Normalization Of Serum Tumor Markers Research Articles

Surveillance of postchemotherapy subcentimeter residual retroperitoneal mass in metastatic nonseminomatous germ cell tumor: Does how you measure matter?

BackgroundApproximately 70% to 80% of patients with metastatic nonseminomatous germ cell tumor (NSGCT) treated with cisplatin-based chemotherapy achieve a complete response, defined as normalization of serum tumor markers and either no residual retroperitoneal mass (RRM) or an RRM <1.0 cm. While there is universal agreement that patients with an RRM ≥1.0 cm should undergo retroperitoneal lymph node dissection (RPLND), many institutions including ours recommend surveillance for patients who achieve a complete response. However, studies have not defined which axis of the RRM should be considered when deciding between surveillance and RPLND. Patients and MethodsGood-risk metastatic NSGCT patients treated with cisplatin-based chemotherapy who achieved a complete response and underwent surveillance were identified using our institution's electronic medical records. A post-hoc review was performed by a blinded radiologist. The RRM dimensions in the transaxial short axis (TSA), transaxial long axis (TLA), and craniocaudal axis (CCA) were recorded. Differences in the frequency of recurrence between groups with an RRM <1.0 cm and ≥1.0 cm in the TLA and CCA were assessed using the Fisher exact test. ResultsThirty-nine patients who met study criteria were included. At a median follow-up of 63.8 months, 2 patients (5.1%) recurred. Both were successfully treated with salvage chemotherapy and RPLND. Thirteen (33%) and 27 (69%) patients had an RRM ≥1.0 cm in the TLA and CCA, respectively. There were no statistically significant differences in the risk of recurrence between patients with an RRM <1.0 cm and ≥1.0 cm in the TLA (P = 0.54) or CCA (P = 0.53). ConclusionsSurveillance is an effective strategy in good-risk NSGCT patients with a postchemotherapy RRM <1.0 cm in the TSA. Our study suggests referencing the TSA and not the TLA or CCA may avoid unnecessary postchemotherapy RPLNDs.

Long-term Surveillance of Patients with Complete Response Following Chemotherapy for Metastatic Nonseminomatous Germ Cell Tumor

BackgroundThere is controversy regarding the management of patients with normal markers and residual masses (≤1 cm) after chemotherapy for nonseminomatous germ cell tumors (NSGCTs). ObjectiveTo determine long-term outcomes of a surveillance strategy in such patients. Design, setting, and participantsA retrospective review of our multidisciplinary testicular cancer database was performed. All patients who underwent primary chemotherapy for metastatic NSGCTs were identified between 1981 and 2016. A complete response (CR) was defined as normalization of serum tumor markers and a ≤1 cm residual mass in the largest axial dimension following chemotherapy. All such patients were surveilled. Outcome measurements and statistical analysisOutcome variables of interest were time to death, time to cancer-specific survival, and time to relapse. Overall survival and relapse-free survival were calculated using the Kaplan-Meier method, and the cumulative incidence of cause-specific survival rates was calculated using competing risk analysis. The impact of risk group and chemotherapy regimen on relapse-free survival was assessed using log-rank test. Results and limitationsDuring the study period, 1429 metastatic germ cell tumor patients were treated with primary chemotherapy. CR was achieved in 191 (18.5%) NSGCT patients. The median age at diagnosis was 27.4 yr, with a median follow-up of 81.1 mo. The majority had American Joint Committee on Cancer stage II at diagnosis (I: 23.8%; II: 49.2%; III: 27%) and International Germ Cell Cancer Collaborative Group good-risk disease (good: 78%; intermediate: 17.8%; poor: 4.2%). Of the 191 patients with a CR, 175 (91.6%) never relapsed and remain disease free. Sixteen (8.4%) patients relapsed after a median of 11.3 mo (range 1–332 mo), with over half (nine patients; 4.7%) relapsing in the retroperitoneum only and salvaged successfully with postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) alone. Of these nine patients, only two (1%) had viable disease in the PC-RPLND specimen. The remaining seven patients had relapses outside the retroperitoneum and received salvage chemotherapy ± postchemotherapy resection. Overall, nine (4.7%) patients have died, but only four (2.1%) from testis cancer. ConclusionsOur data, the largest series to date, confirm that surveillance is safe and effective for men who achieve a CR following chemotherapy for metastatic NSGCTs. Patient summarySurveillance is a safe strategy for patients who achieve a complete response following chemotherapy for metastatic testis cancer.

