Summary:

1. A. Intravesical Bacillus Calmette-Guerin (BCG)
2. B) Gemcitabine/carboplatin followed by avelumab maintenance
3. D) Dose-dense MVAC
4. C. Nitrosoureas like carmustine may cause disease
5. A. Repeat staging with transurethral resection of bladder tumor (TURBT)
6. C. Cisplatin
7. B) Gemcitabine/carboplatin followed by avelumab maintenance
8. B. Carboplatin + gemcitabine
9. C. Avelumab maintenance
10. B. Vision disorders is a major concern, C. FGFR2/3 alterations should be tested before treatment (Erdafitinib)
11. C. Chemoradiation with cisplatin and 5-fluorouracil (5-FU)
12. pembrolizumab (D)
13. D) LL is unlikely to derive any overall survival benefit from adjuvant sunitinib.
14. C) Lenvatinib + pembrolizumab
15.  Axitinib + pembrolizumab
16. D) Pazopanib
17. B) Thyroid function
18. B) Hypertension
19. D) Electrolyte abnormalities should be replaced, then repeat his ECG
20. A) Cabozantinib
21. C. RB
22. D. FLCN
23. D. Ipilimumab/nivolumab
24. A) Good risk
25. D) G-CSF may increase one’s risk of bleomycin induced pulmonary toxicity, but this risk is not proven and G-CSF may still be used when necessary in patients receiving BEP.
26. A) Secondary malignancies and cardiovascular disease
27. A. Good risk
28. B. Four cycles of BEP (bleomycin/etoposide/cisplatin) chemotherapy
29. C) Partial nephrectomy then observation
30. D) Pazopanib
31. A) Cardiac arrhythmias

Exam Questions And Answers

Bladder Cancer

Management

• BCG-unresponsive definitions: Strict criteria now guide when to stop BCG; recurrence within 1 year (CIS) or 6 months (papillary) defines unresponsiveness
• Bladder-sparing hierarchy: Step-therapy approach typically starts with gemcitabine/docetaxel (cost-effective), then nadofaragene, then pembrolizumab
• Category 2A vs 2B: Health plans scrutinize 2B recommendations more closely; additional justification may be required
• Enfortumab Vedotin: Now integrated into first-line with pembrolizumab; monitor for skin reactions, peripheral neuropathy, and hyperglycemia

A. CT is a 71-year-old man who presented to his primary care doctor with complaints of hematuria and urinary urgency. He was referred to a urologist for cystoscopy, which revealed a lesion in the bladder. Subsequently, he underwent a TURBT ( transurethral resection of the bladder tumor) followed by single-dose intravesical chemotherapy. Pathology revealed Tis (in situ), non-muscle invasive urothelial carcinoma (UC)

The best treatment option for CT (71-year-old man with Tis/CIS, non-muscle-invasive UC) is:

A. Intravesical Bacillus Calmette-Guérin (BCG)

Why BCG?

1. Guideline-Recommended for CIS (Tis):
   1. BCG is the gold standard for high-grade Tis (carcinoma in situ) due to its superior ability to reduce progression risk (~50% lower vs. chemo).
   2. Mitomycin (B) is less effective for CIS.
2. High-Risk Features of CT’s Case:
   1. Tis (CIS) is aggressive and has a high risk of progression to muscle-invasive disease if untreated.
   2. BCG induces an immune response that targets microscopic CIS lesions.
3. Evidence-Based Outcomes:
   1. Complete response (CR) rate: ~70% with BCG (vs. ~40–50% with mitomycin).
   2. Maintenance BCG (3-year protocol) further improves long-term outcomes.

Why Not the Other Options?

• B. Intravesical Mitomycin (MMC):
  • Used for low/intermediate-risk Ta/T1 tumors, but less effective for CIS.
  • Lacks the immune-stimulating benefits of BCG.
• C. Systemic Gemcitabine + Cisplatin:
  • Reserved for muscle-invasive (T2+) or metastatic bladder cancer, not non-muscle-invasive (Tis/Ta/T1).
  • Overly aggressive for this stage and carries more toxicity.

Next Steps for CT

1. BCG Induction: 6 weekly intravesical instillations.
2. Maintenance BCG: 3-week courses at 3, 6, 12, 18, 24, and 36 months (per SWOG protocol).
3. Surveillance: Frequent cystoscopy/cytology (every 3–6 months) due to high recurrence risk.

