Proceedings: Radiation therapy in malignant testis tumors. II: Carcinoma

Treatment of stage I seminoma: should beta-HCG positive seminoma be treated aggressively?

To assess the prognostic value of beta-HCG positive stage I seminoma, clinical records of 122 patients with testicular germ cell tumour were reviewed. Fifty-five patients (mean age 38.7 years) of 122 (45.1%) had stage I seminoma. Preorchiectomy beta-HCG level was determined in 54 patients. Twenty-nine patients of 54 (53.7%) had elevated preorchiectomy beta-HCG level. No significant relationship was found in the rate of locally progressive cancer between beta-HCG positive and negative cases. Treatment consisted of radiotherapy after inguinal orchiectomy for beta-HCG negative cases, and chemotherapy or radiotherapy for beta-HCG positive cases. Tumour recurrence was found in one patient with normal beta-HCG level. Our limited series demonstrated that preorchiectomy elevated beta-HCG had no significant relationship to local tumour invasion or prognostic value. Therefore, infradiaphragmatic radiation therapy may be useful for beta-HCG positive stage I seminoma.

Prognostic value of BHCG and local tumor invasion in stage I seminoma of the testis

Approximately 10-15% of patients with stage 1 pure seminoma of the testis have an elevated preorchiectomy serum beta human chorionic gonadotropin level [1-4]. The prognostic significance of this elevation is unknown. We performed a multi-institutional retrospective review of 332 men with stage I pure seminoma of the testis and evaluated the prognostic significance of this elevation and the prognostic value of local invasion of the primary tumor. Twenty-five of 191 evaluable patients (13%) had elevated preorchiectomy beta human chorionic gonadotropin. All normalized postoperatively and are alive without evidence of disease with a median follow-up of 50 months (range 1-124 mo). Of 191 patients, 190 (99.5%) are alive and free of disease. One patient underwent salvage chemotherapy for a chest recurrence, and he is alive and free of disease at 72 months. We conclude that elevated preorchiectomy serum beta human chorionic gonadotropin level and local invasion of the primary tumor do not portend a poor prognosis in patients with clinical stage I pure seminoma of the testis.

Low-dose radiotherapy for stage I seminoma: early results

One hundred and one patients with stage I seminoma were irradiated with total doses of 30, 25.5 and 20 Gy to gradually reduced target volumes (paraaortic, pelvic, and inguinal regions to paraaortic only). Low doses and small target volumes resulted in excellent survival and freedom of recurrence but in more frequent nausea.

Gynaecomastia caused by a primary mediastinal seminoma

The case of a young man aged 26 is reported. He presented with a short history of painful gynaecomastia, and no other associated symptoms. Radiological investigations showed a mass in the anterior mediastinum. Endocrine investigations showed high circulating oestradiol and high hCG-beta levels. There was no evidence of primary testicular tumour or metastases. Surgical removal of the mediastinal mass led to normalization of oestradiol and hCG-beta levels and regression of gynaecomastia. Histology showed the tumour to be a primary mediastinal seminoma staining positively for hCG-beta. Further treatment consisted of chemotherapy with etoposide and cis-platinum. The patient has remained well with no evidence of disease recurrence. The tumour markers remain normal.

Prognosis of human chorionic gonadotropin-producing seminoma treated by postoperative radiotherapy

PURPOSE

To clarify the controversy about the management and prognosis of human chorionic gonadotropin-producing seminoma, the records of 132 patients with abnormal human chorionic gonadotropin values treated with radiotherapy were analyzed.