Surveillance of postchemotherapy subcentimeter residual retroperitoneal mass (RRM) in metastatic nonseminomatous germ cell tumor (mNSGCT).

391 Background: Approximately 30 – 60% of patients with mNSGCT treated with cisplatin-based chemotherapy (CBCT) achieve a complete response (CR), defined as normalization of serum tumor markers with either no RRM or a RRM &lt; 1 cm. While there is universal agreement that patients with a RRM ≥ 1 cm should undergo retroperitoneal lymph node dissection (RPLND), many institutions, including ours, recommend surveillance for patients who achieve a CR. However, studies have not defined which axis of the RRM should be considered when making this decision. Methods: The electronic medical records (2007 – 2017) at the Hospital of the University of Pennsylvania (HUP) were searched to identify good-risk mNSGCT patients treated with CBCT who achieved a CR and underwent surveillance. Consistent with RECIST 1.1, we define a CR as no RRM or a RRM &lt; 1 cm in the transaxial short axis (TSA). We do not consider the transaxial long axis (TLA) or the craniocaudal axis (CCA). A post-hoc review was performed by a blinded radiologist and the RRM dimensions in the TSA, TLA, and CCA were recorded. Differences in the frequency of recurrence between groups with a RRM &lt; 1.0 cm and ≥ 1.0 cm in the TLA and CCA were assessed using the Fischer exact test. Results: 39 patients met study criteria and were included. At a median follow-up of 50.8 months, only 2 patients (5.1%) recurred. Both were successfully treated with RPLND and salvage chemotherapy. Post-hoc review of imaging: median TSA 6 mm (range, 0-11); median TLA 8 mm (range, 0-14); median CCA 11 mm (range, 0-34). Thirteen (33%) and 27 (69%) patients had a RRM ≥ 1 cm in the TLA and CCA, respectively. There were no statistically significant differences in the risk of recurrence between patients with a RRM &lt; 1.0 cm and ≥ 1.0 cm in the TLA (p=0.54) or CCA (p=0.53). Conclusions: Surveillance is an effective strategy in patients with mNSGCT and a post-chemotherapy RRM &lt; 1.0 cm in the TSA. Our study suggests that referencing the TSA and not the TLA or CCA in this decision-making may avoid unnecessary post-chemotherapy RPLND.

Prognostic impact of normalization of serum tumor markers following neoadjuvant chemotherapy in patients with borderline resectable pancreatic carcinoma with arterial contact.

The survival benefit of neoadjuvant therapy for patients with borderline resectable pancreatic carcinoma has been reported recently. However, prognostic factors for this strategy have not been clearly elucidated. The aim of this study was to clarify prognostic factors for patients with borderline resectable pancreatic carcinoma who received neoadjuvant chemotherapy. Medical records of 66 patients with pancreatic carcinoma with arterial contact who intended to undergo tumor resection following neoadjuvant chemotherapy were analyzed retrospectively. Prognostic factors were investigated by analyzing the clinicopathological factors with univariate and multivariate survival analyses. Gemcitabine plus S-1 was generally used as neoadjuvant chemotherapy. The objective response rate was 24%, and normalization of serum tumor markers following neoadjuvant chemotherapy was achieved in 29 patients (44%). Of the 66 patients, 60 patients underwent tumor resection and the remaining six patients did not due to distant metastases following neoadjuvant chemotherapy. For all 66 patients, overall 1-, 2-, and 5-year survival rates were 87.8, 54.5, and 20.5%, respectively (median survival time, 27.1 months) and multivariate analysis revealed that normalization of serum tumor markers was found to be an independent prognostic factor of better overall survival (P = 0.023). Moreover, for 60 patients who undergo tumor resection, normalization of serum tumor markers (P = 0.005) was independently associated with better overall survival by multivariate analysis. Patients with pancreatic carcinoma with arterial contact who undergo neoadjuvant chemotherapy and experience normalization of serum tumor markers thereafter may be good candidates for tumor resection.

