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Scrotal ultrasound can readily determine whether the mass is intratesticular or extratesticular in origin Once the diagnosis of testicular cancer has been established by inguinal orchiectomy, clinical staging of the disease is accomplished by chest, abdominal, and pelvic CT scanning
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An incorrect diagnosis is made at the initial examination in up to 25% of patients with testicular tumors Scrotal ultrasonog-
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it will harbor residual cancer and 40% of the time it will be teratoma Even if patients have a complete response to chemotherapy, retroperitoneal lymphadenectomy is advocated by some as 10% of patients may harbor residual carcinoma and 10% may have teratoma in the retroperitoneum If tumor markers fail to normalize following primary chemotherapy, salvage chemotherapy is required (cisplatin, etoposide, bleomycin, ifosfamide)
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treated on protocols to search for optimal therapy for refractory or poorly responsive malignancies Treatment may be inadequate or ineffective because of drug resistance of the tumor cells and is attributed to spontaneous genetic mutations in subpopulations of cancer cells prior to exposure to chemotherapy After chemotherapy has eliminated the sensitive cells, the resistant subpopulation grows to become the predominant cell type (Goldie-Coldman hypothesis) This is the basis of alternating non-cross-resistant chemotherapy regimens
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Patients with bulky retroperitoneal or disseminated disease treated with primary chemotherapy followed by surgery have a 5-year disease-free survival rate of 55 80%
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Heidenreich A et al Organ-sparing surgery for malignant germ cell tumor of the testis J Urol 2001 Dec;166(6): 2161 5 [PMID: 11696727] Huyghe E et al Increasing incidence of testicular cancer worldwide: a review J Urol 2003 Jul;170(1):5 11 [PMID: 12796635] Jewett MA et al Management of recurrence and follow-up strategies for patients with nonseminoma testis cancer Urol Clin North Am 2003 Nov;30(4):819 30 [PMID: 14680317] Patel MI et al Management of recurrence and follow-up strategies for patients with seminoma and selected high-risk groups Urol Clin North Am 2003 Nov;30(4):803 17 [PMID: 14680316] Pettersson A et al Age at surgery for undescended testis and risk of testicular cancer N Engl J Med 2007 May 3;356(18):1835 41 [PMID: 17476009]
TOXICITY & DOSE MODIFICATION OF CHEMOTHERAPEUTIC AGENTS
Acute and chronic toxicities of various drugs used to treat cancer are summarized in Table 39 11 Appropriate dose modification may minimize these side effects, so that therapy can be continued with relative safety Dose modifications are usually considered in settings where treatment is given with palliative intent Dose intensity and schedule should be maintained if at all possible in the adjuvant setting, when treatment is directed toward preventing recurrence or metastases of the cancer
1 Bone Marrow Toxicity
Depression of bone marrow is usually the most serious limiting toxicity of cancer chemotherapy Autologous bone marrow or peripheral blood stem cell transplantation or rescue can reduce the myelosuppressive toxicity of high-dose chemotherapy; however, cost and toxicity limit its general use Growth factors that stimulate myeloid proliferation (eg, G-CSF; filgrastim, the longer acting pegfilgrastim, and GM-CSF; sargramostim) or erythroid proliferation (epoetin alfa [erythropoietin]) and the longer acting darbepoetin alfa are now used to ameliorate bone marrow toxicity G-CSF and GM-CSF have been shown to shorten the period of neutropenia following both standard and high-dose chemotherapy as well as to allow dosing of chemotherapy at more frequent intervals The risk of febrile neutropenia and mucosal toxicity is reduced as well Myeloid growth factors are also used to stimulate circulation of stem cells in the peripheral blood either at steady state or during white blood cell recovery following myelosuppressive chemotherapy These cells are then harvested using an apheresis machine and frozen for later use When stimulated peripheral blood stem cells are used instead of or in conjunction with bone marrow for autologous transplantation following high-dose chemotherapy and radiotherapy, recovery of both neutrophils and platelets may be hastened by as much as 7 10 days as opposed to the use of bone marrow alone Recombinant growth factors are expensive and must be used judiciously Published standard practice guidelines are referenced at the end of this section Epoetin alfa (erythropoietin) and the newer darbepoetin alfa have been shown to improve anemia associated with malignancy or cancer chemotherapy Patients must have adequate iron stores to respond to this agent, and even patients with marrow infiltration with tumor may benefit Higher doses are necessary for patients with cancer than for patients with renal failure (40,000 units a week compared with about 10,000 units a week epoetin alfa) It is useful to check the level of erythropoietin before instituting therapy in patients with
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