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Câncer de Testículo

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Câncer de Testículo

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Câncer de Testículo

  1. 1. CANCER DE TESTICULO<br />Lucas Nogueira<br />Abril 2010 <br />
  2. 2. INCIDÊNCIA<br />Neoplasia mais freqüente em homens com idade inferior a 45 anos.<br />Compõem cerca de 1% a 1,5% dos tumores do sexo masculino e cerca de 5% de todos os tumores urológicos.<br /> Incidência de cerca de três a seis casos para cada 100.000 homens / ano na sociedade oriental.<br />
  3. 3. Number of new cases and age-standardised* incidence rates for testicular cancer, Great Britain, 1975–2003<br />
  4. 4. Age-standardised* incidence and mortality rates for testicular cancer, Great Britain, 1975–2004<br />
  5. 5. Number of new cases and age-specific incidence rates for testicular cancer, UK, 2003<br />
  6. 6. PATHOGENESIS<br /><ul><li>Race
  7. 7. Socioeconomic class/occupation
  8. 8. Infertility
  9. 9. Cryptorchidism
  10. 10. High levels of maternal estrogens
  11. 11. Low and high birth weights
  12. 12. Neonatal jaundice</li></li></ul><li>Origem<br />Tumoresoriginados das célulasgerminativas (espermatogônia)<br />70%apresentamalterações no chromossomo12p (i12p)<br />Predictable differentiation pathway<br />
  13. 13.
  14. 14. GERM CELL TUMORS:WHO CLASSIFICATION<br />Tumors of one histologic type:<br />Seminoma<br />SpermatocyticSeminoma<br />Embryonal Carcinoma<br /> Yolk Sac Tumor<br />Polyembryoma<br />Choriocarcinoma (and variants)<br />Teratoma<br /> - with “secondary somatic malignancy”<br />Tumors of more than one histologictype<br />
  15. 15. Incidence<br />Teratomas and yolk sac tumors in neonates and infants<br /> - 0.12 per 100,000<br />Seminomas and mixed GCT occurring after puberty<br /> - 6.0 per 100,000<br />Spermatocytic Seminoma in older males<br /> - 0.2 per 100,000<br />
  16. 16. FREQUENCY OF HISTOLOGIC TYPES OF TESTICULAR GERM CELL TUMORS<br />Pure histology%<br />Seminoma 26.9<br />Spermatocytic2.4<br />Emb Ca 3.1<br />Yolk Sac Tumor2.4<br />Teratoma 2.7<br />Choriocarcinoma 0.1<br />ITGCN 0.6<br />Mostofiet al, 1987<br />Mixed histology%<br />EC + YST + T + SCT 14.3<br />Seminoma + SCT 8.2<br />ECA + YST + T + S + SCT 7.4<br />ECA + YST + Teratoma 4.7<br />YST + Teratoma2.5<br />ECA + Teratoma1.4<br />Other combinations 24.0<br />
  17. 17. TESTICULAR GERM CELL TUMORSHISTOGENESIS<br />Itu<br />YST<br />YST<br />Itu<br />S<br />S+<br />AFP<br />EC+<br />AFP<br />M Ter<br />Germ<br />Cell<br />IGCNU<br />S<br />S+<br />ECD<br />EC<br />I Ter<br />Itu<br />EC<br />EC+<br />STGC<br />S+<br />STGC<br />Itu<br />Troph<br />CC<br />
  18. 18. Tumor Markers<br />Human Chorionic Gonadotropin (HCG)<br />Trophoblastic origin<br />Alpha-Fetoprotein (AFP)<br />Yolk Sac origin<br />Lactic Acid Dehydrogenase (LDH)<br />Corresponds to tumor bulk<br />
  19. 19. FIVE YEAR SURVIVAL FOR PATIENTS WITH SEMINOMA<br />HistologyStage IStage IIStage III<br />Classical 68/71 (95%) 11/19 (58%) 3/6 (50%)<br />Anaplastic 11/11 (100%) 7/11 (64%) 2/3 (68%)<br />Cockburn et al.<br />
  20. 20. NONSEMINOMATOUS GERM CELL TUMORS OF THE TESTIS<br />Pathologic risk factors for relapse:<br /><ul><li> vascular invasion
  21. 21. predominant embryonal carcinoma (>80%) histology</li></li></ul><li>VASCULAR INVASION VERSUS TUMOR RECURRENCE<br /> VI + VI - P<br /> Local Pathology 12/34 (35%) 51/268 (19%) <0.05<br /> Central Pathology 52/125 (42%) 16/199 (8%) <0.001<br />TCIS. JCO 1992; 10:69.<br />
