San Antonio, Texas USA (UroToday.com) In this session, Dr. Feldman used a case-based format to discuss the common pitfalls in the medical management of germ cell tumors. He divided his talk into early germ cell tumors (GCT) and advanced GCT. In the early GCT space, he first discussed the importance of tumor marker timing.
Systemic treatment decisions ought to be based on post-orchiectomy markers. Next, he addressed the approach to borderline enlarged retroperitoneal lymph nodes with normal tumor marker levels and advocated against rushing immediately to surgery. He prefers short interval imaging (6-8 weeks) in these patients which better differentiates those who will need surgery from those who will not. Third, he touched on situations in which a falsely elevated beta-HCG may occur (low testosterone levels or marijuana use) and noted that borderline elevated AFP levels may be normal in some patients. Finally, he reminded the audience to offer referral to sperm baking prior to active treatment in these men.
With regard to advanced GCT, he again emphasized the importance of treating based on post-orchiectomy markers. The International Germ Cell Cancer Collaborative Group (IGCCCG) risk classifications are also done at the time of post-orchiectomy nadir. Next, he presented a case in which PET scanning was used prior to referral to his center in the post-chemotherapy residual mass setting for non-seminomatous germ cell tumors. This is not the correct management since teratoma is not PET avid. The take-home here is that residual postchemotherapy lymphadenopathy in the presence of negative markers in non-seminomatous disease should be referred for surgery. Third, Dr. Feldman cited a paper from Dr. Einhorn’s group in Indiana noting the importance of allowing time for very high beta HCG levels to nadir. Close follow-up rather than salvage treatment should be employed in this setting. Other clinical pearls for the medical oncology audience are the importance of not substituting carboplatinum for cisplatin and maintaining correct dosing. Finally, Dr. Feldman encouraged the audience to refer difficult cases to major centers citing data that outcomes are better in high volume centers for poor risk GCTs. He closed by suggesting that “the rarer and highly curable a cancer when treated correctly, the greater the potential benefit for referral.”
Presented By: Darren R. Feldman
Written By: Benjamin T. Ristau, MD, Society of Urologic Oncology Fellow, Fox Chase Cancer Center
17th Annual Meeting of the Society of Urologic Oncology - November 30 -December 2, 2016 – San Antonio, Texas USA