Carcinoma of the testis

Advances made in the treatment of testicular cancer in the U.S. Military: 1946 to the present

Testicular cancer is presently one of the most curable solid tumors, and thanks to diagnostic, surgical, and medical advances over the last several decades, the treatment of this tumor serves as a paradigm for multimodal treatment of solid malignancies. Due to testicular cancer's predilection for younger patients, many of the seminal improvements and discoveries were made possible as a result of initial investigatory groundwork laid by military physicians treating servicemen. This article reviews historical contributions of the United States Military Medical Departments in the arena of testicular cancer treatment in the post-World War II era.

Second cancers among 40,576 testicular cancer patients: focus on long-term survivors

BACKGROUND

Although second primary cancers are a leading cause of death among men with testicular cancer, few studies have quantified risks among long-term survivors.

METHODS

Within 14 population-based tumor registries in Europe and North America (1943-2001), we identified 40,576 1-year survivors of testicular cancer and ascertained data on any new incident solid tumors among these patients. We used Poisson regression analysis to model relative risks (RRs) and excess absolute risks (EARs) of second solid cancers. All statistical tests were two-sided.

RESULTS

A total of 2,285 second solid cancers were reported in the cohort. The relative risk and EAR decreased with increasing age at testicular cancer diagnosis (P < .001); the EAR increased with attained age (P < .001) but the excess RR decreased. Among 10-year survivors diagnosed with testicular cancer at age 35 years, the risk of developing a second solid tumor was increased (RR = 1.9, 95% confidence interval [CI] = 1.8 to 2.1). Risk remained statistically significantly elevated for 35 years (RR = 1.7, 95% CI = 1.5 to 2.0; P < .001). We observed statistically significantly elevated risks, for the first time, for cancers of the pleura (malignant mesothelioma; RR = 3.4, 95% CI = 1.7 to 5.9) and esophagus (RR = 1.7, 95% CI = 1.0 to 2.6). Cancers of the lung (RR = 1.5, 95% CI = 1.2 to 1.7), colon (RR = 2.0, 95% CI = 1.7 to 2.5), bladder (RR = 2.7, 95% CI = 2.2 to 3.1), pancreas (RR = 3.6, 95% CI = 2.8 to 4.6), and stomach (RR = 4.0, 95% CI = 3.2 to 4.8) accounted for almost 60% of the total excess. Overall patterns were similar for seminoma and nonseminoma patients, with lower risks observed for nonseminoma patients treated after 1975. Statistically significantly increased risks of solid cancers were observed among patients treated with radiotherapy alone (RR = 2.0, 95% CI = 1.9 to 2.2), chemotherapy alone (RR = 1.8, 95% CI = 1.3 to 2.5), and both (RR = 2.9, 95% CI = 1.9 to 4.2). For patients diagnosed with seminomas or nonseminomatous tumors at age 35 years, cumulative risks of solid cancer 40 years later (i.e., to age 75 years) were 36% and 31%, respectively, compared with 23% for the general population.

CONCLUSIONS

Testicular cancer survivors are at statistically significantly increased risk of solid tumors for at least 35 years after treatment. Young patients may experience high levels of risk as they reach older ages. The statistically significantly increased risk of malignant mesothelioma in testicular cancer survivors has, to our knowledge, not been observed previously in a cohort of patients treated with radiotherapy.

Primary malignant extragonadal germ cell tumors. An analysis of the effect of the effect of radiotherapy

A retrospective analysis was performed on all patients diagnosed with biopsy-proven extragonadal germ cell tumors at the University of Virginia (Charlottesville, VA), The Medical University of South Carolina (Charleston, SC), the Bethesda Naval Hospital (Bethesda, MD), and The Medical College of Virginia (Richmond, VA) for the time period of January 1965 to December 1984. A total of 54 patients were treated with the initial sites of presentation observed: mediastinum, 26; central nervous system, 14; retroperitoneum, eight; and sacrococcygeal region, six. Megavoltage irradiation was used in 44 patients with a dose range of 2400 to 5580 cGy (mean, 4213 cGy). With a minimum follow-up of 4.0 years and a mean follow-up of 10.8 years, the 5-year actuarial survival for the entire population was 57.8%. Local control was achieved in 26 of 44 (59%) of the irradiated population. Factors of prognostic significance included histologic type at presentation, site of presentation, and radiation doses greater than or equal to 4000 cGy. Radiotherapy appears to be an effective modality in patients with extragonadal seminomas; however, the nonseminomatous tumors do not appear to be as radioresponsive.

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.

Immunohistological determination of proliferative activity in seminomas

The proliferative activity and growth pattern of 20 seminomas were determined immunohistologically with the monoclonal antibody Ki-67. A growth fraction of tumour cells between 50 and 80% was found in seminomas with an almost even distribution of proliferating cells in all sections, regardless of tumour size. There was a slight tendency towards a greater growth fraction in tumours at an advanced histopathological stage. No positive correlation could be found between growth fraction and tumour size or lymphocytic infiltration. The results confirm the well known sensitivity of seminomas to radiation and chemotherapy and show that the determination of proliferative activity should be included in the histopathological routine diagnosis of malignant tumours with regard to systemic treatment and prognosis.