If BCG Fails

• BCG-unresponsive CIS: Switch to pembrolizumab or clinical trials (e.g., Nadofaragene firadenovec).
• Radical cystectomy (if high-risk progression).

Key Point

BCG is the only FDA-approved and guideline-endorsed first-line therapy for CIS (Tis). Mitomycin or systemic chemotherapy is inappropriate for this scenario

Which of the following is not correct regarding bladder cancer risk?

• A. Cigarette smoking, some chemicals & chronic inflammation are risk factors
• B. Del Chromosome 9, RAS, RB & TP53 are genetic abnormalities in disease
• C. Nitrosoureas like carmustine may cause disease
• D. Person is advised to drink lots of fluids to avoid risk

Answer: C. Nitrosoureas like carmustine may cause disease

A 62-year-old man develops hematuria and is referred to a urologist. Staging cystoscopy reveals a sessile bladder tumor. Pathology from the transurethral resection shows high-grade urothelial carcinoma invading the lamina propria but no muscle is included in the sample and is staged as T1.

Which therapy would you recommend?

• A. Repeat staging with transurethral resection of bladder tumor (TURBT)
• B. Intravesical bacillus Calmette–Guérin (BCG)
• C. Watchful waiting
• D. Chemoradiation
• E. Cystectomy

Answer: A) Repeat staging with transurethral resection of bladder tumor (TURBT)

Explanation

T1 high-grade urothelial carcinoma is a high-risk non-muscle-invasive bladder cancer (NMIBC). However, the initial resection did not include muscle in the sample, raising concern for possible understaging (missed muscle invasion).

• Next step: A repeat TURBT within 2–6 weeks is mandatory to:
• Confirm the absence of muscle invasion (rule out T2 disease).
• Ensure complete resection of the tumor.
• Guide further therapy (e.g., BCG vs. radical cystectomy if persistent T1 or upstaging).

Why not the other options?

• B) Intravesical BCG: BCG is indicated for high-risk NMIBC (T1/CIS), but only after confirming no muscle invasion with repeat TURBT.
• C) Watchful waiting: Unacceptable for high-grade T1 disease due to high progression risk.
• D) Chemoradiation: Reserved for muscle-invasive disease (T2+) or select patients unfit for cystectomy.
• E) Cystectomy: May be needed if repeat TURBT shows persistent T1 or muscle invasion, but not first-line for initial staging.

A 69-year-old man with localized T1 bladder cancer was treated with bacillus Calmette-Guérin (BCG). Repeat transurethral resection of bladder tumor (TURBT) shows residual urothelial carcinoma without muscularis propria invasion (muscularis propria is present in the specimen).

Which treatment would NOT be considered for his BCG-refractory bladder cancer?

A. Cystectomy
B. Pembrolizumab
C. Cisplatin
D. Intravesicular gemcitabine

Correct Answer: C) Cisplatin

1. Clinical Context:

   • The patient has BCG-refractory T1 disease (residual tumor after BCG, but no muscle invasion).
   • Muscularis propria was sampled, confirming non-muscle-invasive (T1) status.
2. Appropriate Options for BCG-Refractory T1 Disease:
   • A) Cystectomy: Gold standard for BCG-refractory high-risk NMIBC (T1/CIS) due to high progression risk.
   • B) Pembrolizumab: FDA-approved for BCG-unresponsive CIS ± papillary tumors in patients ineligible for cystectomy.
   • D) Intravesical gemcitabine: An alternative for BCG-refractory disease, though less effective than radical therapy.
3. Why Cisplatin (C) is NOT Considered:
   • Cisplatin is used for metastatic or muscle-invasive bladder cancer (MIBC), not for non-muscle-invasive (T1) disease.
   • It has no role in BCG-refractory NMIBC management.

Key Point:

For BCG-refractory T1 bladder cancer, cisplatin is inappropriate; options include cystectomy, immunotherapy (e.g., pembrolizumab), or intravesical chemotherapy (e.g., gemcitabine).

A patient (CT) initially responded to maintenance BCG therapy but later developed gross hematuria. Repeat TURBT revealed muscle-invasive urothelial carcinoma with distant metastases. Pathologic analysis showed PD-L1 CPS = 10%. The patient has a good performance status (ECOG PS = 0) but a reduced CrCl of 40 mL/min.

