Devita, Hellman, and Rosenberg's Cancer

LWBK1006-22 LWW-Govindan-Review December 12, 2011 19:7

Chapter 22•Cancer of the Testis 303

risk or intermediate risk, based on the following: primary site of tumor,

pulmonary versus nonpulmonary metastases and AFP level. Patients are

classified as good risk if they have a seminoma of any primary site, pul-

monary only visceral metastases and normal AFP level. Patients are clas-

sified as intermediate risk if they have a seminoma of any primary site,

nonpulmonary visceral metastases and normal AFP level. Elevated AFP

levels are inconsistent with diagnosis of seminoma and patients should be

treated for NSGCT, even if pathology fails to identify an NSGCT com-

ponent.

Answer 22.14. The answer is C.

Options A and B are commonly used in patients with good-risk tumors

with equivalent efficacy. In patients with high-risk disease, however, the

standard approach consists of four cycles of BEP.

Answer 22.15. The answer is D.

VIP has similar results compared with BEP and may be offered to patients

with contraindications to BEP. In a large US trial comparing four cycles

of BEP with two cycles of BEP followed by high-dose chemotherapy and

stem cell support, the latter showed no significant survival benefit.

Answer 22.16. The answer is B.

Although significant pulmonary toxicity from bleomycin is rare, it may

be fatal. Because the predictive ability of pulmonary function tests such as

vital capacity and diffusion capacity of carbon monoxide is not proven,

this agent is typically avoided in patients with pre-existing pulmonary

compromise. Therefore, BEP and BOP should, if possible, not be used.

Four cycles of EP are equivalent to three cycles of BEP in patients with

good-risk germ cell tumors, but inferior to four cycles of BEP. The best

option in this patient is four cycles of VIP.

Answer 22.17. The answer is B.

Patients who fail to respond or relapse after first-line chemotherapy with

BEP represent a heterogeneous population with a wide range of cure

rates after salvage chemotherapy. The 3-year survival is approximately

35% in patients with primary tumors of the testicle or retroperitoneum

and those who achieved a complete response to first-line chemotherapy.

In contrast, the probability of cure from conventional therapy is less than

10% in patients with less than complete response to initial chemotherapy

or relapsed mediastinal tumors.