Nonseminomatous Tumors Research Articles

Isolated eyeball metastasis of non-seminomatous germ cell testicular tumor

Testicular tumors most frequently metastasize to regional lymph nodes. Non-seminomatous tumor metastasis of testicle (NSGCTT) to the eyeball is rare. We presented a 24-year old man, referred to the ophthalmologist due to acute pain and abrupt loss of sight in the left eye accompanied by its enlargement. Orbital and endocranial computerized tomography (CT) was carried out, indicating the tumor in the left eye. His previous medical history provided the information that the right testicle was painlessly enlarged for 8 months. Ultrasonography showed a completely tumorously altered testis. Abdominal and chest CT failed to reveal any secondary deposits in visceral organs and lymph glands. Tumor markers (AFP - alpha-fetoproteins, beta hCG - human choronic gonadotropin beta) were elevated. Right radical orchiactomy was performed (showed NSGCTT), followed by polychemotherapy with cisplatinum 100 mg/m2, etoposide 120 mg/m2, bleomycin 15 mg/m2 (PEB x 4), resulting in normalization of tumor marker values and significant regression of the left eyeball. Next, the left eye enucleation and ocular prosthesis implantation was carried out. Pathohistological evaluation indicated fibrosis and necrosis only. In a 5-year follow-up period, the patient was free of recurrence. Isolated hematogenous metastasis of the NSGCTT to the eye is rare. In our case, the left eye was the only metastatic localization. After chemotherapy and eye enucleation the patient was in a 4-year follow-up period free of the recurrence.

Survival outcomes for men with mediastinal germ-cell tumors: The University of Texas M. D. Anderson Cancer Center experience

ObjectivePrimary mediastinal germ-cell tumors are rare, and the effect of newer drugs and treatment strategies in this disease on overall survival is not known. We retrospectively assessed treatment outcomes at a single institution. Materials and methodsWe identified men seen at our institution from 1998 through 2005 for mediastinal germ-cell tumors. Medical records were reviewed for patient characteristics, histology, tumor markers, treatment, and survival outcome. ResultsThirty-four patients met study criteria, of whom 27 had nonseminomatous germ-cell tumor (NSGCT) and 7 had pure seminoma. Eleven patients (41%) with NSGCT were alive at last contact with a median overall survival time of 33.5 months. Among 13 patients with NSGCT referred to us at initial diagnosis, 7 (54%) were alive and recurrence-free at a median follow-up of 56.5 months. Progression-free survival was associated with absence of risk factors (any histology other than endodermal sinus tumor, β-hCG > 1000 mIU/mL, or disease outside the mediastinum). For the patients whose disease progressed (n = 5) or who had been referred to us for salvage treatment (n = 14), the 3-year overall survival from the date of first progression was 23%. Conversely, patients with seminoma did uniformly well with platinum-based chemotherapy; most did not undergo radiation or surgery. ConclusionChemotherapy given to maximum effect followed by surgical consolidation resulted in long-term progression-free survival for 54% of patients with mediastinal NSGCT. The number of risk factors present at diagnosis may be associated with survival outcome and should be studied in a larger test group.

Long-Term Results of Laparoscopic Retroperitoneal Lymph Node Dissection (RPLND) in Low-Stage Nonseminomatous Germ-Cell Testicular Tumors (NSGCTT) Performed by a Senior Surgeon: 1999–2003

