IGCCCG Amsterdam Consensus Meeting

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IGCCCG Amsterdam Consensus Meeting
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(E-) IGCCCG

• A meeting, 1997
• 1st meeting , 2003
• 3 nd meeting , 2006. (EU USA Can)
• Urologists / Oncologists / Radiotherapists /
  Pathologists

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Methodology

• Revision literature since 2004 / EBM
• Comparison , modification previous text
• Consensus
• Redaction Committee
• Document Circulation Corrections

FINAL DOCUMENT
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Guidelines Consensus
Guidelines documents to improve clinical
practice, Gathering the best evidence
available Consensus general agreement
(unanimity). Issues discussed until broad
agreement
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Consensus vs Guidelines

• There is no need for consensus once the evidence
  is high
• What is a high level of evidence ?
• Level 1a _ Systematic Review Metanalysis
• Level 1 b _ Randomized study of good quality
• Observational studies_ Level 3

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Consensus vs Guidelines

• There is no need for consensus once the evidence
  is high
• What is a high level of evidence ?
• Level 1a _ Systematic Review Metanalysis
• Level 1 b _ Randomized study of good quality
• Observational studies_ Level 3

Consensus reserved for those matters with low
level of evidence !
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Diagnosis Staging

• Markers mandatory
• AFP, b-HCG
• LDH in metastatic disease
• Imaging
• Testis US / Chest X-ray
• CT scan abdomen pelvis
• Chest CT scan ( not mandatory in Seminoma Stage
  I)
• MRI chest abdomen if CT contraindicated
• MRI brain and Bone scan if symptoms
• PET scan residual lesion in seminoma ( 3 cm)
• Fertility investigation (offered)

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Treatment of Primary (testicular)

• Radical orchiectomy
• Before any further treatment
• If life threatening situation may be delayed
• Organ preserving (In experienced centres)
• Synchronous bilateral tumor
• Metachronous contralateral
• In solitary testis and sufficient endocrine
  function

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Tin detection Treatment

• Detection
• 9 of all patients
• 34 if testis lt 12 ml and age lt 40 y
• 99 detected biopsy ( double)
• Biopsy recommended if risk factors
• Treatment
• if fertility maintained delay treatment
• if fertility no relevant irradiation (
  20 Gy)
• in extragonadal orchiectomy
• if ChT only treatment if Tin in (re)
  biopsy after ChT

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Classification

• Histological WHO
• Standarized histo-pathological report
• Clinical
• TNM (Serum Tumor Markers S)
• IGCCCG prognostic grouping classification in
  metastatic disease
• Good
• Intermediate
• Poor

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Prognostic Factors (Low volume)

• Seminoma (EBM IIb)
• Size gt 4 cm
• Infiltration rete testis
• Non Seminoma
• Venous or lymphatic infiltration (VI) (EBM IIb)
• No independent in addition to VI
• Proliferation rate
• Embrional carcinoma

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Fertility issues

• Baseline fertility assessment
• (T, LH, FSH, Semen analysis)
• Posibility cryoconservation (EBM IIb IV)
• TESE in Tin or bilateral
• Lifelong Testosterone replacement in bilateral
  orchiectomy
• Depending on levels after unilateral
• Contraception during Chemo / Radio and for 1 year
  after is suggested (EBM III)

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Treatment Seminoma CS I
Or
Either
Surveillance
Adjuvant Carboplatin
Adjuvant Radiotherapy ,20 Gy
Relapse rate 12 -16
Relapse rate 3 - 4
Relapse rate 3 - 4
Risk - adapted approach may be chosen If
limited locoregional relapse Rx or Chx If
extensive locoregional or systemic relapse
Chemotherapy
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Treatment Non Seminoma CS I
High risk Vascular invasion
Low risk No vascular invasion

• Adjuvant chemotherapy
• (2 cycles BEP)
• NS-RPLND or
• Surveillance

• Surveillance
• Adjuvant chemotherapy
• (2 cycles BEP)
• NS-RPLND

Risk adapted treatment should be chosen If
relapse, 3-4 cycles BEP (or VIP) followed by
resection if residual tumor
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Treatment Seminoma CS IIA / B

• Seminoma CS IIA (LN 2 cm)
• Radiotherapy.
• P-A and Ipsilateral iliac ( 30 Gy)
• Seminoma CS IIB (LN 2 -5 cm)
• Radiotherapy (P-A, ipsilateral iliac, 36 Gy)
• Chemotherapy (3 x BEP or 4 x EP)

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Treatment Non Seminoma CS II A / B

• CS IIA, marker
• Chemotherapy ( 3 x BEP)
• If residual tumor resection
• CS IIA, marker -
• NS-RPLND either / or Follow up after 6 weeks
• PS I Follow-up
• PS II A / B Follow-up / 2 x BEP
• Progressive disease .. 3 x BEP , /- / or
  RPLND
• No changes . NS-RPLND
• Regression .. Follow-up

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Treatment Advanced Disease
Good
Intermediate / Poor

• BEP X 4
• (5 days schedule only)
• If conditions against Bleo
• PEI ( VIP)

• BEP x 3 over 5 d
• EP x 4 ( if against Bleo )

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Residual Tumor
Markers normalized Resectable disease
Markers elevated but plateau
Markers increase
Follow-up 4-12 wk
No increase markers
Increase markers
RESECTION
Incomplete resection of viable tumors
Salvage Chemotherapy
Necrosis /Teratoma Complete resection (lt 10
viable)
gt10 viable Tumor cells
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Follow-up

• Aims
• Detection of relapse (including late relapse)
• Diagnosis of second cancers
• Prevention, early diagnosis treatment of
  physical and psychological morbidity related to
  GCC and its therapy

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Follow-up

• Method
• Regular clinical examination
• Monitoring serum markers
• Imaging investigations
• Frequency type (low evidence in general)
• Estimated risks of relapse
• Treatment strategy
• Time elapsed since end of therapy

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Frequency visits Seminoma Stage I

• CT abdomen not recommended in Para- aortic RT

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Controversial / No Consensus

• Risk adapted management in Stage I GCC
• MAY BE chosen in Seminoma
• SHOULD BE chosen in Non Seminoma
• Low stages Seminoma
• Radiation or Surveillance /Chemotherapy as
  primary treatment
• Treatment of metastatic disease
• G-CSF and antibiotics in neutropenia.
• Follow-up
• Scarcety of data but for Seminoma Stage I
• Data of Rustin on Stage I follow-up incorporated
  later

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• More controversial points identified along these
  two days
• Still a long way to reach consensus
• How to integrate individual or country policies
  in such a document ?

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