Nonseminomatous Germ Cell Tumors Of The Testis Research Articles

Results of adjuvant chemotherapy for low-stage nonseminomatous germ cell tumors of the testis with vascular invasion

Vascular invasion has been well established as one of the prime prognostic indicators in nonseminomatous germ cell tumors of the testis (NSGCT). In a retrospective series of node negative or minimally involved patients by radiology, only eight of 28 (28.6%) survived when vascular invasion was detected, compared with 50 of 72 (69%) without vascular invasion. In 1977 a policy of adjuvant cytotoxics (vinblastine and bleomycin) was added to the radiotherapy which was standard postorchidectomy treatment at the Peter MacCallum Cancer Institute. When platinum-based combination regimens were found to be effective, the radiotherapy was discontinued. Only two relapses with the original treatment occurred with one death 10 years later. The modified Einhorn protocol used as primary postorchidectomy treatment has prevented relapse in all six cases in whom it was used. The overall survival rate at 2 to 10 years is 94%. There are important implications in these findings for the "watch policy" which is becoming increasingly popular. In our opinion patients should not be merely watched when histologic sectioning of the primary reveals invasion of the vessels, of whatever type, by the tumor. Instead they should be treated.

The Management of Advanced Testicular Teratoma

Of 320 patients with metastatic malignant non-seminomatous germ cell tumours of the testis (NSGCT) treated with chemotherapy, 266 (83%) are alive and well after a median follow-up of 39 months. Deaths from treatment-related causes occurred in 9 patients and were related to intensity of chemotherapy. Relapse after chemotherapy was rare except in presentations with large tumour volume and high serum marker concentrations and a strategy has been developed of risk-related choice of chemotherapy in order to reduce treatment toxicity in good prognosis sub-groups of patients.

Primary chemotherapy for clinical stage II nonseminomatous germ cell tumors of the testis: a follow-up of 50 patients.

Fifty patients with clinical stage II nonseminomatous germ cell tumor of the testis (NSGCTT) were treated with primary chemotherapy followed by a retroperitoneal lymph node dissection (RPLND) in selected patients. The study population included 34 patients with retroperitoneal masses and elevated levels of serum biomarkers (alpha-fetoprotein [AFP] and beta-human chorionic gonadotropin [BHCG] ), five with needle aspiration biopsy-proven retroperitoneal metastases but normal levels of biomarkers, and 11 in whom there were rising levels of serum biomarkers but no radiographic evidence of retroperitoneal metastases. Forty-eight patients (96%) achieved a complete response (CR), with a mean disease-free survival of 132 weeks (range, 55 to 273 weeks). Two patients developed recurrent disease. One died and one achieved a second CR with further therapy (48 + weeks). Postchemotherapy RPLND was required in 11 patients (22%). Patients with embryonal carcinoma had a lower frequency of RPLND (8%) than patients with teratomatous elements in their primary tumor [36%, P = .014]. To reduce the frequency of double therapy (surgery +/- chemotherapy), we propose individualized therapy. Patients presenting with clinical stage II embryonal carcinoma of the testis should receive primary chemotherapy. Patients with clinical stage II NSGCTT and teratomatous elements in their primary tumor continue to require an RPLND. Those patients with intermediate volume disease (greater than 2 cm less than or equal to 5 cm in maximum diameter) may be treated with an RPLND only. Patients with higher volume teratomatous elements (greater than 5 cm less than or equal to 10 cm in maximum diameter) are likely to require the combination of chemotherapy and surgery.

Hodgkin's disease during surveillance of Stage I testicular teratoma

It has become an established practice in some specialised centres for patients with Stage I non-seminomatous germ-cell tumours of the testis to be kept under close surveillance following orchidectomy. We report a patient with testicular teratoma treated with orchidectomy alone who, during the period of close observation, developed Hodgkin's disease. The patient, a 20-year-old man, had an inguinal orchidectomy for left testicular enlargement which was histologically a malignant teratoma, undifferentiated. Initial chest radiography, lymphography and computed tomography (CT) of the chest and abdomen were normal. Serum alpha fetoprotein (AFP) and beta human chorionic gonadotrophin (BHCG) were undetectable.

Surveillance or lymph node dissection in clinical stage I non-seminomatous germinal testis cancer?

Surveillance following orchiectomy alone has gained popularity in the management of clinical stage I non-seminomatous germ cell tumours (NSGCT) of the testis. However, long-term follow-up of the retroperitoneal nodes can be difficult. We analysed the results of 71 consecutive patients followed for more than 1 year. Fifty men (70.5%) remain disease-free and 21 (29.5%) have relapsed. Relapses occurred 2 to 36 months after orchiectomy (median 6 months). Retroperitoneal nodes were involved in 12 cases (17%). In only one patient were retroperitoneal metastases diagnosed when smaller than 2 cm and in four they were diagnosed when larger than 5 cm. Furthermore, the late relapses occurred in the retroperitoneal nodes. After treatment of metastases, 69 patients (97%) are alive, disease-free and off therapy. As retroperitoneal relapses do not occur after a properly executed retroperitoneal lymph node dissection (RPLND) and ejaculation problems can be avoided with unilateral RPLND, it is suggested that RPLND can be used for clinical stage I NSGCT of the testis in experienced surgical centres, with the advantage of an easier follow-up.

