Nonseminomatous testicular cancer

Non-Seminomatous germ cell tumors of the testicle include non-seminoma tumors, mixed seminoma/non-seminoma tumors, and seminoma tumors in patients with elevated serum alpha-fetoprotein.
Assessment for metastatic disease includes CT scans of the abdomen, pelvis and chest.
Pet/CT scans are not clinically indicated for non-seminomatous lesions.
Brain MRI‘s are indicated for patients with neurologic symptoms, post orchiectomy serum beta hCG levels of greater than 5000 international units/L  or AFP greater than 10,000 ng per ml , non-pulmonary visceral metastases or extensive lung metastases.
Patients with elevated levels of serum beta hCG, LDH, or AFP are followed with repeated tests for a treatment decisions.

Twenty-five to 30% of patients with clinical stage I disease have occult lymph node metastases.

As many as 20% of patients with suspicious findings on CT scan have pathologically stage I disease.

Cure rates for clinical stage I and low-volume stage II testis tumor patients approach 100%.

Most patients with clinical stage I disease can be cured with orchidectomy alone.

5 year survival rates exceed 97%.

Improved prognosis due to cisplatin-based chemotherapy.

For stage I disease retroperitoneal lymph node dissection followed by adjuvant chemotherapy, if metastases are present or initial surveillance followed by chemotherapy for relapse result in long-term survival rates of 98-99%.

Patients with stage I nonseminoma with normal post orchiectomy serum AFP and beta hCG levels have three management options after orchiectomy: surveillance, nerve sparing or PLND, or chemotherapy.

Survival for patients with stage I non-seminoma without risk factors managed by surveillance, nerve sparing RPLND or one cycle of BEP (bleomycin , etoposide and cisplatin) exceed 98%.

Surveillance is the preferred option for patients with pN1 disease and chemotherapy is the preferred option for patients with pN2 disease.

Chemotherapy is the only option for patients with pN3 disease.

Predictors for occult metastases are the presence of vascular invasion, high proliferative activity and increasing percentage of embryonal carcinoma.

5 year actuarial risk of cardiovascular death after a myocardial infarction is 35.8% in long term survivors.

Prior mediastinal radiation, Platinum, Velban, Bleomycin chemotherapy regimen and recent smoking history important risk factors for cardiovascular disease.

Treatment options after inguinal orchiectomy for stage I disease include: surveillance, systemic therapy, and retroperitoneal lymph node dissection (RPLND).

The major morbidity associated with bilateral RPLND is retrograde ejaculation, resulting in infertility.

Nerve sparing dissection techniques preserve integrated ejaculation in 90% of cases and is recommended.

Stage II disease may be treated with systemic therapy or RPLND: systemic therapy is preferred if serum tumor markers are elevated and or if enlarged lymph nodes or greater than 3 cm in greatest dimension.

RPLND is preferred if primary treatment of stage I or II tumors with transformed teratoma and should be considered for stage II tumors with teratoma predominance if serum tumor markers are normal.

Stage II in stage III disease treated with systemic therapy should be followed by surgical resection of any residual masses.

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