Laparoscopic RPLND for low-stages NSGCTT is controversial: it is performed and recommended by excellent laparoscopic surgeons, but it is not widely used. The aim of this paper is to evaluate the results achieved by a senior surgeon, expert in open RPLND, who was introduced to laparoscopic surgery by excellent laparoscopists (LN, CU, GJ). of the 48 operated patients, 36 had primary RPLND for clinical stage I disease (22 TIN0, 7 TxN0, 5 T2-3 N0 and 2 TIS1 N0) and 12 had post-chemotherapy surgery for IIA and IIB retroperitoneal nodes with normalized AFP and HCG. L-RPLND was performed with 4 ports and the en bloc removal of unilateral retroperitoneal nodes with the spermatic vessels. No post-operative adjuvant chemotherapy was planned for patients with documented nodal metastases as for open RPLND since 1985. Average operative time was 3.30' for the 36 clinical stage I patients and 4 hours for post-chemotherapy surgery. Blood loss was minimal in all cases, because of early conversion to open surgery in all patients with no immediate hemostasis at L-RPLND. Metastases were found in 6 (17%) out of the 36 clinical stage I patients: none in the 22 pTI, 1 in the 7 Tx, 3 in the 5 pT2-3 and in 2 of the 2 pT1S1 patients. Residual teratoma was found in 6 of the 12 patients who received neo-adjuvant chemotherapy for clinical stage IIA or IIB disease. The other 6 had fibrosis-necrosis. Further metastases developed in 2 of the 30 patients with negative nodes: 1 in the lung in a pT1, and 1 in a pT2 patient with increasing markers. Surprisingly, the first two pT2-3 patients with positive nodes developed liver metastases in a few months after L-RPLND. Consequently, all following patients with active metastases at L-RPLND received 2 courses of adjuvant PEB. All 4 patients who relapsed were cured, are alive and disease-free. L-RPLND is a very demanding operation, which appears to be more a staging procedure than a curative operation. It is ideal for pT1 clinical stage I and for post-chemotherapy stages IIA& B with residual teratoma and normalized markers, but wait & see in good risk and open RPLND in high risk patients are very competing. Only few reports compared laparoscopic versus open RPLND, but not in a randomized study.

Laparoscopic Retroperitoneal Lymph Node Dissection with Therapeutic Intent in Men with Clinical Stage I Nonseminomatous Germ Cell Tumors

Laparoscopic retroperitoneal lymph node dissection (RPLND) as a primary means of therapy for patients with clinical stage I nonseminomatous germ-cell tumors (NSGCTs) remains controversial. The object of this study was to assess the outcomes of patients with clinical stage I NSGCTs who underwent laparoscopic RPLND with therapeutic intent. We retrospectively reviewed the pathologic and clinical outcomes of 26 consecutive patients who underwent a laparoscopic RPLND with therapeutic intent for clinical stage I NSGCT from July 2006 to March 2009. Patients underwent an extended template laparoscopic RPLND including dissection behind the great vessels. A full bilateral dissection was performed if metastatic disease was discovered intraoperatively. Of the 26 patients, 9 (35%) were discovered to have pathologic stage II disease. The mean number of nodes removed at the time of laparoscopic RPLND was 28 (range 6-82). Of six patients found to have pN₁ disease, four (67%) did not receive adjuvant chemotherapy and are without evidence of disease at a mean follow-up of 24 months. Two (12%) patients with pathologically confirmed stage I disease had recurrence after laparoscopic RPLND, both outside of the retroperitoneum. Laparoscopic RPLND with therapeutic intent can be performed with acceptable oncologic efficacy with the additional benefit of decreased morbidity and shorter convalescence times. Early data suggest that patients with pathologic N₁ disease can be safely observed after laparoscopic RPLND, although longer follow-up and additional patients are needed to validate these results.

Poor prognosis nonseminomatous germ-cell tumours (NSGCTs): should chemotherapy doses be reduced at first cycle to prevent acute respiratory distress syndrome in patients with multiple lung metastases?