  22. 22. Exploração Inicial<br />Todo paciente com massa testicular suspeita, deve ser submetido à exploração cirúrgica por via inguinal com exteriorização do testículo .<br />Orquiectomia com ressecção do epidídimo e todo o cordão espermático deve ser realizada se tumor for encontrado.<br />Se houver dúvida diagnóstica, biopsia testicular pode ser realizada através de congelação<br />Richie JP et al, 2002<br />
  23. 23. Primary Tumor<br />Radical Inguinal Orchiectomy<br />high ligation of the spermatic cord<br />Transscrotal Approach<br />2.9% vs 0.4% local recurrence rate<br />
  24. 24. Estadiamento<br />
  25. 25. Estadiamento<br />
  26. 26. Estadiamento<br />
  27. 27. Estadiamento<br />
  28. 28. Estadiamento<br />
  29. 29. Estadiamento<br />
  30. 30. Estadiamento<br />
  31. 31. GruposPrognósticos<br />
  32. 32. Prognóstico Intermediário<br />
  33. 33. Prognóstico Ruim<br />
  34. 34. Estadio I – Fatores Prognósticos<br />Seminoma<br />tamanho do tumor (> 4 cm)<br />invasão de retetestis. <br />Não seminomatosos<br />Infiltração vascular / linfática <br />carcinoma embrionário (acima de 50%)<br />estádio patológico (pT >2)<br />marcadores tumorais elevados<br />ausência de teratoma maduro ou tumor de saco vitelino<br />idade avançada do paciente.<br />
  35. 35. Seminoma<br />
  36. 36. Seminoma EC1<br />Aproximadamente 70%<br />20% recorrência em 5 ano<br />Tratamento adjuvante (fatores prognósticos):<br />vigilância ativa<br />radioterapia linfonodalretroperitonial (RXT)<br />quimioterapia (QT). <br />O prognóstico é excelente, com taxas de sobrevida livre da doença em longo prazo próximas de 100%<br />
  37. 37. Seminoma EC1<br />Vigilância Ativa<br />20% recorrência em 5 ano<br />Alta eficácia da RTx ou QTx em caso de recorrência<br />Seguimento rigoroso através de TC, Rx tórax e marcadores<br />Baixo índice de aderência<br />Exposição a radiação<br />
  38. 38. Seminoma EC1<br />Vigilância Ativa<br /><ul><li>Follow-up schedule
  39. 39. PE, CXR, STM
  40. 40. Monthlyx1 year,
  41. 41. 2 months x 2 years,
  42. 42. 3 months x 3 years,
  43. 43. Annually
  44. 44. CT AP
  45. 45. q4 months x 2 years, then annually</li></li></ul><li>Seminoma EC1<br />Radioterapia<br />Região para-aórtica e inclusão dos linfonodos ilíacos ipsilaterais(20-24 Gy) <br />Taxa de recorrência de apenas 1 a 3% em cinco anos, sendo que quase a totalidade das recorrências ocorre fora do campo irradiado.<br />Seguimento rigoroso através de TC, Rx tórax e marcadores<br />A não inclusão dos linfonodos ilíacos associada à diminuição dos efeitos colaterais, porém com aumento de 2% da taxa de recorrência.<br />
  46. 46. Seminoma EC1<br />Linfadenectomia Retroperitonial<br />Não há recomendação para esta modalidade em paciente neste estádio clínico. <br /> <br />
  47. 47. Seminoma EC1<br />Quimioterapia<br />Quimioterapia com dose única de carboplatina é um tratamento alternativo à vigilância ativa e à radioterapia em pacientes com seminoma EC I (risco intermediário).<br />Estudos recentes mostraram vantagem no uso de 2 ciclos de carboplastina em relação às outras modalidades, mas resultados em longo prazo ainda são necessários para sua indicação<br />
  48. 48. Seminoma EC IIAB<br />N1 – menos de 5 linfonodos, < 2cm<br />N2 <br />Mais de 5 linfonodos, < 2 cm<br />Linfonodos entre 2 e 5 cm<br />Evidência de extensão extra-gonadal<br />S0 ou S1<br />
  49. 49. Seminoma EC IIAB<br />Vigilância Ativa<br />Não há indicação neste grupo<br />