The role of chemotherapy and surgery in the treatment of retroperitoneal metastases in advanced nonseminomatous testis cancer.

This study evaluates the effect of combination chemotherapy on retroperitoneal metastases from nonseminomatous germ cell tumors of the testis (NSGCTT). Sixty-six patients with Stage III or bulky Stage II NSGCTT with clinically documented retroperitoneal metastases first received systemic chemotherapy. Seventeen patients had minimal and 49 had advanced retroperitoneal metastases. The retroperitoneal metastases were classified as advanced if the patient had a palpable retroperitoneal mass, ureteral deviation on intravenous pyelogram, or a mass with a diameter greater than or equal to 5 cm documented by a computerized axial tomographic scan, a pedal lymphangiogram, or surgery. The patients with lesser but clinically evident retroperitoneal metastatic deposits were considered to have minimal retroperitoneal metastases. A complete remission of retroperitoneal metastatic deposits was achieved in 50 (76%) patients, with chemotherapy alone in 25 (38%), and with combined chemotherapy and surgery in 25 (38%). The resected deposits consisted of mature teratoma in 15 and malignant elements in 10. A complete remission using chemotherapy alone occurred in 13 of 17 (76%) with minimal and in 12/49 (24%) with advanced retroperitoneal metastases, and in 17/30 (57%) without and 8/36 (22%) with teratoma in the testis tumor. The data strongly implied that the bulk of the metastatic deposits was a more important prognostic variable than the histology of the primary tumor. The adverse relationship of a teratomatous differentiation on the response rates with chemotherapy alone was offset by the success of supplemental surgery. This study suggests the benefit of a postchemotherapy retroperitoneal lymph node dissection (RPLND) in patients with initially bulky retroperitoneal metastases (complete response [CR] increased from 24% to 67%; an additional 47% patients had no evidence of disease). The patients with minimal retroperitoneal metastases usually achieved a CR with chemotherapy alone. A routine RPLND after the chemotherapy is not indicated in patients with initially minimal retroperitoneal metastases.

Orchiectomy alone in the treatment of clinical stage I nonseminomatous germ cell tumor of the testis.

Forty-five patients with clinical stage I nonseminomatous germ cell tumor of the testis (NSGCTT) were entered in a prospective clinical trial to receive no treatment other than orchiectomy until clinical evidence of relapse. Of this group, 36 patients (80%) have been continuously free of disease for a median duration of 19.5 months after orchiectomy. Nine patients (20%) have relapsed, eight within seven months of orchiectomy. Seven of nine relapsing patients have been rendered free of disease with chemotherapy and/or surgery for a median duration of seven months (range, one to 33 months) after completion of treatment; the other two patients are presently under treatment although one has progressive disease. The relapse rate was higher in patients with embryonal carcinoma than in those with teratocarcinoma, 57% versus 17%. These preliminary results imply that the omission of routine lymphadenectomy or lymph-node irradiation in clinical stage I NSGCTT deserves further trial.

Expectant therapy for clinical stage A nonseminomatous germ-cell tumors of the testis? No

Expectant therapy is based on the accuracy of noninvasive staging methods, a belief that the complications of surgery (such as ejaculatory dysfunction) are unacceptable, and the efficacy of combination chemotherapy. The authors dispute the accuracy of noninvasive staging, review the recent data suggesting that infertility is a less common complication of surgery than has been supposed, and highlight the short-term and long-term toxic effects of chemotherapy in support of their conviction that surgical treatment is preferable to expectant therapy for clinically low-stage nonseminomatous testicular cancer.

19 Steroids and other markers in non-seminomatous germ-cell tumors of the testis

19 Steroids and other markers in non-seminomatous germ-cell tumors of the testis

Prognostic factors in clinical stage I non-seminomatous germ-cell tumours of the testis.

Prognostic factors have been studied in 59 men with clinical Stage I non-seminomatous germ-cell tumours of the testis (NSGCTT) seen at the Royal Marsden Hospital between 1973 and 1978. Fourteen of the patients relapsed, and 45 have remained continuously disease-free. Two factors were identified which showed a significant correlation with relapse following radiotherapy: local extent of the primary tumour, and rate of decline of serum alpha-foetoprotein (AFP) and beta-human chorionic gonadotrophin (hCG) levels following orchidectomy. High serum marker levels at the time of referral after orchidectomy were not prognostically significant per se. The presence of tissue-associated hCG in the primary tumour was not prognostically significant. The results were compared with histology and pathological stage of the primary tumour in patients presenting with lung metastases but no clinical evidence of lymph-node disease. Embryonal carcinoma was more commonly associated with a locally invasive primary tumour and with extralymphatic spread than was teratocarcinoma.