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.

Retroperitoneal malignancies several years after initial treatment of germ cell cancer of the testis

Three patients (aged 56, 40, and 38 years, respectively) presenting with large retroperitoneal masses 10 to 18 years after prior orchiectomy for testicular neoplasms (seminoma and embryonal carcinoma) are presented. Despite aggressive chemotherapy in all three patients and surgical excision of the tumor in two, two of the men subsequently died 11 to 16 months after initial diagnosis of the retroperitoneal tumors, and one is living with the disease. Theoretic etiologic mechanisms for the development of late retroperitoneal tumors in these men are discussed, including (1) metastatic disease from a second primary tumor in the remaining testicle, (2) a primary extragonadal retroperitoneal tumor, and (3) delayed transformation of metastatic teratomatous retroperitoneal tumor from the original primary into malignant neoplasm.

Preoperative irradiation for unresectable rectal and rectosigmoid carcinomas

The records of 25 patients with unresectable carcinoma of the rectum and rectosigmoid who received preoperative radiation therapy (RT) were reviewed. Twenty patients were considered to be resectable following RT (80%). Sixteen patients (64%) underwent curative resections. All patients with unresectable tumors following RT died with tumor within two and one half years (median survival, 11 months). For patients undergoing curative resection, the probability of two- and five-year survival was 56% and 43%, respectively. In this latter group, five of seven patients with treatment failures (71%) had a pelvic component of disease. The incidence of pelvic recurrence was correlated with the pathologic stage, extent of resection and preoperative radiation dose. The need for more aggressive treatment for patients with these advanced tumors is emphasized. Future treatment alternatives are discussed.

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.

Computerized tomography: how accurate for abdominal staging of testis tumors?

To assess the ability of computerized tomography to predict correctly the presence of retroperitoneal lymphadenopathy, a prospective study was performed on 30 patients with all stages of testis tumor. All patients underwent a computerized tomography scan within 1 week before retroperitoneal lymphadenectomy and the results then were correlated with gross and histologic findings. The computerized tomography scan suggested retroperitoneal lymphadenopathy in 14 patients, in 1 of whom no retroperitoneal lymphadenopathy was found at exploration (false positive, 7 per cent). The sensitivity (computerized tomography negative divided by true positive) was 90 per cent, for an over-all accuracy of 73 per cent. Most importantly, however, 7 of the 16 computerized tomography scans (44 per cent) interpreted as normal proved to be false negative. Of these 7 scans 5 were in patients with tumors classified as stage B2 or greater. We conclude that the computerized tomography scan, when positive, is highly likely to detect metastatic nodal involvement. However, the false negative rate, even in patients with tumor-filled lymph nodes 2 to 3 cm. in diameter, limits the reliability of a negative computerized tomography scan to exclude metastases. Technological improvements are needed to refine the technique and, thus, to reduce the false negative rate.

Radiation therapy for nonseminomatous germ cell tumors of the testis: a reappraisal

We analyzed the efficacy of radiation therapy and retroperitoneal lymphadenectomy preceded and followed by radiation therapy as curative treatment in 113 patients with clinical stages I and II nonseminomatous germ cell tumors of the testis. Radiation therapy alone was curative in 86 and 82 per cent of the patients with clinical stages I and II disease, respectively, and radiation therapy before and after retroperitoneal lymphadenectomy was curative in 89 and 73 per cent of patients with clinical stages I and II disease, respectively. Of 26 patients with clinical stage II disease in the group receiving radiation therapy before and after retroperitoneal lymphadenectomy only 13 (50 per cent) had pathologic documentation of retroperitoneal metastasis or histologic evidence of nodal metastases that had been destroyed by radiation therapy alone. When analyzed by pathologic stage radiation therapy before and after retroperitoneal lymphadenectomy was curative in 91 and 51 per cent of patients with stage I and II disease, respectively. In our series clinical overstaging may have been responsible for the favorable results of radiation therapy alone, and radiation before and after retroperitoneal lymphadenectomy in the treatment of clinical stage II nonseminomatous germ cell tumors.

Treatment experience with nonseminomatous testicular cancer in patients with stage II and stage III disease

Thirty-eight patients with nonseminomatous testicular cancer were treated with cis-platinum, bleomycin, and vinblastine in combination without a prolonged maintenance phase. Twenty-Six patients with Stage III disease were treated. Seventy-six percent of those patients treated achieved complete remission. At a median survival time of 30 months, no patient who achieved a complete remission has relapsed. Twelve Stage II patients given adjuvant therapy remain free of disease at a median time of 23 months. Markedly elevated serum lactate dehydrogenase levels and massive disease were common findings in the patients who did not achieve complete remission. One drug death occurred secondary to sepsis. Symptoms of depression and anxiety were significant dose-limiting factors in this group of patients.