BackgroundPatients with extensive lung metastases from nonseminomatous germ-cell tumours (NSGCTs) and dyspnoea at presentation are at high risk of acute respiratory distress syndrome (ARDS) and death within the first weeks after chemotherapy induction. This syndrome is linked to acute intra-alveolar haemorrhage related to early tumour necrosis, which in turn, can be complicated by pulmonary infection promoted by neutropenia. The management of these patients was modified at Institut Gustave Roussy in 1997 to try to avoid this complication. Patients and methodsData concerning all patients with lung metastases from NSGCT and dyspnoea or a partial pressure of oxygen (pO2) <80 mmHg treated from 1980 to 2006 in our institution were collected. Patients were treated in a specialised intensive care unit. From 1980 to 1997, the first chemotherapy cycle consisted in a full-dose regimen. After 1997, a 3-day reduced induction regimen of EP (cisplatin 20 mg/m2/day and etoposide 100 mg/m2/day) was used, with bleomycin and two additional days of EP being postponed to day 15, with the regular BEP regimen being started at day 21. ResultsTwenty-five patients with poor-risk disseminated NSGCT according to the International Germ Cell Consensus Classification Group had extensive lung metastases plus dyspnoea at presentation (n = 6), a pO2 <80 mmHg (n = 2), or both criteria (n = 17). Median human chorionic gonadotrophin was 200000 UI (range 11–8920000), and 18 of 25 (72%) patients also had nonpulmonary visceral metastases. During the 1980–1997 period, 13 of 15 patients (87%) developed ARDS, 10 of whom died, and only 4 of 15 (27%) patients were long-term survivors. In contrast, during the 1997–2006 period, only 3 of 10 patients (30%) developed ARDS (P = 0.01), 2 of whom died, and 4 of 10 (40%) eventually survived. ConclusionInitial reduction of chemotherapy doses during the first cycle of chemotherapy for poor prognosis NSGCT with extensive lung metastases seems to prevent the risk of early death due to ARDS.

Worm-like thrombus in left main coronary artery after cytostatic treatment

This paper reports a 43-year-old patient who had a large, mobile, worm-like thrombus in the left main coronary artery after receiving a chemotherapy regimen containing cisplatin, bleomycin and etoposide for a nonseminomatous testes tumor. The patient was successfully treated with thrombolytic therapy. Physicians should be aware that thrombotic events may be observed after the administration of certain chemotherapeutic agents, particularly cisplatin.

Non-risk-adapted surveillance for patients with stage I nonseminomatous testicular germ-cell tumors: diminishing treatment-related morbidity while maintaining efficacy

BackgroundWith treatment leading to nearly uniform cure in clinical stage I nonseminomatous testicular cancer (CSI-NSGCT), diminishing treatment-related morbidity has become the primary concern. This study examined feasibility and outcome of active surveillance as treatment in an unselected CSI patient population. Materials and methodsAll patients with CSI-NSGCT referred from 1998 to 2007 to the British Columbia Cancer Agency and the Oregon Testis Cancer Program were retrospectively reviewed. A total of 233 patients were identified, of which 223 chose active surveillance. ResultsVascular invasion (VI) was absent, present and unknown in 66%, 27% and 7% of cases, respectively. Overall, 49% of patients had embryonal predominant disease. Fifty-nine patients (26%) relapsed, all but one with good prognosis disease. VI was present in 30 relapsed patients. Most patients relapsed within 2 years (88%). Only 7 of 223 patients (3%) relapsed beyond 2 years. All relapses were in long-term remission following chemotherapy with or without retroperitoneal lymph node dissection (RPLND). Only 17 of 223 patients (8%) required postorchiectomy surgery. Disease-specific survival is 100% after a median follow-up of 52 months (3–136). No patient has required second-line chemotherapy. ConclusionsActive surveillance for all CSI-NSGCT patients is associated with excellent outcomes comparable with the best results reported with primary RPLND or adjuvant chemotherapy. Nearly 75% of patients are spared any therapy after orchiectomy.

Laparoscopic Postchemotherapy Retroperitoneal Lymph Node Dissection in Nonseminomatous Testicular Cancer Patients

Abstract Introduction: Laparoscopic retroperitoneal lymph node dissection (LRPLND) has become an accepted staging method for clinical stage I nonseminomatous germ cell testicular tumor.1,2 As a res...

Impact of delayed orchiectomy (OE) on overall survival (OS) in patients (pts) with metastatic germ cell tumors (mGCT).

