Medication Summary
BEP (bleomycin, etoposide, cisplatin [Platinol]) is the most common chemotherapy regimen administered for germ cell tumors. It is usually administered in 4 cycles. Additional agents involved in primary, high-risk, and salvage protocols may include ifosfamide and vinblastine.
Antineoplastic agents
Class Summary
These agents inhibit deregulated growth of cells.
Bleomycin (Blenoxane)
Composed of cytotoxic glycopeptide antibiotics, which appear to inhibit DNA synthesis with some evidence of RNA and protein synthesis inhibition to a lesser degree; used in the management of several neoplasms as a palliative measure.
Etoposide (VP-16)
Arrests cells in the G2 portion of the cell cycle and induces DNA strand breaks by interacting with DNA topoisomerase II and forming free radicals.
Cisplatin (Platinol, Platinol-AQ)
Inorganic metal complex thought to act analogously to alkylating agents; inhibits DNA synthesis and thus cell proliferation by causing DNA crosslinks and denaturation of double helix.
Ifosfamide (Ifex)
Related to nitrogen mustards and is a synthetic analog of cyclophosphamide; inhibits DNA and protein synthesis and thus cell proliferation by causing DNA cross-linking and denaturation of double helix.
Vinblastine (Alkaban-AQ, Velban)
Inhibits microtubule formation, which in turn, disrupts the formation of mitotic spindle, causing cell proliferation to arrest at metaphase.
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Testicular seminoma. A 57-year-old man presents with abdominal pain of slow onset. CT scanning shows a large 25-cm retroperitoneal lesion encompassing the aorta and renal vasculature and displacing the right kidney laterally. The patient had a history of cryptorchidism repaired at age 8 years. Testes were normal and descended; however, ultrasonography showed a small 5-mm lesion on the right testis, which proved to be pure seminoma at orchiectomy. The beta-human chorionic gonadotropin level was 70 mIU/mL (reference range, < 5 mIU/mL), and the alpha-fetoprotein level was within the reference range; no metastatic lesions were observed above the diaphragm, indicating stage IIb (bulky), T1N3M0. The patient was referred for 4 cycles of cisplatin-based chemotherapy.
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Testicular seminoma. This scrotal ultrasound of a 37-year-old man with a painless mass in his right testis shows a right testis with hypoechoic solid masses compared to the homogeneous, more hyperechoic, healthy left testis. Levels of serum beta-human chorionic gonadotropin and alpha-fetoprotein were within the reference range, and the metastatic workup findings were negative. Histopathology showed a pure seminoma. Metastatic workup showed no nodal or distant spread, T1N0M0 stage I. After orchiectomy, the patient underwent adjuvant external beam radiotherapy to the para-aortic nodes. At a 3-year follow-up study, the patient is disease free and has a greater than 95% chance of remaining disease free.
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Testicular seminoma. This is a classic seminoma at low power. Uniform tumor cells are observed with mild inflammatory response (lymphocytes). Other seminoma findings not seen could include a fibrovascular stroma, syncytiotrophoblastic cells, and multinucleated histiocytes.
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This is a classic testicular seminoma, high-power view, from a 37-year-old man with a painless mass in his right testis. Levels of serum beta-human chorionic gonadotropin and alpha-fetoprotein were within the reference range, and the metastatic workup findings were negative. Histopathology showed a pure seminoma. Metastatic workup showed no nodal or distant spread, T1N0M0 stage I. After orchiectomy, the patient underwent adjuvant external beam radiotherapy to the para-aortic nodes. At a 3-year follow-up study, the patient is disease free and has a greater than 95% chance of remaining disease free. See related image for a scrotal sonogram of this patient. Note here that tumor cells are uniform, have abundant clear cytoplasm, a large centrally located nucleus, and a variable mitotic pattern.
Tables
pTx |
Primary tumor cannot be assessed |
p0 |
No evidence of primary tumor |
pTis |
Germ cell neoplasia in situ |
pT1 |
Tumor limited to the testis without lymphovascular invasion |
| pT1a | Tumor smaller than 3 cm |
| pT1b | Tumor 3 cm or larger |
pT2 |
Tumor limited to the testis and epididymis with lymphovascular invasion OR |
Tumor invading hilar soft tissue or epididymis or penetrating viceral mesothelial layer covering the external surface of tunica albuginea with or without lymphovascular invasion |
|
pT3 |
Tumor invades the spermatic cord with or without lymphovascular invasion |
pT4 |
Tumor invades the scrotum with or without lymphovascular invasion |
Nx |
Nodes not assessed |
N0 |
No regional lymph node metastasis |
N1 |
Lymph node mass or multiple lymph node masses ≤ 2 cm in greatest dimension |
N2 |
Lymph node mass or multiple lymph node masses >2 cm but ≤ 5 cm in greatest dimension |
N3 |
Lymph node mass >5 cm in greatest dimension |
pN0 |
No evidence of tumor in lymph nodes |
pN1 |
Lymph node mass ≤ 2 cm in greatest dimension |
≤ 5 nodes positive |
|
pN2 |
Lymph node mass >2 cm but < 5 cm in greatest dimension |
>5 nodes positive |
|
Evidence of extranodal extension of tumor |
|
pN3 |
Lymph node mass >5 cm in greatest dimension |
M0 |
No evidence of distant metastases |
M1a |
Nonregional nodal or pulmonary metastases |
M2b |
Nonpulmonary visceral metastases |
S |
LDH |
hCG† (mIU/mL) |
AFP (ng/mL) |
||
Sx |
Not assessed |
Not assessed |
Not assessed |
||
S0 |
≤ N |
and |
Normal |
and |
Normal |
S1 |
< 1.5 x N |
and |
< 5,000 |
and |
< 1,000 |
S2 |
1.5-10 x N |
or |
5,000-50,000 |
or |
1,000-10,000 |
S3 |
>10 x N |
or |
>50,000 |
or |
>10,000 |
Stage grouping |
T |
N |
M |
S |
Stage 0 |
pTis |
N0 |
M0 |
S0 |
Stage I |
T1-T4 |
N0 |
M0 |
Sx |
Stage IA |
T1 |
N0 |
M0 |
S0 |
Stage IB |
T2-4 |
N0 |
M0 |
S0 |
Stage IS |
Any T |
N0 |
M0 |
S1-S3 |
Stage II |
Any T |
N1-3 |
M0 |
Sx |
Stage IIA |
Any T |
N1 |
M0 |
S0-S1 |
Stage IIB |
Any T |
N2 |
M0 |
S0-S1 |
Stage IIC |
Any T |
N3 |
M0 |
S0-S1 |
Stage III |
Any T |
Any N |
M1 |
Sx |
Stage IIIA |
Any T |
Any N |
M1a |
S0-S1 |
Stage IIIB |
Any T |
Any N |
M0-M1a |
S2 |
Stage IIIC |
Any T |
Any N |
M0-M1a |
S3 |
… |
Any T |
Any N |
M1b |
Any S |