MP81-20 IRINOTECAN AND NEDAPLATIN AS SALVAGE THERAPY FOR PATIENTS WITH ADVANCED GERM CELL TUMOR FOLLOWING INTENSIVE TREATMENT WITH CISPLATIN-BASED COMBINATION CHEMOTHERAPIES

You have accessJournal of UrologySexual Function/Dysfunction: Penis/Testis/Urethra: Benign Disease & Malignant Disease II1 Apr 2016MP81-20 IRINOTECAN AND NEDAPLATIN AS SALVAGE THERAPY FOR PATIENTS WITH ADVANCED GERM CELL TUMOR FOLLOWING INTENSIVE TREATMENT WITH CISPLATIN-BASED COMBINATION CHEMOTHERAPIES Masatomo Nishikawa, Hideaki Miyake, and Masato Fujisawa Masatomo NishikawaMasatomo Nishikawa More articles by this author , Hideaki MiyakeHideaki Miyake More articles by this author , and Masato FujisawaMasato Fujisawa More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2073AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To analyze the clinical outcomes of the irinotecan plus nedaplatin (IN) regimen in patients with advanced germ cell tumors (GCTs) refractory to cisplation-based combination chemotherapies. METHODS This study included a total of 20 consecutive advanced GCT patients who were categorized into intermediate- or poor-risk GCT groups according to the International Germ Cell Consensus Classification, and were judged to show refractory or relapsed disease after BEP (bleomycin, etoposide and cisplatin) and TIP (cisplatin, ifosfamide and paclitaxel) therapies. All 20 patients subsequently received IN therapy (irinotecan, 100 mg/m2 on days 1 and 15; nedaplatin, 100 mg/m2 on day 1) every 4 weeks. RESULTS Following a median of 3 cycles of IN, 9 patients (45%) achieved the normalization of serum tumor markers. In addition, surgical resection of the residual tumors following IN was performed in 5 patients, of whom 4 were pathologically diagnosed with no viable cancer cells. At a median follow-up of 9 months, 11 patients (55%) were alive, including 7 (35%) with no evidence of disease, whereas the remaining 9 (45%) died of disease progression. The median duration of overall survival after the introduction of IN in these 20 patients was 13.4 months. Severe hematological toxicities were observed in all patients, but were manageable. Although fatal treatment-related interstitial pneumonia occurred in 1 patient, other non-hematological toxicities were generally tolerable. CONCLUSIONS Considering the markedly unfavorable characteristics of the included patients with advanced GCT who were intensively treated with cisplatin-based combination chemotherapies, IN could be regarded as having promising therapeutic activity with an acceptable toxicity profile. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1060 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Masatomo Nishikawa More articles by this author Hideaki Miyake More articles by this author Masato Fujisawa More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Irinotecan and nedaplatin as salvage therapy for patients with advanced germ cell tumors following intensive treatment with cisplatin-based combination chemotherapies.

To analyze the clinical outcomes of the irinotecan plus nedaplatin (IN) regimen in patients with advanced germ cell tumors (GCTs) refractory to cisplatin-based combination chemotherapies. This study included a total of 20 consecutive advanced GCT patients who were categorized into intermediate- or poor-risk GCT groups according to the International Germ Cell Consensus Classification, and were judged to show refractory or relapsed disease after bleomycin, etoposide and cisplatin and cisplatin, ifosfamide and paclitaxel therapies. All 20 patients subsequently received IN therapy (irinotecan 100 mg/m(2) on days 1 and 15; nedaplatin 100 mg/m(2) on day 1) every 4 weeks. Following a median of 3 cycles of IN, 9 patients (45 %) achieved normalization of serum tumor markers. In addition, surgical resection of the residual tumors following IN was performed in 5 patients, of whom 4 were pathologically diagnosed with no viable cancer cells. At a median follow-up of 9 months, 11 patients (55 %) were alive, including 7 (35 %) with no evidence of disease, whereas the remaining 9 (45 %) died of disease progression. The median duration of overall survival after the introduction of IN to these 20 patients was 13.4 months. Severe hematological toxicities were observed in all patients, but were manageable. Although fatal treatment-related interstitial pneumonia occurred in 1 patient, other non-hematological toxicities were generally tolerable. Considering the markedly unfavorable characteristics of the included patients with advanced GCT who were intensively treated with cisplatin-based combination chemotherapies, IN could be regarded as having promising therapeutic activity with an acceptable toxicity profile.

