumor retroperitoneal lymph node dissection or BEP chemotherapy

Germ Cell Tumor
Germ Cell Tumor

Which chemotherapy regimens are recommended for early relapse germ cell tumor?

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VeIP, TIP, VIP , VIP preferred is no prior exposure to etoposide

Germ Cell Tumor
Germ Cell Tumor

What 2 things must be done for mediastinal nonseminomatous germ cell tumor?

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VIP regimen for 4 cycles and surgery

Germ Cell Tumor
Germ Cell Tumor Part 2

Germ Cell Tumor Part 2

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Germ Cell Tumor Part 2

Germ Cell Tumor Part 2
Germ Cell Tumors

When is neutropenia alone an indication to dose reduce or delays cycle of chemotherapy for testicular cancer?

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Only if it was coupled with fevers

Germ Cell Tumors
Germ Cell Tumors

Which 2 types of lung injury can occur with bleomycin?

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Pneumonitis and pulmonary fibrosis

Germ Cell Tumors
Germ Cell Tumors

How much of a cumulative dose of bleomycin is required before the risk of pulmonary toxicity starts to significantly increase?

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450 units

Germ Cell Tumors
Germ Cell Tumors

What are the main risk factors that predict for bleomycin lung toxicity?

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Advancing age/kidney dysfunction/prior history of thoracic radiotherapy

Germ Cell Tumors
Germ Cell Tumors

What is the mortality associated with pulmonary fibrosis from bleomycin?

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Approximately 50%

Germ Cell Tumors
Germ Cell Tumors

What signs and symptoms may suggest lung toxicity from bleomycin?

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Nonproductive cough/crackles/exertional dyspnea

Germ Cell Tumors
Germ Cell Tumors

Has cisplatin been associated with lung toxicity in testicular cancer patients?

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Yes -restrictive lung changes can be seen above a cumulative dose of 850 mg

Germ Cell Tumors
Germ Cell Tumors

Which anesthesia associated complication can be seen in testicular cancer patients exposed to bleomycin?

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Adult respiratory distress syndrome

Germ Cell Tumors
Germ Cell Tumors

Which 2 major electrolytes can be wasted as a result of cisplatin induced nephrotoxicity?

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Magnesium and phosphorus

Germ Cell Tumors
Germ Cell Tumors

How can bleomycin induced lung injury to be minimized?

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Minimizing exposure to high levels of oxygen and avoiding volume overload

Germ Cell Tumors
Germ Cell Tumors

Have inferior outcomes been demonstrated when cisplatin is substituted for carboplatinum when treating testicular cancer?

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Yes

Germ Cell Tumors
Germ Cell Tumors

Which chemotherapy agents utilized in testicular cancer can lead to drug-induced thrombotic microangiopathy?

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Cisplatin as well as bleomycin and vinblastine

Germ Cell Tumors
Germ Cell Tumors

When does spermatogenesis mostly recover in patients exposed to 3 or more cycles of BEP ?

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3 years

Germ Cell Tumors
Germ Cell Tumors

Does chemotherapy treatment in patients with testicular cancer resulted in lower testosterone levels?

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Yes – up to 5-fold likelihood of having reductions in testosterone levels

Germ Cell Tumors
Germ Cell Tumors

Which surgical intervention has resulted in ejaculatory dysfunction in patients with testicular cancer?

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Retroperitoneal lymph node dissection

Germ Cell Tumors
Germ Cell Tumors

What metabolic abnormalities can occur in patients exposed to cisplatin?

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Dyslipidemia as well as the metabolic syndrome

Germ Cell Tumors
Germ Cell Tumors

What cardiovascular complications can occur as a result of cisplatin therapy for testicular cancer?

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Coronary artery disease as a result of atherosclerosis

Germ Cell Tumors
Germ Cell Tumors

What are the 2 major contributors to cardiovascular disease in patients with testicular cancer?

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Cisplatin exposure as well as mediastinal radiotherapy

Germ Cell Tumors
Germ Cell Tumors

Which chemotherapy agent utilized in testicular cancer can lead to hypertension?

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Cisplatin

Germ Cell Tumors
Germ Cell Tumors

Which vascular phenomenon can result from bleomycin and cisplatin exposure?

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Raynaud’s phenomenon

Germ Cell Tumors
Germ Cell Tumors

Is proprioception affected by cisplatin in testicular cancer patients?

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Yes

Germ Cell Tumors
Germ Cell Tumors

What are the 2 types of ototoxicity seen with cisplatin therapy?

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Sensorineural hearing loss and tinnitus

Germ Cell Tumors
Germ Cell Tumors

How common is audiometric hearing loss in patients exposed to cisplatin therapy for testicular cancer?

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90%

Germ Cell Tumors
Germ Cell Tumors

How common is the lifetime risk of developing a solid tumor in seminoma patients?