Which therapy would be most appropriate at this time?

A) Pembrolizumab
B) Gemcitabine/carboplatin followed by avelumab maintenance
C) Gemcitabine/cisplatin followed by avelumab maintenance
D) Enfortumab vedotin

Correct Answer: B) Gemcitabine/carboplatin followed by avelumab maintenance

1. Clinical Context:

   • Metastatic urothelial carcinoma with PD-L1 CPS = 10% (intermediate expression).

   • Renal impairment (CrCl 40 mL/min): Contraindicates cisplatin, which requires CrCl ≥60 mL/min.
   • ECOG PS 0: Indicates fitness for aggressive therapy.
2. Treatment Options:
   • A) Pembrolizumab:
     • Approved for first-line monotherapy in CPS ≥10% patients unfit for platinum chemotherapy.
     • This patient is fit for platinum therapy (ECOG 0), making combination chemotherapy preferred over immunotherapy alone.
   • B) Gemcitabine/carboplatin + avelumab maintenance:
     • Preferred choice: Carboplatin is the platinum alternative for cisplatin-ineligible patients (CrCl <60 mL/min).
     • JAVELIN Bladder 100 trial showed survival benefit with avelumab maintenance after platinum-based chemotherapy.
   • C) Gemcitabine/cisplatin + avelumab maintenance:
     • Contraindicated due to renal impairment (cisplatin requires CrCl ≥60 mL/min).
   • D) Enfortumab vedotin:
     • Second-line therapy for progression after platinum + immunotherapy; not first-line.
3. Key Considerations:
   • Cisplatin ineligibility drives selection of carboplatin-based therapy.
   • Maintenance avelumab improves survival in responders to platinum chemotherapy, regardless of PD-L1 status.

A 65-year-old woman with metastatic bladder cancer presents with comorbidities including hypertension and chronic kidney disease (baseline creatinine = 2). Tumor testing shows PD-L1 <1% and an FGFR2 mutation.

What is the appropriate first-line treatment?

A. Dose-dense MVAC (ddMVAC) with growth factor support
B. Carboplatin + gemcitabine
C. Pembrolizumab
D. Erdafitinib
E. Enfortumab vedotin

Answer: B. Carboplatin + gemcitabine

An 84-year-old man with metastatic bladder cancer and diabetic neuropathy was treated with gemcitabine/carboplatin (cisplatin-ineligible due to neuropathy). After 6 cycles, imaging shows partial response. He maintains excellent functional status.

What is the recommended next management step?

A. Two additional cycles of gemcitabine/carboplatin
B. Switch carboplatin to cisplatin
C. Avelumab maintenance
D. NGS with PD-L1 testing
E. Surveillance → immunotherapy at progression
F. Hospice

Correct Answer: C) Avelumab maintenance

Key Points:

1. Current Evidence-Based Standard:

   • JAVELIN Bladder 100 trial (NEJM 2020) established avelumab maintenance as standard of care for:

     • Patients with stable disease or better after 4-6 cycles of first-line platinum chemotherapy
     • Demonstrated overall survival benefit (31% risk reduction) regardless of PD-L1 status
2. Why Other Options Are Less Appropriate:
   • A) Continuing chemotherapy beyond 6 cycles increases toxicity without proven benefit
   • B) Cisplatin remains contraindicated due to pre-existing neuropathy
   • D) While molecular testing is valuable, it should not delay maintenance therapy
   • E) Early immunotherapy is superior to waiting for progression
   • F) Patient is responding to treatment with excellent functional status
3. Practical Considerations:
   • Maintenance avelumab begins 4-10 weeks after last chemotherapy dose
   • Continue until progression or unacceptable toxicity
   • No need for PD-L1 testing to initiate maintenance
4. Special Population Note:
   • While elderly (84 years), his excellent functional status supports aggressive therapy
   • Avelumab is generally well-tolerated in older adults

Which of the following is correct about erdafitinib therapy? (Choose 2)

A. It may cause hypophosphatemia
B. Vision disorders is a major concern
C. FGFR2/3 alterations should be tested before treatment
D. It is approved for 1st-line treatment for metastatic bladder cancer in cisplatin-ineligible patients

Correct Answers: B) Vision disorders is a major concern and C) FGFR2/3 alterations should be tested before treatment

Rationale:

1. B) Vision Disorders:

• • Ocular toxicity (e.g., central serous retinopathy, blurred vision) is a class-effect of FGFR inhibitors and requires regular ophthalmologic monitoring.
  • Up to 50% of patients develop eye-related adverse events, with 25% requiring dose interruptions.