METHODS AND MATERIALS

The records of 1169 patients with pure seminoma treated in 10 institutions were screened for serum or urinary human chorionic gonadotropin. One hundred and thirty two patients with elevated human chorionic gonadotropin were found: 96 Stage I, 20 IIA, 7 IIB, 8 III and 1 IV. Median age was 34 y., mean follow-up was 5.0 years [range 1-12 y]. All received infradiaphragmatic radiotherapy (median dose 30 Gy), 25 (2 Stage I, 11 IIA, 5 IIB and 7 III) supradiaphragmatic radiotherapy (median dose: 28.5 Gy) and 10 had also initial chemotherapy (3 Stage IIB 6 III and 1 IV). Patients were allocated to three groups according to human chorionic gonadotropin values: (a) moderate elevation: up to 10 times (104 pts), (b) high elevation: 10 to 100 times (20 pts), (c) very high elevation: over 100 times the upper limit of normal value (8 pts).

RESULTS

The proportion of Stage I, II and III was 76%, 19%, 5% in the ME group versus 50%, 35%, 15% in the high elevation group (p < 0.05). In the very high elevation group there were 7 Stage I and 1 Stage IV. Of 132 patients, six died (three dead of disease, two suicides, one acquired immunodeficiency syndrome). The 5 years overall survival probability was 94%. There were seven recurrences (initial stage: 1 Stage I, 2 IIB, 3 III and 1 IV). Of these, there were one in-field recurrence, 3 out of field and 3 in both sites. In 5 of 7, the human chorionic gonadotrophin level was again elevated at recurrence. The 5 years recurrence-free-survival probability was 94% (98% for Stage I, 100% for Stage IIA and 65% for Stage IIB and III [p < 0.001 between I and IIB + III, p < 0.05 between IIA and IIB + III]). Four of the 7 recurrences were salvaged by chimiotherapy +/- radiotherapy. In the high elevation and very high elevation groups, the 5 years recurrence-free-survival was 88%, vs. 96% for the moderate elevation group (p = 0.10).

CONCLUSION

Based on this series of patients, human chorionic gonadotropin production is not an unfavorable prognostic factor in pure seminoma. Even in the subgroups with high or very high human chorionic gonadotropin levels (who had a higher proportion of advanced stages), the prognosis remained excellent. In Stage I and IIA seminoma with abnormal human chorionic gonadotropin levels, recurrence rate after post-operative radiotherapy alone is extremely low.

Brain metastases and testicular tumors: Long-term survival

In this updated and expanded retrospective analysis, the treatment records of 24 patients with brain metastases from nonseminomatous germ cell testicular tumors (NSGCT's) treated at the Indiana University Department of Radiation Oncology from 1975 through 1988 were reviewed. All patients received standard cisplatin-based induction chemotherapy. These patients were divided into three groups. Group 1 (n = 10) consisted of patients who presented initially with brain metastases and had no prior systemic treatment. Group 2 (n = 4) consisted of those patients who, after achieving a complete response (CR) with cisplatin, vinblastine, and bleomycin (PVB) +/- doxorubicin, developed a relapse confined to the brain. Group 3 (n = 10) consisted of those patients who were initially treated with PVB +/- doxorubicin or bleomycin, etoposide, and cisplatin (BEP) and eventually developed progressive disease and brain metastases. Group 1 was treated with whole brain irradiation (WBRT) and PVB +/- doxorubicin or BEP. Group 2 was treated with WBRT, cisplatin-based chemotherapy +/- surgical excision. Group 3 was usually treated with WBRT palliatively. Six patients, three in Group 1 and three in Group 2, are alive and disease-free with follow-up of 5+ years from beginning WBRT. Two additional patients in Group 1 survived 5+ years from beginning WBRT before dying with disease. No patient in Group 3 survived. Patients with brain metastases who have potentially controllable systemic disease should be treated curatively with WBRT (5000 cGy/25 fractions) +/- surgical excision and concomitant chemotherapy.