Efficacy and tolerability of TIP (paclitaxel, ifosfamide and cisplatin) incorporated into induction chemotherapy for patients with intermediate- or poor-risk metastatic germ cell tumors.

The objective of this study was to analyze the clinical outcomes of TIP (paclitaxel, ifosfamide and cisplatin) incorporated into induction chemotherapy for patients with metastatic germ cell tumor (GCT) characterized by unfavorable clinical features. This study included 37 patients, who were categorized into intermediate- or poor-risk GCT according to the International Germ Cell Consensus Classification (IGCCC). All 37 patients received two cycles of bleomycin, etoposide and cisplatin (BEP) followed by several cycles of TIP. Following treatment with TIP, 25 patients achieved the normalization of serum tumor markers. In addition, surgical resection of the residual tumors following TIP was performed in 17 patients who were pathologically diagnosed with no viable cancer cells. At a median follow-up of 36 months, 31 patients were alive, including 27 with no evidence of disease, whereas the remaining six died of disease progression. The 5-year disease-free survival (DFS) and overall survival (OS) rates in these 37 patients were 72.9 and 85.3%, respectively. Despite the lack of a significant predictor of OS, univariate analysis identified the presence of a choriocarcinoma element and IGCCC as significant predictors of DFS, of which only the presence of a choriocarcinoma element appeared to be independently associated with DFS. In this series, treatment-related death did not occur, although 27 patients had at least one adverse event corresponding to grade 3 ≤. Collectively, it would be of worth to pursue the significance of the early incorporation of TIP into induction chemotherapy for patients with intermediate- or poor-risk metastatic GCT in the future.

Comparison of angiotensin converting enzyme inhibitors and angiotensin II type 1 receptor blockade for the prevention of premalignant changes in the liver

Aim We investigate and compare the possible antitumor activity of clinically used angiotensin converting enzyme (ACE) inhibitors; captopril, perindopril and angiotensin II type 1 receptor (AT1R) blocker, losartan against hepatocarcinogenesis initiated by diethylnitrosoamines (DENA) and promoted by carbon tetrachloride (CCl 4). Main methods Diethylnitrosamine (DENA) (200 mg/kg i.p.) initiated and carbon tetrachloride (CCl 4) (2 ml/kg i.p.) promoted hepatocarcinogenesis in male Wistar rats after 8 weeks. Results Hepatocarcinogenesis was manifested biochemically by elevation of serum hepatic tumor markers tested; α-feto protein (AFP) and carcinoembryonic antigen (CEA). In addition, hepatic carcinogenesis was further confirmed by a significant increase in hepatic tissue growth factors; vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (FGF). Moreover a marked increase in matrix metalloproteinase-2 and hydroxyproline content were also observed. Hepatocarcinogenesis was further confirmed by a significant decrease in hepatic endostatin and metallothonein level. Key findings Long-term administration of the selected drugs for 2 weeks before and throughout the experimental period produced a significant protection against hepatic carcinogenesis. The present results claimed that different doses of the selected drugs succeeded in normalization of serum tumor markers. Furthermore, the drugs reduced the elevated level in the hepatic growth factors, matrix metalloproteinase-2 and hydroxyproline induced by the hepatocarcinogen. Moreover, the amelioration was also accompanied by augmentation of hepatic content of metallothionein and endostatin. Histopathological examination of liver tissues of rats treated with DENA–CCl 4 correlated with the biochemical observations. Significance These findings suggest a similar protective effect of ACE inhibitors; captopril; perindopril and AT1R blocker, losartan against premalignant stages of liver cancer in the DENA initiated and CCl 4 promoted hepatocarcinogenesis model in rats. Therefore, RAS especially angiotensin II (Ang II) and AT1R interaction plays a pivotal role hepatocarcinogenesis development.

