Stage 2a and 2b NSGCT can refer to nodal disease at presentation, or relapsing nodes on surveillance, or marker negative patients with equivocal imaging findings.
Nodal disease with elevated markers
Chemotherapy – BEP x 3 or EP x 4
Nodal disease with normal markers
Nerve sparing RPLND in experienced centre
Consider observation if < 2 cm or morphologically benign – but operate if fails to resolve or progresses
Positive disease on primary RPLND for stage 1
70 – 80 % are cured, but up to 30 % with develop disease outside retroperitoneum requiring chemo
Can consider adjuvant 2 x BEP, but 70 % are overtreated
Stage 3 / metastatic disease
- Good risk (S0 or S1)
- BEP x 3 or EP x 4
- Intermediate risk (S2)
- BEP x 4 (alternative 4 x VIP)
- Poor risk (S3 / extrapulmonary mets / mediastinal primary)
- BEP x 4 – recheck tumour markers after 1st cycle, and intensify chemo if no marker decline
Residual post-chemo mass in NSGCT
Residual masses after chemo in NSGCT:
10 % cancer
50 % teratoma
40 % fibrosis / necrosis
No current role for FDG-PET.
Re-stage with CT 3-4 weeks after last cycle of chemo. May take a bit of time for masses to shrink. Can continue monitoring until plateaus/stop shrinking (2 monthly CT/markers). (assuming markers zero – if markers not zero, needs ongoing chemo)
Nothing available to accurately predict what mass could be – so resection of all masses > 1 cm is mandatory. Usually aim for surgery 6- 8 weeks after finishing chemo.
If < 1 cm – generally equivocal – usually benign with < 10 % relapsing on surveillance.
Post-chemo surgery is difficult and demanding, and may require radical resection including other organs or great vessels.
After RPLND for post-chemo mass:
- If teratoma, or necrofibrosis – no further treatment required
- If incomplete resection of viable cancer – “consolidation chemo” – 2 adjuvant doses of cisplatin based chemo
- If complete resection of viable cancer and < 10 % of specimen – consolidation chemo generally not used
Salvage chemotherapy:
- Approx 50 % of patients who relapse after first line chemotherapy can get long term remission from salvage chemo
- 4 cycles of cisplatin + ifosfamide + either etoposide, paclitaxel and potentially gemcitabine – no head to head trials
de novo life threatening metastatic disease:
Upfront chemotherapy can be used prior to orchidectomy for patients presenting with high volume metastatic disease and significant compromise i.e. acute respiratory distress from high volume pulmonary metastases.
Brain mets:
- Rare, 1 %
- Choriocarcinomas highly vascular – can bleed during chemo
- 5 year OS for brain mets is 57 % for seminoma, 33 % for NSGCT
- Treat with BEP x 4, then consider resection of residual masses
- The role of radiotherapy is unclear
Mixed seminoma and NSGCT
- Treat essentially as NSGCT