The biological and clinical significance of HCG-containing cells in seminoma

The morphological appearance, incidence and prognostic significance of human chorionic gonadotrophin (HCG)-containing cells in seminomas were examined in a retrospective series of 228 orchidectomy specimens, obtained between 1958 and 1972. Sections from each tumour were stained with haematoxylin and eosin (H & E) and immunocytochemically for HCG. In 33 (14.5%) of the tumours HCG-containing cells were observed, but in only 12 were these recognised in an initial study of the H & E stained sections. HCG staining was seen predominantly in syncytiotrophoblastic giant cells and rarely in "mulberry" cells and mononuclear seminoma cells. Of the patients whose tumours included HCG-containing cells 23% died of their disease within 2 years of orchidectomy, compared with only 8% of the patients whose tumours lacked this feature. It is concluded that immunocytochemical staining for HCG should form part of the routine histological assessment of seminomas, and that the presence of HCG-containing cells indicates a more aggressive disease.

Seminoma with elevated human chorionic gonadotropin. The case for retroperitoneal lymph node dissection

An elevated serum level of human chorionic gonadotropin (HCG) in a patient whose primary tumor histologically appears to be a pure seminoma implies the presence of syncytiotrophoblastic giant cells either detectable by careful step sectioning of the primary tumor or present in metastatic disease. Inasmuch as the malignant potential and radioresponsiveness of syncytiotrophoblastic giant cells are unknown and the serum elevation of HCG may signal metastatic embryonal carcinoma, retroperitoneal lymph node dissection with adjuvant chemotherapy dependent on pathologic staging should be considered for patients with seminoma and postorchiectomy elevated HCG levels. An illustrative case is herein reported.

The significance of giant cells in human testicular seminomas. A clinico-pathological study

In order to study the nature and significance of various giant cells encountered in seminomatous tumors of the testis, we reviewed the morphology of 243 consecutive pure seminomas and 107 combined (mixed) tumors, as well as the long term clinical follow-up in 26 patients. Giant cells were grouped into histiocytic or neoplastic ones and the latter subtyped according to morphologic and immunocytochemical characteristics. Neoplastic giant cells were found in 34.6% of all pure seminomas and in 11.2% of all combined tumors, i.e. twice as often as histiocytic giant cells in either tumor group. The various types of neoplastic giant cells were found alone or in combinations with other types. Giant cells capable of elaborating B-HCG were seen in 19.3% of all pure seminomas and in 9.3% of seminomatous components of combined tumors. These incidences argue strongly against a trophoblastic element infiltrating a seminoma from a concomitant occult choriocarcinomatous focus. Large mononuclear giant cells, seen in spermatocytic seminomas, were observed in 15.6% of all pure seminomas, particularly in combination with B-HCG producing giant cells. Another type, characterized by marginated nuclei and eosinophilic cytoplasm were invariably part of a mononuclear cell population of similar features and encountered focally in 9.1% of all pure seminomas. Clinical follow-up, particularly in cases with B-HCG positive giant cells, revealed that treatment as for conventional seminomas at an early stage at least is followed by an excellent course.

Testicular carcinoma. A curable malignancy

The progress in the management of testicular germ cell tumours is reviewed. A marked improvement of the treatment results has been obtained in non-seminomas, especially by the use of cis-platinum based chemotherapy. At present long term survival can be expected in 85 per cent of all non-seminomas and in 95 per cent of all seminomas after adequate treatment. The natural history of the disease, symptomatology, diagnostic procedures, staging and different treatment modalities, as surgery, radiation therapy, chemotherapy and their combination, are discussed.

Five-year survival of patients with disseminated nonseminomatous testicular cancer treated with cisplatin, vinblastine, and bleomycin

Ninety-one patients with disseminated testicular non-seminomas were treated with 3 to 4 cycles of cisplatin, vinblastine, and bleomycin (PVB) induction chemotherapy followed by cisplatin and vinblastine maintenance therapy for 1 year. The follow-up of these patients ranges from 24 to 66 months. Forty-nine (54%) patients achieved complete remission by chemotherapy alone and 14 (15%) were rendered free of tumor by surgery after chemotherapy, for a total complete remission rate of 69%. Three complete responders relapsed within 13 months, and two died. One additional complete responder died of a noncancer-related cause. One of the surgical complete responders relapsed and died. Overall, 58 (64%) patients remain free of disease. The 5-year survival is 95% for complete responders, 32% for partial responders, and 72% overall. This combination regimen has significantly improved the survival of disseminated testicular cancer patients, equaling that of Stage II patients in older literature.