Long-Term Follow-Up of Cisplatin Combination Chemotherapy in Patients With Disseminated Nonseminomatous Germ Cell Tumors: Is a Postchemotherapy Retroperitoneal Lymph Node Dissection Needed After Complete Remission?

Controversy arises regarding the optimal management of patients with nonseminomatous germ cell tumor (NSGCT) who achieve a serologic and radiographic complete remission (CR) to systemic chemotherapy. Some authors recommend postchemotherapy retroperitoneal lymph node dissection (PC-RPLND), whereas others omit surgery and observe these patients. In an attempt to address this question, we report the long-term follow-up of patients treated at Indiana University who were observed without PC-RPLND. This is a retrospective analysis of patients with NSGCT who achieved a CR to first-line chemotherapy and were monitored without further therapy. CR was defined as normalization of serum tumor markers and resolution of radiographic disease (residual mass < 1 cm). One hundred forty-one patients were identified. Five patients (4%) had less than 2 years of follow-up. After a median follow-up of 15.5 years, 12 patients (9%) experienced relapse. Of these 12 patients, eight patients currently have no evidence of disease (NED), and four patients died of disease. The estimated 15-year recurrence-free survival (RFS) and cancer-specific survival rates were 90% and 97%, respectively. The estimated 15-year RFS for good-risk patients (n = 109) versus intermediate- or poor-risk patients (n = 32) was 95% and 73% (P = .001), respectively. Six patients (4%) experienced recurrence in the retroperitoneum, of whom two patients died of disease. Five patients had late relapse (range, 3 to 13 years), including two patients in the retroperitoneum. All five patients currently have NED. Patients obtaining a CR after first-line chemotherapy can be safely observed without PC-RPLND. Relapses are rare and potentially curable with further treatment.

Malignant transformation of testicular teratoma: A chemoresistant phenotype

Purpose To review our experience in the management of malignant transformation of teratoma (MTT). Materials and methods Nine patients with MTT were identified from January 1980 to August 2005, with all pathological specimens re-reviewed by a single genitourinary pathologist. Results Two patients presented with clinical stage I disease in which malignant transformation occurred within the primary testis tumor (rhabdomyosarcoma in 1 and adenocarcinoma in 1). These patients underwent a primary retroperitoneal lymph node dissection (RPLND). No viable tumor was identified in the specimen, and both patients were alive without disease at 16 months follow-up. Of the remaining 7 patients, the clinical stages were IIA (N = 1), IIB (N = 3), and III (N = 3), and all were treated with chemotherapy followed by RPLND. The MTT histology of these RPLND specimens consisted of adenocarcinoma (N = 3), rhabdomyosarcoma (N = 2), angiosarcoma (N = 1), and astrocytoma (N = 1). Following preoperative chemotherapy, a significant radiologic response (defined as more than a 25% reduction in maximum tumor circumferential diameter) was demonstrated in 1 patient, and normalization of serum tumor markers was demonstrated in 6. At a mean follow-up of 5 years, 3 of these 7 patients were alive with no evidence of disease, 1 had persistent disease, and 3 had died of disease, and their median disease-specific survival duration was 4.6 years. Conclusions In our experience, MTT is significantly resistant to current chemotherapeutic regimens, as demonstrated by its poor radiologic response to treatment. Alternative therapeutic strategies targeted to MTT are thus needed.