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Up to 36% by age 75

Germ Cell Tumors
Germ Cell Tumors

What is the most common solid tumor in testicular cancer patients?

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Lung cancer

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Germ Cell Tumors

Which chemotherapeutic agent utilized commonly for testicular cancer predisposes patients to secondary myelogenous leukemia?

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Etoposide as characterized by chromosome 11 (11q23) translocation

Germ Cell Tumors
Germ Cell Tumor Part 2

Germ Cell Tumor Part 2

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Germ Cell Tumor Part 2

Germ Cell Tumor Part 2
Germ Cell Tumor Part 2

Which disease occurs with primary mediastinal nonseminomatous germ cell tumor?

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M7 AML, myelodysplastic syndrome, malignant mastocytosis, malignant histiocytosis

Germ Cell Tumor Part 2
Germ Cell Tumor

What are the 4 types of nonseminomatous germ cell tumor?

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Yolk sac tumor, choriocarcinoma, embryonal carcinoma, teratoma

Germ Cell Tumor
Germ Cell Tumor

What is first line chemotherapy for nonseminomatous mediastinal germ cell tumor?

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VIP for 4 cycles

Germ Cell Tumor
Germ Cell Tumor

What is first line chemotherapy for nonseminomatous mediastinal germ cell tumor?

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VIP for 4 cycles

Germ Cell Tumor
Germ Cell Tumor

Why is bleomycin /etoposide /cis-platinum avoided in mediastinal nonseminomatous germ cell tumor?

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Because high percentage of patients will go on to have surgery and this increases the risk of bleomycin associated toxicity

Germ Cell Tumor
Germ Cell Tumor

What is the primary treatment for mediastinal immature teratoma?

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VIP plus surgery

Germ Cell Tumor
Germ Cell Tumor

What 2 things must be done for mediastinal nonseminomatous germ cell tumor?

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VIP regimen for 4 cycles and surgery

Germ Cell Tumor
Germ Cell Tumor

Which disease occurs with primary mediastinal nonseminomatous germ cell tumor?

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M7 AML, myelodysplastic syndrome, malignant mastocytosis, malignant histiocytosis

Germ Cell Tumor
Germ Cell Tumor

What are the 4 types of nonseminomatous germ cell tumor?

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Yolks sac tumor, choriocarcinoma, embryonal carcinoma, teratoma

Germ Cell Tumor
Germ Cell Tumor

What is the approach to relapsed testicular germ cell tumor with brain metastases?

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Chemotherapy followed by surgery or surgery to a single metastatic lesion followed by adjuvant chemotherapy

Germ Cell Tumor
Germ Cell Tumor

What is the half-life for alpha-fetoprotein?

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7 Days

Germ Cell Tumor
Germ Cell Tumor

By definition what is a pure seminoma?

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Alpha-fetoprotein within normal limits
No evidence of non-seminoma component on histology

Germ Cell Tumor
Germ Cell Tumor

What is a normal alpha-fetoprotein cut-off for testicular germ cell tumor?

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Normal is less than or equal to 20

Germ Cell Tumor
Germ Cell Tumor

What does an extremely elevated beta hCG suggest during a diagnosis of testicular germ cell tumor?

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Choriocarcinoma

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Germ Cell Tumor

Which tumor marker is least important to trend for NSCGCT and SGCT?

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Lactate dehydrogenase

Germ Cell Tumor
Germ Cell Tumor

What is the stage of mediastinal nonseminomatous germ cell tumor with no distant metastases?

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Stage IIIc

Germ Cell Tumor
Germ Cell Tumor

What are some poor risk features of a nonseminomatous germ cell tumor?

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Primary mediastinal disease with or without metastases, metastases besides the lung, pelvic lymph nodes, alpha-fetoprotein greater than 10,000, beta hCG greater than 50,000, LDH greater than 10 times the upper limit of normal

Germ Cell Tumor
Germ Cell Tumor

Involvement of which lymph node stations for testicular germ cell tumor changes the staging from stage II to stage III?

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Stage II retroperitoneal lymph nodes
Stage III pelvic lymph nodes

Germ Cell Tumor
Germ Cell Tumor

What defines poor risk testicular germ cell tumor?

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Primary mediastinal GCT, S3, non-lung metastases

Germ Cell Tumor
Germ Cell Tumor

What defines poor risk testicular germ cell tumor?

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Primary mediastinal GCT, S3, non-lung metastases

Germ Cell Tumor
Germ Cell Tumor

What are 3 postoperative adjuvant management options for stage I seminoma?

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Carboplatinum, radiotherapy to retroperitoneal lymph nodes, observation

Germ Cell Tumor
Germ Cell Tumor

What is the typical adjuvant carboplatinum dose for stage I seminoma?