Radiotherapy of testicular tumours: an analysis of patients treated in Scotland between 1950 and 1969

The results of treatment of 838 patients who were irradiated for germ cell tumours of the testis between 1950 and 1969 are presented. The overall 10-year survival rate was 61.8%. For seminomas alone it was 75.3% and for teratomas 37.7%. No increase in survival was found which could be attributed to the introduction of megavoltage beams.

The Southwest Oncology Group experience: adjuvant therapy for stage IB and II non-seminomatous testicular cancer

During a two year period, 65 patients with Stage II non-seminomatous testis cancer were randomized to receive adjuvant chemotherapy and radiation. Of the 52 evaluable patients, 23 received radiation followed by chemotherapy (sequential), and 29 received the same chemotherapy as initial treatment, but had drug treatment temporarily interrupted for radiation (sandwich). The combined treatment was well tolerated, but did not eliminate recurrence. With regard to duration of survival and disease-free survival, no statistically significant difference could be found between the sequential and sandwich approaches.

The differentiation of malignant lymphoma from anaplastic seminoma in a patient presenting with testicular and jaw swelling

The histologic differentiation of anaplastic seminoma from lymphoma is often difficult. In the case presented, a malignant lymphoma showing prominent testicular and jaw involvement was initially interpreted as seminoma. The histologic and ultrastructural criteria for differentiation, as well as a comparison of the clinical and epidemiologic characteristics of these tumors, are discussed. A reassessment of previously reported cases of seminoma metastatic to the jaws/antrum, made relative to these data, suggests that in most cases the tumors may actually be lymphomas.

Experience with beta-HCG-positive seminoma

The clinical findings, diagnosis and course of disease of eight patients with histological pure seminoma of the testis and positive serum beta-HCG levels are presented. In addition to routine investigations, immunohistochemical examination of the formalin-fixed specimen by the immunoperoxidase technique was also carried out. Serum alpha-feto-protein levels of all eight patients remained normal. There was no correlation between serum beta-HCG level and tumour stage. The longest period of observation was 48 months, the shortest 11 months. All patients were treated primarily by radiotherapy. One patient also received chemotherapy and one patient underwent bilateral lymphadenectomy 13 months after radiotherapy.

The management of nonseminomatous testicular cancer: current therapy and future directions

Carcinoma of the testes is the fourth leading cause of death in males between the ages of 15-54, and its incidence may be increasing. Nonseminomatous testicular cancer represents 50% of all testicular tumors. There have been recent advances in diagnosis, staging and therapy of these tumors. Currently, there is a high success rate with platinum containing combination chemotherapy regimens in patients with advanced stages of disease. The article reviews the evolution of successful chemotherapy and the issues of adjuvant therapy for early stage disease, radiation therapy and the role of retroperitoneal lymphadenectomy and surgery following chemotherapy.

Surgical resection of residual tumor after chemotherapy in non-seminomatous testicular cancer

Fifteen patients with disseminated non-seminomatous testicular cancer, 13 of whom had advanced disease, underwent surgery for residual tumor after induction chemotherapy. Complete remissions were achieved in 7 of 9 patients with mediastinal or pulmonary metastases and in 2 of 6 patients with retroperitoneal metastases. Patients with alpha-fetoprotein (AFP) levels over 10(4) ng/ml at diagnosis and/or a positive AFP preoperatively failed to achieve complete remission. Complete remissions were obtained in all 8 patients who had resection of necrosis, mature teratoma, immature teratoma or mature teratoma with malignant foci, but in only 1 of 7 patients who had resection of embryonal carcinoma or yolk sac tumor with other components. Of 9 patients with complete remission, 8 have remained free of disease after a median follow-up time of 29 months (range 6-66 months) and one had a contralateral non-seminomatous testicular cancer removed after 60 months. In addition to being therapeutically successful, the combined use of chemotherapy followed by surgery for residual tumor may lead to a better understanding of the influence of chemotherapy on the biology of testicular carcinoma.