The role of postchemotherapy surgery in managing metastatic germ cell tumors

The role of postchemotherapy surgery in managing metastatic germ cell tumors

Significance of Primary Tumor Size and Preorchiectomy Serum Tumor Marker Level in Predicting Pathologic Stage at Retroperitoneal Lymph Node Dissection in Clinical Stage A Nonseminomatous Germ Cell Tumors

To determine whether the size of the primary tumor and degree of preorchiectomy serum alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (beta-hCG) elevation predict for retroperitoneal pathologic findings in patients with clinical Stage A nonseminomatous germ cell tumor undergoing primary retroperitoneal lymph node dissection. The testicular cancer database was queried to identify patients with clinical Stage A nonseminomatous germ cell tumor with normalization of serum tumor markers after orchiectomy who had undergone retroperitoneal lymph node dissection. A total of 779 patients were identified. The preorchiectomy serum tumor marker level was recorded and categorized into the following subsets: AFP: less than 20 (normal), 20 to 100, 100 to 1000, and more than 1000 ng/dL; and beta-hCG: less than 5.0 (normal), 5 to 100, 100 to 1000, and more than 1000. The association between AFP, beta-hCG, and primary tumor size and retroperitoneal pathologic findings was determined. The retroperitoneal pathologic examination revealed metastatic disease in 207 patients (26.6%). The preorchiectomy serum beta-hCG level, as a categorical variable, was not predictive of positive retroperitoneal pathologic findings (P = 0.187). The preorchiectomy serum AFP did predict for positive retroperitoneal pathologic findings, with lower serum AFP levels associated with a greater incidence of retroperitoneal metastasis (P <0.001). The primary tumor size was not predictive of positive retroperitoneal pathologic findings (P = 0.113). Neither the primary tumor size nor the preorchiectomy beta-hCG level was predictive of retroperitoneal metastases. However, a normal preorchiectomy AFP level was associated with a greater incidence of retroperitoneal metastases.

No need for contralateral lung surgery in case of evidence of post-chemotherapy necrosis alone in residual lung masses in patients with disseminated non seminomatous germ cell tumors

4524 Background: Resection of residual lesions after primary chemotherapy and normalization of serum tumor markers is part of the multimodality treatment of advanced non seminomatous germ cell tumors (NSGCT). Multiple resections are currently recommended in case of multiple sites of residual disease. Methods: A multicenter retrospective study of 71 pts with thoracic residual masses after first-line cisplatin-based chemotherapy for disseminated NSGCT. Results: The histologic findings in residual lesions included complete necrosis, teratoma, and viable cancer in 31%, 55%, and 14% of patients, respectively. Discordant histopathologic findings were evidenced between retroperitoneal lymph node and thoracic (lung or mediastinal lymph nodes) residual masses in 31% of cases (n= 52). For example, 3 of the 15 pts with necrosis (20%) alone in RPLND had either teratoma or viable cancer in their lung metastases. In contrast, only 2 of 39 patients (5%) who had a bilateral pulmonary resection had discordant histological findings between the 2 lungs. Of 20 patients with necrosis alone in residual masses in the first lung, 19 (95%) also had necrosis alone in residual masses in their contralateral lung. Only one patient had necrosis alone in the first lung and some mature teratoma in the contralateral lung. Conclusions: These results support published data on discordant histopathologic findings between retroperitoneal and thoracic residual masses. Most importantly, they show that the pathologic concordance rate between the 2 lungs is high. Therefore, we recommend avoiding contralateral lung surgery when only necrosis is found in the first lung after primary chemotherapy for NSGCT. No significant financial relationships to disclose.

Liver transplantation for growing teratoma syndrome: Report of a case

Liver transplantation is a well-established treatment for liver failure and for a selected group of patients with hepatic tumors. The growing teratoma syndrome refers to the phenomenon whereby germ cell tumors enlarge after chemotherapy despite complete eradication of malignant cells and normalization of serum tumor markers. We present the case of a young patient with rapidly growing teratomatous masses in his liver who was treated with liver transplantation from a live donor. We discuss his postoperative management, follow-up, and briefly review literature on the subject.