1. C) FGFR2/3 Testing Required:
   • Erdafitinib is FDA-approved only for tumors with FGFR2/3 genetic alterations (mutations or fusions).
   • Next-generation sequencing (NGS) is mandatory before initiation (response rates ~40% in FGFR-altered tumors vs. <10% in wild-type).

Why Other Options Are Incorrect:

• A) Hypophosphatemia: Incorrect – Erdafitinib causes hyperphosphatemia (due to on-target FGFR inhibition), requiring phosphate monitoring and potential dose reduction.
• D) 1st-line Approval: Incorrect – Erdafitinib is currently approved only after platinum failure, though trials are ongoing for 1st-line use in FGFR-altered, cisplatin-ineligible patients.

Key Clinical Pearls:

• Baseline Requirements:
  • Confirm FGFR2/3 alteration via NGS.
  • Ophthalmologic exam before starting therapy.
• Monitoring:
  • Phosphate levels weekly for 1 month, then monthly.
  • Monthly eye exams for visual changes.

A 54-year-old man presents with gross hematuria. He undergoes transurethral resection of bladder tumor (TURBT), which diagnoses muscle-invasive (T2) bladder cancer. He has no comorbidities; however, he strongly prefers to not have urostomy.

What would be the optimal management of his bladder cancer?

A. Cystectomy with ileal conduit
B. Repeat TURBT and bacillus Calmette–Guérin (BCG)
C. Chemoradiation with cisplatin and 5-fluorouracil (5-FU)
D. Immune-checkpoint inhibitor therapy
E. Surveillance

Renal Cell Carcinoma

Management

• Nivolumab/ipilimumab update: Now Category 1 for favorable risk patients based on 9-year CheckMate 214 data showing 35% OS at 9 years in low-risk patients
• NCCN vs. CSCO: Chinese guidelines differ in immunotherapy sequencing; consider regional variations
• SBRT considerations: For T1a/T1b tumors in non-surgical candidates, SBRT achieves 90-100% local control; BED should be ≥80 Gy
• nccRCC options: IO/TKI combinations now included based on phase 2 data; chromophobe histology may benefit from everolimus combinations due to mTOR pathway alterations

 

LL undergoes surveillance instead of adjuvant therapy. At his 6-month follow up, he is noted to have lymphadenopathy on his abdominal CT. A chest CT shows a 2 cm lung lesion. Biopsy of the lung lesion was consistent with metastatic clear cell renal cell carcinoma. His BP is 124/72 (on amlodipine). Pertinent labs: SCr 1 mg/dl, Ca 9.3 mg/dl, Alb 4.2 g/dl, WBC 7.0 x 10⁹/L, ANC 4.0 x 10⁹/L, Hgb 11.1 g/dL, Platelets 250K, Karnofsky performance score is 90%.

LL presents to his oncologist after 15 months (or 9 months) of stable disease while on axitinib + pembrolizumab. His treatment course thus far is notable for immune-related hypothyroidism, which is stable on levothyroxine. His ECOG performance status has declined from 0 to 1. His follow-up imaging reveals progressive disease with metastases to 2 bone sites.

Which of the following genes disorders not associated with RCC?

• A. VHL
• B. mTOR
• C. RB
• D. FLCN

The correct answer is: C. RB

Here’s a brief overview of each gene and its association with Renal Cell Carcinoma (RCC):

Conclusion: RB is not commonly associated with renal cell carcinoma, making it the correct answer.

A 51-year-old man, former smoker, presented to the ED complaining of acute onset left flank pain. Past medical history is significant for spontaneous pneumothoraces requiring bilateral thoracotomies and pleurodesis, and right upper lobectomy at 22 years old. Family history is significant for emphysema in mother, aunt, sister, and a son with history of pneumothorax. CT imaging on admission revealed a 0.5 cm kidney stone in the left mid-ureter and an indeterminate 3 cm lesion on the right kidney. He was eventually discharged with outpatient follow-up. During active surveillance, his right kidney mass increases in size. He is referred to urology for further evaluation. The patient undergoes a right radical nephrectomy with pathology revealing a diagnosis of chromophobe renal cell carcinoma.