Gonadotrophin-producing seminoma: a distinct category of germ cell neoplasm

Gonadotrophin-producing seminomas can be identified in two ways: detection of human chorionic gonadotrophin (HCG) in the serum or urine, or histological identification of syncytiotrophoblastic giant cells, which can be shown to contain HCG by means of indirect immunoperoxidase techniques. A review of the histories of 14 patients with such tumours shows that they are associated with a worse prognosis than that of 'typical' seminomas, and tend to present with a more advanced stage of disease. These tumours are thus distinct, clinically and biologically, from typical seminomas, and their treatment needs to be planned accordingly.

Testis cancer: the pendulum swings. Experience in 430 patients

A review of 430 patients with testis cancer followed for at least 3 years is presented. A protocol for actinomycin D therapy before and after node dissection had been instituted in 1966. In the 58 protocol cases studied there appeared to be an increase in the survival of patients with stage A disease and a significant increase in the survival of patients with stage B disease. There was an improvement in the survival of patients with stage C disease treated with actinomycin D alone. Since 1976 all patients with stages B and C disease have been treated with multiple drug regimens, showing dramatic results. The therapy of testis tumors is multimodal, using lymphadenectomy, radiation therapy and chemotherapy, but the pendulum has swung so that chemotherapy has assumed the vital role in management.

Paratesticular rhabdomyosarcoma in children

The clinical characteristics, surgical treatment, clinical grouping, chemotherapy, radiotherapy, complications and survival of paratesticular rhabdomyosarcoma are discussed. When the combined approach of radical inguinal orchiectomy, retroperitoneal node dissection, chemotherapy and radiotherapy when indicated is used a survivorship in excess of 80 per cent can be anticipated for all stages of disease. A combined multidisciplinary approach to this lesion is stressed to achieve improved survivorship in this previously lethal lesion.

Combination chemotherapy with cis-diammine-dichloro-platinum, vinblastine, and bleomycin in advanced testicular non-seminoma

40 patients with disseminated testicular non-seminoma were treated with cis-diammine-dichloro-platinum, vinblastine, and bleomycin. Complete remission was achieved in 24 (60%) patients and partial remission in 11 (28%). 22 of the 24 complete responders, who have been followed-up for a median of 11 months, have been tumour-free for 5--30 months. There were 3 drug-related deaths. This regimen is the most effective remission-induction treatment available for disseminated testicular non-seminoma. Patients should be treated in centres experienced in the specialised management of this potentia-ly curable disease.

Management of advanced testicular seminoma

The treatment of seminoma (stages A, B1 and B2) with conventional x-ray therapy can be expected to give satisfactory cure rates. However, the cure rate for patients with advanced stages of B3 and C disease, treated with conventional radiation therapy, is unacceptable (22 per cent). It appears that with a pre-radiation/chemotherapeutic plan consisting of actinomycin D, vincristine and cyclophosphamide survival can be improved dramatically in these patients. After a rest period of 2 to 4 weeks radiation therapy is given to the retroperitoneal, mediastinal and supraclavicular lymph nodes as per standard therapy. If evidence of bulk disease persists or if positive alpha-fetoprotein or beta-human chorionic gonadotropin has been detected then retroperitoneal lymph-adenectomy should be done after completion of the radiation therapy. With adjuvant chemotherapy 5 of 5 patients survive free of disease 18 months to 5 years after therapy.