4584 Background: Classically OE is the first step of the treatment of mGCT. However some pts have severe symptoms of disease, which require immediate beginning of chemotherapy (CT) followed by OE. The retrospective analysis was performed to find any impact of time constraints of delayed OE on survival in pts with mGCT. Methods: We analyzed data of 1483 CT-naïve pts with advanced mGCT of testis treated in our department from 1986 to 2009. Delayed OE was performed on 71(4,8%) pts. Seminoma – 8 pts (11,2%), nonseminomatous tumor – 50 pts (70,4%), unknown histology – 13 pts (18,4%). Twenty, 40% and 40% of pts belonged to good, intermediate and poor IGCCCG prognostic groups respectively. Median time from the beginning of the CT to OE was 18 (range, 1-250) days. OE was performed on 39 (55%) pts during cycle 1, 11 (15.5%) pts - after completion of induction CT, other pts – during cycles 2-4. Median follow-up time was 156 (range, 3 - 241) months. Etoposide and cisplatin containing CT was performed on 66 pts (93%). Results: Three-year OS for all 1,478 pts was 75%. Primary tumor had excellent response to CT: among pts who had delayed OE after completion of CT (n=11) only mature teratoma (n=4) and necrosis (n=7) were found. The 3-year OS in pts with delayed OE was 63%. OE performed after completion of CT was associated with better prognosis. The 3-year OS in pts with delayed OE performed during the 1st cycle (group 1) was 67%, during 2nd – 4th cycles of CT – 39% (group 2), and after completion of CT – 88% (group 3) (groups 1 vs. 3: HR 3,7, 95% CI 0,69 to 10,1, g=0,15; groups 2 vs. 3: g=0,01, HR 8,1, 95% CI 1.32 to 18.72). It seems that if OE had been performed during CT, the beginning of next cycle was delayed and dose intensity of CT was decreased. Conclusions: In case of severe symptoms of disease, which require an immediate start of CT, performing OE simultaneously with other surgeries after completion of induction CT was associated with better OS, when compared with performing OE during induction CT. No significant financial relationships to disclose.

Update on testicular germ cell tumors

To discuss several important developments in testicular germ cell tumors in the past year. Genomic studies are examining gene expression as possible markers for disease relapse and chemotherapy resistance. Optimal treatment strategies for early-stage nonseminomatous tumors continue to evolve and patient compliance with posttreatment surveillance schedules remains problematic. Advanced and platinum-refractory disease states continue to be challenging entities in terms of optimizing therapy and outcome. Significant challenges remain for treatment of certain categories of testicular germ cell tumors. Treatment and surveillance paradigms continue to be defined and refined as research in these areas continues.

Outcome following resection for patients with primary mediastinal nonseminomatous germ-cell tumors and rising serum tumor markers post-chemotherapy

BackgroundTo assess the outcome of surgical resection in patients with primary mediastinal nonseminomatous germ-cell tumors (PMNSGCT) with rising serum tumor markers (STM) following standard platinum-based chemotherapy. Patients and methodsA total of 158 consecutive patients with PMNSGCT who received platinum-based chemotherapy followed by complete surgical extirpation of residual disease at Indiana University from 1982 to 2007 were retrospectively reviewed. Thirty-five of these 158 patients had rising STM at time of resection. ResultsThirty-five patients (34 males and 1 female) comprise the basis of this report. Three patients had rising human chorionic gonadotropin, and the remaining 32 patients had rising alpha-fetoprotein at the time of thoracic surgery. Twenty-four of the 35 (69%) pathologically demonstrated viable germ-cell tumor, while 8 patients had teratoma and 3 patients had necrosis only at time of resection, despite the presence of rising STM. Twenty-seven patients normalized their tumor markers postoperatively. Twenty-one of 35 died, 5 were lost to follow-up, and 9 are alive. Of the nine patients alive, seven are continuously disease free with median follow-up of 64 months (range 25–220 months). ConclusionThe presence of rising STM doesn’t preclude successful therapy with surgical resection, especially if carried out by experienced thoracic surgical oncologists.