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Area under the curve = 7 x 2 doses

Germ Cell Tumor
Germ Cell Tumor

Which 3 tissues do you see extranodal germ cell tumors in?

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Pineal gland, mediastinum, sacrum

Germ Cell Tumor
Germ Cell Tumor

Why do teratomas need to be resected in nonseminomatous germ cell tumors ?

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They can have dedifferentiated features

Germ Cell Tumor
Germ Cell Tumor

Which cytogenetic abnormality is seen in primary mediastinal nonseminomatous germ cell tumor with associated hematologic malignancy?

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Isochrome 12p

Germ Cell Tumor
Germ Cell Tumor

In patients with stage II or stage III seminoma, what are the different chemotherapy options ?

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Good risk – etoposide plus cisplatin for 4 cycles or bleomycin etoposide cisplatin for 3 cycles
Poor risk – bleomycin etoposide cisplatin for 4 cycles

Germ Cell Tumor
Germ Cell Tumor

When would you consider using the VIP chemotherapy regimen for testicular cancer?

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Intermediate or poor risk or relapsed disease

Germ Cell Tumor
Germ Cell Tumor

Which situation for non-seminomatous germ cell tumor is the only time when active surveillance is appropriate?

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Stage I without high risk features

Germ Cell Tumor
Germ Cell Tumor

Which testicular cancer is stage I in 80% of new diagnoses?

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Seminoma

Germ Cell Tumor
Germ Cell Tumor

What is the primary treatment for mature mediastinal teratoma?

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Surgery

Germ Cell Tumor
Germ Cell Tumor

What is the only feature of seminoma that changes patients from good-risk to intermediate-risk?

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Presence of non-lung or lymph node metastases

Germ Cell Tumor
Germ Cell Tumor

What is the primary treatment for brain metastases from testicular cancer?

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Chemotherapy but also consider radiotherapy and surgery

Germ Cell Tumor
Germ Cell Tumor

Within how many years do most relapses occur?

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2 years

Germ Cell Tumor
Germ Cell Tumor

Which testicular germ cell tumor is hypoechoic on scrotal ultrasound without a cystic component ?

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Seminoma

Germ Cell Tumor
Germ Cell Tumor

What scans should be completed during testicular cancer workup?

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CT scan of the abdomen and pelvis, chest x-ray

Germ Cell Tumor
Germ Cell Tumor

What salvage chemotherapy can be offered relapsed non-seminomatous testicular germ cell tumor?

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VIP

Germ Cell Tumor
Germ Cell Tumor

What is the management for non-seminomatous germ cell tumor when tumor markers don’t return to normal status post chemotherapy?

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Retroperitoneal lymph node dissection versus very close surveillance or tumor markers

Germ Cell Tumor
Germ Cell Tumor

With tissues are involved in T3 and T4 testicular cancer?

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T3 spermatic cord
T4 scrotum

Germ Cell Tumor
Germ Cell Tumor

Prior to doing any intervention for testicular germ cell tumor, with discussion should be had with men?

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Sperm banking

Germ Cell Tumor
Germ Cell Tumor

Which genetic syndrome has a correlation with testicular germ cell tumor?

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Klinefelter syndrome, primary mediastinal

Germ Cell Tumor
Germ Cell Tumor

Which cytogenetic changes are seen with testicular germ cell tumors?

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Isochrome 12p

Germ Cell Tumor
Germ Cell Tumor

Which organ clears bleomycin ?

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Kidney

Germ Cell Tumor
Germ Cell Tumor

What constitutes S1, S2, S3 staging for testicular germ cell tumor?

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S0 – all tumor markers within normal limits
S1 – LDH up to 1.5 x ULN, alpha-fetoprotein up to 1,000, Beta-HCG up to 5,000
S2 – LDH between 1.5-10x ULN , AFP between 1,000-10,000, Beta-HCG 5,000-50,000

Germ Cell Tumor
Germ Cell Tumor

When can contralateral testicle biopsy be performed for testicular germ cell tumor?

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Never

Germ Cell Tumor
Germ Cell Tumor

What is not an option for stage I seminoma in the adjuvant setting?

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Retroperitoneal lymph node dissection

Germ Cell Tumor
Germ Cell Tumor

What is the danger with testicular germ cell tumor brain metastases?

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Spontaneous bleeding with or without chemotherapy

Germ Cell Tumor
Germ Cell Tumor

Which chemotherapy regimen is best for testicular germ cell tumor brain metastases?

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Either BEP or VIP

Germ Cell Tumor
Germ Cell Tumor

How do you treat residual testicular germ cell tumor brain metastases after completing chemotherapy?

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Surgery or radiotherapy
Consider stereotactic XRT for isolated mets versus whole brain for a high number of metastases

Germ Cell Tumor
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