Testicular seminoma metastatic to the orbit

Painful exophthalmos, ophthalmoplegia, and visual loss in the right eye developed in a 28-year-old man four months after he underwent a radical orchiectomy and irradiation for a seminoma of the right testicle. Prednisone therapy failed to relieve the symptoms, and an orbital biopsy found a metastatic testicular seminoma. Orbital irradiation with radioactive cobalt reduced the exophthalmos, reversed the ophthalmoplegia, and improved his visual acuity. Previous cases of nonmetastatic exophthalmos in patients who had testicular seminoma have been reported, but, to the best of our knowledge, this is the first report of a patient who had orbital seminoma metastatic from the testis. Successful irradiation of the orbital focus can minimize ocular morbidity and may improve the prognosis.

Retroperitoneal block dissection in the treatment of nonseminomatous tumors of the testis

Fifteen patients with nonseminomatous tumors of the testis, stages I and II, underwent a retroperitoneal block dissection as part of their treatment regimen. Nonseminomatous germ cell and paratesticular tumours were reported. The preoperative measures and operative technique of the anterior transabdominal approach are described. There were no deaths or major postoperative complications encountered, in spite of the magnitude of the surgery involved. In two patients the tumor had occurred in an undescended testis. No patient had normal ejaculatory function after the operation. Special attention is drawn to the proper management of patients having undergone a transscrotal biopsy or orchiectomy. Five patients with a relatively long-term follow-up, are free of disease and doing well.

Metastatic non-seminomatous testis tumors: morbidity of treatment

There were 28 patients with metastatic non-seminomatous testis tumors treated by a regimen of combined retroperitoneal lymphadenectomy and multiple drug chemotherapy. We have outlined the morbidity of this plan of management with a followup of 3 to 8 years. Survival for all patients with stage B disease is 100 per cent and with stage C disease it is 58 per cent (8 of 14 patients).

[Sequential combination chemotherapy with vinblastine/bleomycin and adriamycin/cis-dichlorodiammineplatinum (II) in non-seminomatous testicular cancer. II. Long-term results of a study with 140 patients with retroperitoneal disease (stage II) (author's transl)]

Following orchiectomy and retroperitoneal lymph node dissection (RND) 140 patients with stage II non-seminomatous testicular cancer were treated by sequential combination chemotherapy consisting of vinblastine/bleomycin and adriamycin/cis-dichlorodiammineplatinum(II) (DDP), plus/minus radiotherapy. 68 stage IIA-patients (complete RND and normal tumor-markers thereafter) received 6 courses of chemotherapy, followed by radiotherapy in 35 patients. 40 stage IIB-patients (minor residual disease after RND or elevated tumor-markers after RND) and 32 stage IIC-patients (advanced residual disease after RND) were treated by at least 12 chemotherapy courses and optional intermittent radiotherapy and/or relaparotomy. In stage IIA and IIB disease the actuarial 4-year survival rates were between 80 and 100%. These favourable results were not significantly influenced by additional radiotherapy and corresponded to the survival rates for 34 stage I-patients. For stage IIC-patients the prognosis was significantly worse with a 12% 4-year survival rate.

The management of disseminated testicular cancer

Fourteen patients with disseminated non-seminomatous germ cell tumours of the testis were treated with a 3-drug combination of vinblastine, bleomycin and cis-diamminedichloroplatinum. Of 13 patients with measurable disease, 9 (69%) had complete and 3 (23%) partial remission. One patient with a solitary metastasis failed to respond but is disease-free following surgical excision. Toxicity was significant but no drug-related deaths occurred and there were no apparent lasting side effects. No patient attaining complete remission has relapsed. Eleven (79%) of the 14 patients are without evidence of disease from 3+ to 36+ months, 6 of these for 2 years or more. Of the patients in partial remission one died at 16 months and one is undergoing further treatment for relapse with liver metastases. One patient remains in partial remission at 30 months. These results demonstrate the efficacy of this drug combination in testicular cancer.

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.

Sandwich therapy in testis tumor: current experience

Sandwich therapy, a regimen of lymphadenectomy combined with preoperative and postoperative cobalt teletherapy, yielded a survival rate of 84% in 13 patients with stages A and B non-seminomatous testis tumor. This statistic is consistent with the previously reported survival rate of 83% achieved among 35 patients treated with this regimen from 1958 to 1970 at our institution. Bone marrow depression, retroperitoneal fibrosis and possible induction of a second malignancy were important side effects of radiation therapy. The superior survival rates with fewer severe side effects of treatment obtained by other investigators using either lymphadenectomy alone or lymphadenectomy combined with chemotherapy have prompted us to discontinue sandwich therapy as standard treatment for non-seminomatous testis tumors at our institution.