ATHENS 4-6 October 2018 European Society of Urogenital Radiology STAGING AND FOLLOW-UP STRATEGIES Ahmet Tuncay Turgut, MD Professor of Radiology Hacettepe University, Faculty of Medicine Ankara 2nd ESUR Teaching Course Multimodality Imaging Approach to Scrotal and Penile Pathologies
Testicular Tumor-Management Accurate clinical staging is critical because prognosis and further treatment depends on the clinical stage of the disease...
Testicular Tumor-Imaging Identifying tumor Staging disease Detecting recurrence
Testicular Tm.-Staging-Requirements To properly stage testicular tumors the following are pre-requisites; Pathology of the tumor specimen History Clinical evaluation Radiological procedure (CT, MRI) Tumor markers (β-hcg, AFP)
Testicular Tumor- Staging TNMS system; tumor lymph node metastasis serum tumor marker
Moreno et al, Radiographics 2015
Testicular Tumor- Staging objectives *To detect lymph node metastases in abdomen, thorax and supraclavicular fossa. *To identify lung metastases. *To identify disseminated blood-borne metastatic disease (e.g, in the liver). *To identify brain metastases in selected patients.
Testicular Tm.-Staging-Imaging Tools IVU Lymphangiography US CT MRI FDG PET PET/CT Bone scan Chest radiography
Staging nodal and metastatic disease Following orchidectomy and an established diagnosis of a testicular germ cell tumour, all patients should have; *Initial staging with CT of chest, abdomen and pelvis. * Subsequently pelvis may be omitted in patients who have had standard inguinal orchidectomy. *In patients who have had a scrotal incision, inguinal hernia repair (where lymphatic drainage may be altered), or in patients who developed testis cancer in an ectopic, undescended testis, the pelvis should be imaged on follow-up examinations.
Testicular Tumor-Metastatic spread Route of disease dissemination is via lymphatic to retroperitoneum (except for choriocarcinoma with hematogenous dissemination)
Testicular Tumor-Metastatic spread Right testicular tm.- primary drainage Paracaval, precaval, interaortocaval LN Left testicular tm. -primary drainage Para-aortic nodal group Interaortocaval lmphatic spread (Cross-over of lymphatic drainage) in the presence of advanced disease Contralateral met. without involvement of the ipsilateral nodes (unusual)
Testicular Tumor-Metastatic spread Nonregional lymph node groups (common iliac, internal iliac, and external iliac nodes, or via the thoracic duct to retrocrural and left supraclavicular nodes) More caudal deposition (external iliac and inguinal lymph nodes) by retrograde spread due to altered lymphatic drainage related to prior scrotal/inguinal surgery
Testicular Tumor-Metastatic spread Inguinal lymphadenopathy Scrotal violations Tm.invasion into epididymis, layers of tunica albuginea, skin
Testicular Tm.-Staging CT of abdomen&pelvis Most common study for assessing retroperitoneum Limitations; Little retroperitoneal fat in young patients Can not detect met. in lymph nodes of normal size Inflammatory LNs vs. enlarged due to malignant disease >1 cm in short axis; highly suspicious for met. (hilar regions of the kidney, para-aortic or caval areas) Cut-off value of 0.7 0.8 cm Short-axis for assessing the likelihood of nodal disease (N0 versus N1 disease); long axis (N1versus N2 and N3 disease)
Testicular Tm.-Staging * Brain CT is performed in; symptomatic patients multiple lung metastases very high serum tumour markers (bhcg).
31 y.o, metastatic seminoma Moreno et al., Radiographics 2016
MGCT (50% teratoma, 45% embryonal carcinoma, 3% yolk sac tumor, 2% choriocarcinoma) Moreno et al., Radiographics 2016
Chorioca. metastatic
Follow-up- surveillance Surveillance for Stage I disease increasingly recognised as the preferred option for both seminoma and NSGCT Avoids unnecessary treatment in 50 90% of patients and disease-free survival of 98% achieved in patients who relapse on surveillance. Surveillance protocols designed to identify relapse at the earliest stage, thereby enabling earlier treatment. In addition to clinical and serum marker assessment, imaging with CT forms the basis of surveillance strategies.
Follow-up- surveillance-nsgct For Stage I, NSGCT surveillance protocols focus on the first year with investigations reducing in intensity in subsequent years. Serum markers checked monthly for the first year, Two monthly chest radiographs and clinical examination, CT scans (abdomen only unless the pelvis is deemed high risk) at 3 months and 1 year Rockall A, Sohaib A. Testicular cancer. In: Nicholson T (ed). Recommendations for cross-sectional imaging in cancer management, Second edition. London: The Royal College of Radiologists, 2014.
Follow-up- surveillance-seminoma For seminomas, as serum marker are less reliable, more imaging is used in surveillance with; 6-monthly abdominal CT and chest radiographs for the first 2 years and the pelvis is only imaged if there has been previous pelvic surgery. Annual abdominal CT and chest radiograph are performed until 5 years following the diagnosis. Rockall A, Sohaib A. Testicular cancer. In: Nicholson T (ed). Recommendations for cross-sectional imaging in cancer management, Second edition. London: The Royal College of Radiologists, 2014.
Follow-up- surveillance-seminoma Rising tumour marker levels will usually precipitate further imaging to identify metastatic disease or a new primary tumour; This usually requires CT of chest, abdomen and pelvis together with ultrasound of the remaining testicle. If no new disease is seen, an MRI of the brain and/or 18FDG PET-CT is also indicated to detect sites of occult metastatic disease. Rockall A, Sohaib A. Testicular cancer. In: Nicholson T (ed). Recommendations for cross-sectional imaging in cancer management, Second edition. London: The Royal College of Radiologists, 2014.
Follow-up for metastatic disease Non-seminomatous. germ cell tumours Residual masses following completion of treatment should be assessed for possible surgical excision in terms of size, precise location and relationship to adjacent structures, including major vessels. 18FDG PET-CT can be used to identify residual active disease in patients with demonstrable residual masses, although mature differentiated teratoma may not be FDG-avid and cannot be excluded with a negative scan. Rockall A, Sohaib A. Testicular cancer. In: Nicholson T (ed). Recommendations for cross-sectional imaging in cancer management, Second edition. London: The Royal College of Radiologists, 2014.
Follow-up for metastatic disease Seminomas In general, seminomatous residual masses are not resected because the majority comprise fibrosis and necrosis, with no evidence of active residual malignancy. A negative 18FDG-PET-CT of a residual mass following chemotherapy for seminoma excludes any viable disease. Rockall A, Sohaib A. Testicular cancer. In: Nicholson T (ed). Recommendations for cross-sectional imaging in cancer management, Second edition. London: The Royal College of Radiologists, 2014.
Acknowledgement; Dr. Shweta Bhatt
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