Retroperitoneal Surgery in the Treatment of Germ-Cell Tumors of the Testis: Retroperitoneal Lymph Node Dissection (RPLND)

Germ-cell tumors of the testis (GCTT) are rare, but have a high social impact. In fact they represent no more than 1% of male tumors (about 700 new cases per year in Italy), but electively occur in young patients, 20 to 40 years old, during their fully mature social and working life. More than 80% of patients are cured and return to a normal social, sexual, and working life. Improvements achieved both in diagnosis, with the use of scans (CT, MRI, US and recently PET) and of serum tumor markers alpha-fetoprotein (AFP), beta-fraction of human chorionic gonadotropin (β-HCG) and lactate dehydrogenase (LDH), and mainly in treatment, through the amelioration of radiotherapy and surgical techniques and, especially, with the introduction of Cisplatin, Etoposide and Ifosfamide in Chemotherapic regimens, have made germ-cell tumor a model of “curable disease”. Retroperitoneal lymph node dissection (RPLND) has indications in patients with clinical stage I (CS1) as well as in advanced disease, where it is integrated in the multimodality treatment. Anatomical studies, as well as a long-term experience, have gradually but consistently modified the surgical techniques of RPLND. Currently, “nerve sparing” RPLND represents a safe management of CS1 nonseminomatous germ cell testicular tumor with minimal morbidity and excellent outcomes. Nonetheless, surveillance and adjuvant chemotherapy are as effective as RPLND, but, in our opinion, associated with some discomforts for the patients. Laparoscopic retroperitoneal lymph node dissection (Lap-RPLND) is gaining popularity as a minimally invasive staging procedure for clinical stage I nonseminomatous testicular carcinoma, but its therapeutic role is still under investigation.

Individual and seminal characteristics of patients with testicular germ cell tumors

To analyze the characteristics of patients with testicular germ cell cancer and compare patients' sperm quality according to histologic type (seminomatous and nonseminomatous tumors). Prospective study. Sperm bank at a university. One hundred consecutive patients with testicular tumor who had been referred to our infertility center for cryopreservation, between 2004 and 2006. A questionnaire, through personal interview, was given to all patients and collection of seminal data before cryopreservation was performed. Patient characteristics, including age, time between diagnosis and orchiectomy, history of cryptorchidism, histologic type, and seminal analysis were taken into consideration. The mean age of the patients at the time of diagnosis was 26.9 years. The mean time between cancer suspicion and the diagnosis of neoplasm was 58.9 days, and 19.4 more days were necessary until orchiectomy was performed. Eleven patients had a history of cryptorchidism. Thirty-seven patients had seminomatous tumors. Men with a seminoma present a higher number of motile and morphologically normal sperm in the ejaculate than men with a nonseminoma, although individual semen variables are not different. The majority of the patients with testicular cancer, referred to our infertility center, are very young, single, do not have children, and are unaware of their fertility potential status by the time diagnosis is made. Men with a nonseminoma present semen of lower quality.

Expression of embryonic stem cell markers in cultured JKT‐1, a cell line derived from a human seminoma

Testicular germ cell tumours (TGCTs), the most frequent solid tumour of the young men, originate from the primitive germ cells. They share some pluripotency stem-cell markers which may help to distinguish between seminoma, the most frequent TGCTs and non-seminoma tumours, such as embryonal carcinoma, teratocarcinoma or choriocarcinoma. Due probably to the propensity of seminoma to apoptosis, only two cell lines originated from pure testicular seminoma, TCam-2 and JKT-1 have been up to now, established, maintained and proposed as representative models of human testicular seminoma. However, both seem, following recent reports, to be able to drift. Thus, the molecular signature of embryonic stem-cell markers of the JKT-1 cells cultured in our laboratory, were studied by RT-PCR, Western blot and immunofluorescence (IF). JKT-1 cells analysed after 30 passages, expressed placenta alkaline phosphatase but not alphafoetoprotein (alphaFP) nor beta-human chorionic gonadotropin. JKT-1 cells also expressed markers of pluripotency such as NANOG and OCT3/4 and more specific seminoma markers, such as AP2gamma and HIWI. However, protein expression of OCT3/4 and AP2y was weak and these JKT-1 cells expressed SOX2, a marker of embryonal carcinoma and did not express c-KIT usually expressed in most seminoma. Possible derivation through in vitro culture conditions was supported by looking at later passages (61) which showed a decrease of NANOG and HIWI protein expression. JKT-1 cells express a signature of markers which is still near from the one express by seminoma cells, allowing carcinogenetic studies. However, because of their great ability to drift as shown for TCam-2, it is recommended to verify and to precise this molecular signature before reporting functional results.