Human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) in sera and tumor cells of patients with testicular seminoma: a prospective study

The HCG and AFP have been quantitated in the sera of 130 patients with the diagnosis of testicular seminoma utilizing a specific double antibody radioimmunoassay. These tumor markers also were localized in tumor cells of some of these patients utilizing an indirect immunoperoxidase technique. 11 of 130 patients had elevated serum levels of HCG. The HCG molecules have been localized in the syncytiotrophoblastic giant cell (STGC) that is occasionally observed in seminomas. None of the patients with pure seminoma had an elevated level of serum AFP. We have concluded that in patients with pure seminoma the level of serum HCG can be elevated (10 of 130 or 7.6%), but we have not observed elevated serum levels of AFP in these patients.

Radiation therapy for germinal tumors of the testes

79 patients with germinal tumors of the testes were treated at the University of Maryland Radiation Therapy Clinic between January 1, 1957 and December 31, 1973. 32 of 33 patients with stage I seminoma had disease controlled for a minimum of three years for a 96.9% 3 year disease-free determinant survival. 4 of 4 patients with stage I carcinoma were treated, two after negative node dissection, and all survived. 15 of 21 patients with stage II seminoma survived for 3 year disease-free Berkson-Gage actuarial survival of 68.5%, 9 of 21 stage II carcinomas, 18 of whom had had positive node dis-sections, survived for a 3 year disease-free Berkson-Gage actuarial survival of 42.8%. Benefit of adjuvant irradiation of the mediastinum and supraclavicular regions is demonstrated for stage II seminomas where 7/8 patients receiving prophylaxis demonstrated a 100% 3 year disease-free Berkson-Gage actuarial survival as opposed to the 50.4% in the 7/13 patients surviving without adjuvant therapy. This benefit is reaffirmed, although more tenuously, by the 71.4% 3 year disease-free Berkson-Gage actuarial survival demonstrated by the 5 of 7 stage II carcinoma patients receiving adjuvant therapy as opposed to the 28.2% demonstrated by the 4 of 14 patients surviving who did not receive adjuvant therapy.

Biochemical markers in advanced testicular tumors: serum lactate dehydrogenase, urinary chorionic gonadotropin and total urinary estrogens

Twenty-seven patients with advanced testicular tumors were screened for serum lactate dehydrogenase (LDH) concentration, and 24-hour urinary excretion of human chorionic gonadotropin (hCG) and total estrogens. The investigation indicates an overall correlation between serum LDH concentration and cancer burden and an overall correlation between the maximum serum LDH and prognosis. It indicates an overall ocrrelation between the hCG determined within 2.5 months after the orchiectomy and prognosis. The relation between total estrogens and cancer burden or prognosis does not support the hypothesis that total urinary estrogens are a biochemical marker in testicular tumors.

Malignant tumors of the testis: analysis of treatment results and sites and causes of failure

A total of 150 patients with germinal testicular neoplasms treated at the University of California, San Francisco, were reviewed. The 5-year actuarial survival rate was 95% for 57 patients with seminoma and 56% for 75 patients with carcinoma. Treatment modalities were compared with respect to sites and causes of failure and complications. The most common sites of failure in the carcinoma patients were lung, and supraclavicular or mediastinal lymph nodes. Scrotal orchiectomy, elevated gonadotropins, elements of choriocarcinoma, and bulky abdominal disease were all correlated with high treatment failure rate.

Carcinoma of the testis

Patients with Stage I or II malignant testis germ cell tumors underwent a randomized prospective study at Walter Reed Hospital, Washington, D.C., from 1968 to 1973. Pure cell lines of seminoma or choriocarcinoma were excluded. Forty patients had inguinal orchiectomy followed by irradiation to the inguinal, iliac, lumbar para-aortic, mediastinal and supraclavicular lymph nodes. Thirty-four patients (85%) in this group are alive and free of tumor a minimum of 3 years. Fifty-one patients received pre- and postoperative irradiation to primary lymphatic pathways in association with bilateral retroperitoneal lymphadenectomy as well as elective irradiation to the mediastinum and supraclavicular regions. Forty-six patients (90%) in this second group are alive and free of tumor a minimum of three years. Both treatment methods represent marked improvement in cure rates compared to lymphadenectomy and postoperative irradiation utilized prior to 1968, but no statistically significant difference from each other.