  50. 50. Seminoma EC IIAB<br />Radioterapia Adjuvante<br />Dose de 30 a 36 Gy, incluindo além da região para-aórtica, a região ilíaca ipsilateral.<br />No EC IIB, as margens laterais devem se estender por 1,5 cm além dos linfonodos acometidos.<br />Taxas de recorrência em 6 anos para estádios IIA e IIB de 5% e 11%, respectivamente; sobrevida global no período próxima a 100% <br />
  51. 51. Seminoma EC IIAB<br />Radioterapia Adjuvante<br />Recorrência: Qtx de salvação conforme grupos de risco.<br />Bom prognóstico: <br />3 ciclos de BEP.<br />Se há contra-indicação à bleomicina, o esquema com 4 ciclos de EP pode ser utilizado.<br />Risco intermediário:<br />4 ciclos de BEP <br />
  52. 52. Seminoma EC IIAB<br />Quimioterapia Adjuvante<br />Esquema de preferência no EC IIB<br />Esquemas (mesma eficácia):<br />4 ciclos de etoposide e cisplastina (EP)<br />3 ciclos de etoposide, cisplastina e bleomicina (BEP) em pacientes com bom prognóstico. <br />
  53. 53. Seminoma EC IIc, III e Extra-gonadal<br />N3 – linfonodos > 5 cm<br />M+ <br />S2 / S3<br />
  54. 54. Seminoma EC IIc, III e Extra-gonadal<br />Quimioterapia Adjuvante<br />Tratamento de escolha<br />Esquemas (grupos de risco)<br />Bom prognóstico: <br />3 ciclos de BEP. <br />Se há contra-indicação à bleomicina, o esquema com 4 ciclos de EP pode ser utilizado.<br />Risco intermediário:<br />4 ciclos de BEP <br />
  55. 55. Massas residuais após quimioterapia<br />Abordagem controversa<br />Características – MR seminoma:<br />Rara possibilidade de presença de tumor viável e teratoma.<br />Obliteração dos planos de ressecção decorrente da reação desmoplástica intensa induzida pela quimioterapia - LNRP<br />
  56. 56. Massas residuais após quimioterapia<br />Massas residuais menores que 3 cm, um mês ou mais após o término da QT, devem ser observadas.<br />Maiores 3 cm -PET scan (FDG-PET) apresenta alto valor preditivo positivo.<br />Sugestão de viabilidadetumoral:<br />Observação - se houver crescimento da massa, quimioterapia ou radioterapia de salvação podem ser utilizados.<br />
  57. 57. Massas residuais após quimioterapia<br />Evidências de viabilidadetumoral:<br />Observação – se crescimento da massa, quimioterapia ou radioterapia de salvação podem ser utilizados.<br />Linfadenectomia Retroperitonial de Resgate (LNRPR) – com ressecção total da massa.<br />Se tumor viável: quimioterapia ou radioterapia de salvação <br />
  58. 58. Complications of Chemotherapy<br />Immediate<br />Hematologic- 9%<br />Mucositis- 25%<br />Sensory Neuropathy- 20%<br />Ototoxicity- 10%<br />Fatigue- 39%<br />Pulmonary- 13%<br />
  59. 59. Complications of Chemotherapy<br />Secondary malignancies- 1.38%<br />Lung, biliary, colon, bladder, stomach, sarcoma<br />Nephrotoxicity- <br />Permanent reduction in GFR 20 – 30%<br />Neurotoxicity-<br />Persistant clinical peripheral neuropathy 20 – 40%<br />Ototoxicity<br />
  60. 60. Complications of Chemotherapy<br />Pulmonary toxicity- Bleomycin<br />40 – 60% fall from baseline of diffusion capacity of CO<br />Close monitoring of post-op fluid management (limit fluids given)<br />Toxicity related to total bleomycin dose<br />Also radiation, renal dysfunction, older age, smoking<br />
  61. 61. Complications of Chemotherapy<br />Raynaud’s phenomenon<br />Episodic vasoconstriction of the digital arteries<br />Related to bleomycin and vinblastine<br />20 – 25% with persistent symptoms<br />Cardiotoxicity<br />Twofold increase in cardiovascular disease<br />Cisplatin implicated<br />
  62. 62. Complications of Chemotherapy<br />Infertility<br />60% with decreased parameters before treatment<br />Impairment of spermatogenesis related to Cisplatin<br />Resolves in 80% of cases within 5 years<br />

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