Tumor Chemoconversion Following Surgery, Chemotherapy, and Normalization of Serum Tumor Markers in a Woman with a Mixed Type Germ Cell Ovarian Tumor

Background. Malignant germ cell tumors of the ovary are often curative after conservative surgery and adjuvant chemotherapy. Persistent tumors despite normalization of serum tumor markers may represent retroconversion to benign masses, but this is rare in ovarian tumors without teratoma elements. The management in such cases has not been defined.Case. A young woman with a stage IIIC mixed germ cell ovarian tumor containing endodermal and dysgerminoma elements and elevated serum tumor markers underwent conservative surgery followed by chemotherapy. Residual tumor persisted on CT despite the normalization of serum tumor markers. The residual tissue was resected and contained benign tissue.Conclusions. In cases where masses persist and serum tumor markers normalize, attaining a histological diagnosis, and not chemotherapy, should be considered.

Mediastinal growing teratoma syndrome

The growing teratoma syndrome refers to the phenomenon whereby germ cell tumors enlarge after chemotherapy despite complete eradication of malignant cells and normalization of serum tumor markers. This clinical scenario must be differentiated from that in which germ cell tumors maintain their malignant characteristics with elevated levels of serum tumor markers. Hospital record review was conducted of 2 cases. Two male patients are presented, 1 with a metastatic germ cell tumor of both the retroperitoneum and mediastinum (with elevated alpha-fetoprotein level) and 1 with a primary germ cell tumor of the mediastinum (with elevated alpha-fetoprotein and beta-human chorionic gonadotropin levels). After completion of chemotherapy and normalization of tumor markers, both patients presented with pulmonary symptoms attributable to their massively enlarging mediastinal teratomas. The clinical and roentgenographic features of patients with thoracic manifestations of the growing teratoma syndrome, as well as its management, are reviewed. After chemotherapy in patients with primary or metastatic mediastinal germ cell tumors whose tumor markers normalize, a growing mass in the mediastinum may represent the growing teratoma syndrome.

Rapidly recycled, intensive alternating chemotherapy in heavily pretreated progressive nonseminomatous germ cell tumors a feasibility study

To evaluate the feasibility and the efficacy of an intensive alternating chemotherapy regimen with hematopoietic growth factor support in the late salvage treatment of patients with metastatic nonseminomatous germ cell tumors (NSGCT), 14 patients with refractory or recurrent disease were treated with a combination regimen of vinblastine and bleomycin (VB) followed by three weekly cycles of BOP (bleomycin + vincristine + cisplatin) and subsequent CISCA (cyclophosphamide + doxorubicin + cisplatin) cycles. All patients experienced a grade 3 or 4 neutropenia despite prophylactic growth factor support; II patients required empiric antimicrobial therapy during the chemotherapy program. No toxic death or other significant adverse effect was seen. Eight patients achieved a complete remission and three patients had a partial remission with normalization of serum tumor markers at completion of chemotherapy. Four patients received high-dose chemotherapy with autologous bone marrow transplantation as consolidation therapy and one patient underwent a salvage surgery. Three patients remain free of disease at over 18, 26, and 36 months after therapy. We demonstrate here the feasibility of an intensive alternating chemotherapy schedule in the late salvage treatment of progressive NSGCT. Our results also suggest that the combination of such an approach with high-dose chemotherapy (HDCT) and/or surgery can be used in a curative attempt after the failure of first line salvage therapy.

Hepatic Resection for Disseminated Germ Cell Carcinoma

Improvements in operative technique and perioperative management have expanded the application of hepatic resection for metastatic cancer. Although a policy of aggressive surgical resection of residual pulmonary and retroperitoneal disease following chemotherapy and normalization of serum tumor markers has been adopted for disseminated germ cell carcinoma, resection of residual hepatic disease in these cases has not been addressed. This report concerns a series of prospectively randomized patients who received systemic cisplatin-based chemotherapy for testis cancer during the past 13 years. Twenty-eight patients underwent resection of residual hepatic disease after serologic remission. Most (23 of 28 patients) of these procedures were performed concomitantly with other cytoreductive procedures. There were no operative deaths, although 28% of the patients developed complications. The 2-year survival rate was 54%, with an average follow-up of 34 months. Patients were stratified into three groups based on the most aggressive histology noted in the resected specimen. Survival is predicted by this histologic classification system. Hepatic resection can be performed safely and is an important component in the treatment of disseminated testicular carcinoma.