Which of the following gene mutations is associated with this patient’s condition?

A. MET
B. FH
C. Succinate dehydrogenase
D. FLCN
E. HBB (hemoglobin subunit beta)"**

Key Clinical Clues:

• Recurrent spontaneous pneumothoraces (personal and family history).
• Chromophobe RCC diagnosis.
• Family history of emphysema and pneumothorax (suggesting a hereditary syndrome).

Answer: D. FLCN

Explanation:

• FLCN (Folliculin): Mutations in this gene cause Birt-Hogg-Dubé (BHD) syndrome, an autosomal dominant disorder associated with:
  • Chromophobe RCC (or hybrid oncocytic tumors).
  • Pneumothoraces (due to lung cysts).
  • Skin fibrofolliculomas.
  • Family history of emphysema/pneumothorax (as seen here).

Why Not Others?

• A. MET: Associated with hereditary papillary RCC (not chromophobe).
• B. FH (Fumarate hydratase): Linked to hereditary leiomyomatosis and RCC (HLRCC), causing aggressive papillary RCC.
• C. Succinate dehydrogenase: Mutations cause SDH-deficient RCC (usually aggressive, not chromophobe).
• E. HBB: Unrelated (associated with hemoglobinopathies like sickle cell disease).

A 65-year-old woman underwent a radical nephrectomy for a right kidney mass 2 years ago, initially identified by CT scan during a workup by her primary care physician for painless hematuria. Pathology revealed a 9 cm renal cell carcinoma (RCC), clear cell histology with 4 of 10 lymph nodes involved by neoplasm. She was observed clinically after the operation. She is referred to you now after a CT obtained for right-sided abdominal pain showed five liver lesions measuring 2 cm each, and scattered non-calcified pulmonary nodules in both lungs. CT-guided biopsy of one of the liver lesions showed clear cell carcinoma consistent with the histopathology of the primary kidney tumor removed 2 years ago.

She has a history of coronary artery disease and well-controlled hypertension and takes a triamterene diuretic as well as aspirin. Her abdominal pain is well controlled with oral analgesics and she is otherwise asymptomatic. Her Eastern Cooperative Oncology Group (ECOG) performance status is 0.

What would you recommend next?

A. Nivolumab
B. Staged resections of liver metastases and lung metastases
C. Cabozantinib
D. Ipilimumab/nivolumab
E. High-dose interleukin-2 (IL-2)
F. Cisplatin and gemcitabine"

Final Answer: D. Ipilimumab/nivolumab

Clinical Summary:

• Diagnosis: Metastatic clear cell RCC (liver and lung metastases) with prior nephrectomy (Stage III at diagnosis).
• Current Status: Asymptomatic, excellent performance status (ECOG 0), no comorbidities precluding systemic therapy.
• Key Consideration: First-line treatment for metastatic clear cell RCC.

Correct Answer: D. Ipilimumab/nivolumab

Explanation:

1. First-Line Therapy for Metastatic Clear Cell RCC:
   • Ipilimumab (anti-CTLA-4) + nivolumab (anti-PD-1) is FDA-approved and supported by the CheckMate 214 trial, showing durable responses and overall survival benefit in intermediate/poor-risk patients.
   • Preferred for this patient due to:
     • High tumor burden (liver/lung metastases).
     • Prior nephrectomy (no primary tumor in situ).
     • ECOG 0 (eligible for immunotherapy).
2. Why Not Other Options?
   • A. Nivolumab monotherapy: Used in second-line post-TKI failure.
   • B. Staged resections: Not feasible for diffuse metastases (liver + lung).
   • C. Cabozantinib: Alternative for poor-risk disease or post-immunotherapy progression.
   • E. High-dose IL-2: Rarely used due to toxicity (contraindicated with CAD/hypertension).
   • F. Cisplatin/gemcitabine: Not effective for RCC (used in urothelial carcinoma).
3. Patient-Specific Factors:
   • No contraindications to immunotherapy (no active autoimmune disease, good performance status).