Retroperitoneal lymphadectomy: indications, complications and expectations

The use of retroperitoneal lymphadenectomy in the management of 152 patients with nonseminomatous germ cell tumors of the testis treated at Anderson Hospital has been reviewed. Complications consisting of wound infection (six cases), acute pancreatitis (two cases), lymphocyst formation (two cases), and chylous ascites (one case) developed in 6.4% of patients. Although ejaculatory impotence is common postoperatively, only 12 marriage units were desirous of having children and 7 of these have had uncomplicated and successful pregnancies. No instances of erectile impotence developed in this series. The indications for the procedure have been defined with regard to accurate staging, combined therapy, and, in selected instances of advanced disease, as a means of monitoring the effects of chemotherapy. The importance of this operative procedure in the multimodal management of patients with nonseminomatous germ cell tumors of the testis cannot be overemphasized.

Prognosis for pathologic stage I non-seminomatous germ cell tumors of the testis managed by retroperitoneal lymphadenectomy

The over-all 3,5 and 10-year survival rate for 87 patients with non-seminomatous germ cell tumors of the testis undergoing retroperitoneal lymphadenectomy was 90.5 per cent. Of the 72 patients receiving no form of therapy other than retroperitoneal lymphadenectomy after operative removal of the testicular tumor the 5-year survival rate was 90.8 per cent. The 5-year survival rates for these 72 patients, calculated according to the histologic characteristics of the primary tumor, were 74.4 per cent for 18 patients with embryonal carcinoma, 93.0 per cent for 36 patients with teratocarcinoma and 100 per cent for 18 patients with teratoma. Although no advantage could be demonstrated for bilateral lymphadenectomy as opposed to unilateral dissection, it is concluded that a modified bilateral dissection should be reserved only for tumors on the left side.

Chemotherapy in stage II testicular tumours: preliminary communication

Twenty-six patients with stage II testicular teratomas (metastatic spread to the retroperitoneal lymph nodes only) were treated after retroperitoneal lymph node dissection (RLD) by cytostatic chemotherapy with or without radiotherapy. So far, eight patients (30.5%) have recurrent disease, with a median interval of 21 months from time of diagnosis to relapse. The 3-year survival rate for the total group (relapse-free and relapsed patients) was 85.7%. The median survival is not yet reached after 36 months. The own results and reports of the literature show an advantage of early cytostatic treatment over its institution in widespread disease only. It remains to be clarified whether chemotherapy in stage II disease prevents or only delays metastatic spread.

Chemotherapy of germ cell tumors of the testis. I. Induction of remissions with vinblastine, actinomycin D, and bleomycin

Patients with disseminated testicular carcinoma were treated with the combination of vinblastine, actinomycin D, and bleomycin in an attempt to induce remission. Of 47 patients receiving an initial adequate trial of this regimen, 34% achieved a complete or partial remission; in the 18 patients with either no prior nonsurgical treatment or treatment with actinomycin D alone, the response rate was 61%. Those who attained complete response status enjoyed significant prolongation of life compared with the nonresponders or partial responders. Responses were seen in all histologic categories and were not related to the performance status of the patient at the start of the trial, to the total dose of drug in the first mouth of therapy, or the extent of hematologic toxicity produced by the drugs. Responders had a higher incidence of stomatitis than nonresponders.

The valve of chemotherapy in the treatment of testicular dysembryoplastic tumors

Chemotherapy appears to be of help in treating dysembryoplastic testicular tumors. It seems better to treat first by surgery (lymphadenectomy) if possible, then (a) if no nodes are involved or only one has been discovered by microscope examination, with chemotherapy for one year; or (b) if two or more nodes are involved, with irradiation of the nodes and chemotherapy. Even if lymphadenectomy is not possible, one course of chemotherapy followed by cobalt and more chemotherapy can bring results in some cases.