Management of good-risk metastatic nonseminomatous germ cell tumors of the testis: current concepts and controversies.

Introduction/Methods:Approximately 30% of nonseminomatous germ-cell tumors (NSGCT) of the testis present with metastatic disease. In 1997, the International Germ Cell Cancer Collaborative Group (IGCCCG) stratified all patients with metastatic NSGCT into various risk groups based on serum tumor markers and presence of visceral disease. We review the literature and present optimal stage-dependent management strategies in patients with favorable-risk metastatic NSGCT.Results:Primary chemotherapy (3 cycles BEP or 4 cycles EP) has been shown to be the preferred modality in patients with Clinical Stage IS (cIS) and in patients with bulky metastatic disease (≥CS IIb) due to their high risk of systemic disease and recurrence. Primary retroperitoneal lymph node dissection appears to be the most efficient primary therapy for retroperitoneal disease <2 cm (CS IIa), with adjuvant chemotherapy reserved for patients who are pathologically advanced (>5 nodes involved, single node > 2 cm) and for those who are non-compliant with surveillance regimens. Following primary chemotherapy, STM and radiographic evaluation are used to assess treatment response. For patients with normalization of STM and retroperitoneal masses < 1 cm, retroperitoneal lymph node dissection or observation with treatment at disease progression are considered options. Due to risk of teratoma or chemoresistant GCT, masses >1 cm and extra-retroperitoneal masses should be treated with surgical resection, which should be performed with nerve-sparing, if possible.Conclusions:In patients with favorable disease based on IGCCCG criteria, clinical stage, STM, and radiographic evaluation are used to guide appropriate therapy to provide excellent long-term cure rates (>92%) in patients with metastatic NSGCT.

Twelve Years of Experience in the Management of Testicular Germ Cell Tumors at a Referral Center in Portugal.

BackgroundTesticular germ cell tumors (TGCT) are generally rare but quite frequent in young males. Guidelines are well established for their management.MethodsWe present the first report from Portugal on clinical, histological, treatment modalities and outcomes of a population with TGCT. Data was retrospectively analyzed for the 1996 through 2008 period, applying a previous internally validated protocol.ResultsSeventy nine patients with TGCT were identified, 40.5% had seminomatous and 59.5% nonseminomatous tumors. Incidence rates were higher among males in their twenties and thirties. Pain and swelling testis were the most common symptoms and microlithiasis was detected in 20.3% of patients. Lower stages were more frequent in seminomatous tumors. Orchiectomy was done in all patients and further therapy was performed by guidelines recommendations in 86.1% of them. Hematological toxicity was found in 44.3% of the population studied and free disease survival rates were at 88.6%.ConclusionsThis retrospective study corroborates the European Western country trends concerning TGCT. Mortality was only seen in nonseminomatous TGCT group. Good risk and lower TGCT stages have no deaths reported. Public health campaigns should be undertaken to guide patients to seek medical advice earlier in the course of the disease.

Mixed germ cell tumor of the testicle with ravdomuosarcomatous component: a case report

IntroductionTesticular tumors can be classified as seminomatous and non-seminomatous germ-cell tumor (NSGCT) types. Mixed germ cell tumors contain more than one germ cell component and are much more common than any of the pure histologic forms representing 32%-60% of all germ cell tumors. The composition of these tumors varies. Here we present a rare case of a mixed germ cell tumor composed of seminoma, Yolk sack tumor and teratoma containing a sarcoma component of somatic type malignancy.Case presentationA 32-year-old Caucasian male presented with history of right-sided scrotal swelling since 6 months. Backache was present since 2 months and a history of right epididimitis was also present since 8 months. Alpha-Fetoprotein, beta-HCG and LDH values were found abmormal. USG of the scrotum revealed a large right testis swelling characterized by scarce cystic elements and calcifications. CT scan of the abdomen showed nodular metastasis involving the interaortocaval, precaval, and right para-aortic lymph nodes. The block of enlarged lymph nodes infiltrated the psoas muscle. The patient underwent right-sided high orchidectomy and was given chemotherapy of the BEP regimen. After the 2nd cycle the patient discontinued the chemotherapy and when he came for follow-up after a gap of 3 months, despite the normalisation in tumor markers values, the retroperitoneal mass was relapsed. CT scan of the chest showed multiple lung metastases.ConclusionMore than 50% of germ-cell tumors include more than 2 basic germ-cell tumor types, with the exception of spermatocytic seminoma. About 90% of the patients with nonseminomatous tumors can achieve complete cure with aggressive chemotherapy and most of them can be cured. Although prognosis of testicular tumors depends largely on clinical stage, histological type and adhesion to the treatment influence the prognosis as well.