Testicular Cancer

Testicular cancer management is fundamentally guided by histology (seminoma vs. nonseminoma), stage (I-III), and risk stratification using the International Germ Cell Cancer Collaborative Group (IGCCCG) system for metastatic disease. The 2026 landscape features emerging options for stage II disease to reduce treatment-related toxicity

Key Pharmacy Pearls for Testicular Cancer (2026):

• Chemotherapy Regimens :
  • BEP: Bleomycin 30 units IV weekly, Etoposide 100 mg/m² IV days 1-5, Cisplatin 20 mg/m² IV days 1-5; cycles repeated every 21 days. BEP x3 for good-risk, BEP x4 for intermediate/poor-risk.
  • EP: Etoposide 100 mg/m² IV days 1-5, Cisplatin 20 mg/m² IV days 1-5; cycles every 21 days x4. Alternative for good-risk when bleomycin contraindicated.
  • TIP: Paclitaxel 250 mg/m² IV day 1, Ifosfamide 1500 mg/m² IV days 2-5, Cisplatin 25 mg/m² IV days 2-5; with mesna and G-CSF; cycles every 21 days .
  • Carboplatin: Single-agent AUC 7 for stage I seminoma adjuvant; 1-2 cycles.
• Bleomycin Toxicity Management:
  • Pulmonary toxicity: Cumulative dose-related; risk factors include age >40, renal impairment, cumulative dose >400 units, concomitant thoracic radiation, tobacco use . Monitor for dyspnea, dry cough, crackles; pulmonary function tests (DLCO) before each cycle.
  • Raynaud phenomenon: Occurs in 18.7-39% of survivors within 4-12 months post-treatment .
  • Bleomycin elimination: Primarily renal; CrCl must be monitored and dose adjusted for renal impairment.
• Cisplatin Long-Term Toxicities :
  • Neurotoxicity: Peripheral neuropathy in up to 40% of survivors; dose-dependent.
  • Ototoxicity: Severe-to-profound hearing loss in nearly 1 in 5 North American survivors; cumulative dose-related.
  • Nephrotoxicity: Monitor CrCl; aggressive IV hydration required with each cycle.
  • Cardiovascular disease: 3-7 fold increased risk of major adverse cardiovascular events.
  • Secondary malignancies: 1.7-fold increased 20-year cumulative incidence of second malignant neoplasms after BEP .
• EP x2 Advantages :
  • For pathologic stage II NSGCT after RPLND, EP x2 offers: fewer treatment visits (10 vs 20-21 with BEP x3 or EP x4), elimination of bleomycin pulmonary/vascular toxicity, less neurotoxicity/nephrotoxicity/myelosuppression, and significantly better paternity rates (100% vs 76-83%).
• pcRPLND Pathology :
  • Viable carcinoma in 10% of specimens; <10% viable cells with complete resection has favorable outcomes without further treatment (HR 3.22 for relapse if ≥10%).
  • Teratoma in 40%; requires resection as chemotherapy-insensitive and can grow or undergo malignant transformation.
  • Necrosis/fibrosis in 50%; surveillance appropriate.
• Fertility Preservation:
  • All men should be offered fertility preservation (sperm banking) before treatment .
  • Chemotherapy (especially alkylating agents) causes dose-dependent gonadal dysfunction.
• Survivorship Monitoring :
  • 10-year survival rate 95%; over 300,000 testicular cancer survivors in US.
  • Monitor for: second malignant neoplasms (GI cancers, leukemia), cardiovascular disease, neurotoxicity, ototoxicity, hypogonadism (11-16%), chronic fatigue (15-27%), anxiety/depression.
  • Circulating platinum detected up to 28 years post-treatment; levels correlate with neurotoxicity severity.

Summary of Key 2026 Updates

A 28-year-old man arrives in your office 4 weeks after undergoing a left orchiectomy with pathology showing dysmorphic cells with a 'fried-egg' appearance which is indicative of seminoma. On further imaging, he is found to have enlarged pelvic lymph nodes and a 2 cm right upper lobe lung metastasis. No other organ metastases are found. You are discussing his prognosis and plan to obtain baseline alpha-fetoprotein (AFP), lactate dehydrogenase (LDH), and beta-human chorionic gonadotropin (beta-HCG) prior to treatment.

How would you characterize his risk of recurrence after definitive treatment?

• A. Good risk
• B. Intermediate risk
• C. Poor risk
• D. Need to know tumor markers prior to discussing risk"

The correct answer is: A. Good risk

Explanation:

This patient has metastatic seminoma, as evidenced by lung metastasis following orchiectomy for a tumor with classic "fried-egg" appearance (indicative of seminoma). To risk stratify, we use the IGCCCG (International Germ Cell Cancer Collaborative Group) risk classification system specifically for seminoma, which differs slightly from nonseminoma.

IGCCCG Risk Stratification for Seminoma:

• Histology = Pure seminoma
• Metastasis = Lung only → ✅ fits Good risk
• No mention of non-pulmonary visceral metastases → ✅
• AFP not yet known, but:
  
  → If AFP is elevated, this would exclude seminoma and indicate mixed/nonseminomatous tumor → reclassification needed.
  
  → But pure seminoma never produces AFP, so in confirmed seminoma, AFP should be normal by definition.

A 56-year-old man who is an active smoker with a history of chronic obstructive pulmonary disease (COPD) initially presented with new cough and progressively increasing shortness of breath over 2 months. Chest CT reveals a 7 × 5.5 cm anterior mediastinal mass (stage II C). Biopsy of mass is performed and is consistent with pure yolk sac tumor. Tumor markers reveal alpha-fetoprotein (AFP) elevation to 8,941 ng/mL, lactate dehydrogenase (LDH) 273, and undetectable beta-human chorionic gonadotropin (beta-HCG). Testicular ultrasound was negative.

What is the most appropriate initial treatment for this patient?

• A. Resection of the mediastinal mass
• B. Four cycles of BEP (bleomycin/etoposide/cisplatin) chemotherapy
• C. Four cycles of VIP (etoposide/ifosfamide/cisplatin) chemotherapy
• D. Four cycles of EP (etoposide/cisplatin) chemotherapy

Answer: B. Four cycles of BEP (bleomycin/etoposide/cisplatin) chemotherapy

A 28-year-old man presents with a left testicular mass that is 2.8 x 1.4 cm on ultrasound. CT abdomen/pelvis shows enlarged para-aortic lymph nodes (long axis is 2.5 cm, short axis is 1.5 cm) around the left renal hilum [stage IIB]. Tumor markers, including alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (beta-HCG), and lactate dehydrogenase (LDH) are obtained and all are normal. He undergoes radical inguinal orchiectomy and is found to have a mixed seminoma (95%) and embryonal carcinoma (5%). He is noted to have lymphovascular invasion and spermatic cord involvement. One month after orchiectomy, tumor markers remain negative.

What is the diagnosis and next step in treatment?

• A. Seminoma; Surveillance
• B. Seminoma; Radiation to ipsilateral iliac and para-aortic lymph nodes
• C. Nonseminoma; 1 to 2 cycles of BEP (bleomycin/etoposide/cisplatin) chemotherapy
• D. Nonseminoma; Bilateral nerve-sparing retroperitoneal lymph node dissection

Key Clinical Features:

• Diagnosis: Mixed germ cell tumor (95% seminoma, 5% embryonal carcinoma) with lymphovascular invasion (LVI) and spermatic cord involvement.
• Stage IIB: Enlarged retroperitoneal lymph nodes (2.5 cm, non-bulky).
• Tumor Markers: Normal pre- and post-orchiectomy (AFP, beta-hCG, LDH).

Correct Answer: D. Nonseminoma; Bilateral nerve-sparing retroperitoneal lymph node dissection (RPLND)

Explanation:

1. Pathology Dictates Management:
   • Despite being predominantly seminoma (95%), any non-seminomatous component (embryonal carcinoma 5%) classifies the tumor as a nonseminoma for treatment purposes.
   • LVI and spermatic cord involvement further support aggressive management.
2. Stage IIB Nonseminoma with Normal Markers:
   • Primary RPLND is the standard for clinical stage IIA/B nonseminoma with normal tumor markers.
   • Nerve-sparing technique preserves ejaculatory function.
3. Why Not Other Options?
   • A/B (Seminoma options): Incorrect due to nonseminoma component. Seminoma management (radiation/chemotherapy) is inappropriate here.
   • C (BEP chemotherapy): Reserved for bulky stage IIC/III or marker-positive disease. Overtreatment for IIB with normal markers.
4. Post-RPLND Considerations:
   • If pathology reveals lymph node involvement, adjuvant chemotherapy (e.g., BEP x1-2) may be considered based on nodal burden.