Massive Hemorrhage From Spontaneous Rupture of a Retroperitoneal Lymph Node in Patient With Metastatic Mixed Germ Cell Tumor

Spontaneous hemoperitoneum secondary to metastatic foci of testicular germ cell tumor is a rare finding and is usually precipitated by the beginning of chemotherapy treatments. This acute presentation is usually due to the rupture of hepatic or gastrointestinal metastasis. We present the case of a 16-year-old boy who was admitted to the emergency room with acute abdominal pain and unstable vital signs, 10 days after a left orchiectomy for a testicular mixed nonseminomatous tumor. An urgent laparotomy demonstrated a significant peritoneal effusion (3 L) secondary to a ruptured retroperitoneal lymph node. More than 90% of the mass was resected with 3 cm of adherent jejunum. Pathologic findings revealed the mass to be composed of more than 95% of choriocarcinoma. The patient recovered well from the surgery and received standard chemotherapy with good response and no residual disease. Two and a half years after diagnosis, the patient is still in remission.

Brain metastases from testicular germ cell tumors: A retrospective analysis

To review our series of testicular germ cell tumors with brain metastases and to establish an optimal treatment strategy for them. Twenty-seven cases of testicular germ cell tumors from three institutions were retrospectively reviewed. Twenty-six were non-seminomatous tumors and only one was a seminoma. Based on the International Germ Cell Consensus Classification, two cases were classified as good prognosis, seven as intermediate prognosis and 18 as poor prognosis. Chemotherapy was carried out in all patients. Additionally, whole-brain radiotherapy was performed in 10 cases, stereotactic radiosurgery in six, whole-brain radiotherapy combined with stereotactic radiosurgery in three and complete surgical resection in five. Three patients received chemotherapy only. Cancer-specific 5- and 10-year survival rates were both 35.9%. The prognosis of those with brain metastases at the time of diagnosis tended to be better than those developing brain metastases during treatment. Those with a single brain metastasis showed significantly better survival than those with multiple brain metastases. No other significant prognostic factor was found at multivariate analysis. Testicular germ cell tumors with brain metastases can be managed with the combination of whole-brain radiotherapy, stereotactic radiotherapy, and/or surgical resection in combination with chemotherapy.

Late relapse of nonseminomatous germ cell tumours

Late relapses of nonseminomatous cell tumours (NSGCTs) are rare and occur by definition at > or =2 years after successful treatment. They represent a major challenge of current treatment and follow-up of the affected patients. We present relevant literature on late-relapsing NSGCTs to provide an overview over the effect of primary treatment, patient and tumour characteristics. Of all patients with NSGCT, 1-6% have a late relapse, with those having extragonadal GCTs being at greatest risk. The predominant site of relapse is the retroperitoneal space. Suboptimal primary treatment, especially insufficient retroperitoneal surgery, increases the risk of late relapses. Radical surgery is probably the most important treatment, with advances in salvage chemotherapy adding to the improved cure rates. Treatment at an experienced institution ensures a 5-year cancer-specific survival of >50%, and this approaches 100% in case of single-site mature teratoma. Diagnosis and proper treatment of patients with late-relapsing NSGCTs is challenging and should be restricted to experienced centres only. Referral of late-relapsing patients to high-volume institutions ensures the best chances of cure and enables increasing understanding of tumour biology and the clinical course of these patients.