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

A 10-year retrospective single-center study of alpha-fetoprotein and beta-human chorionic gonadotropin in Romanian children with (para)gonadal tumors and cysts

OBJECTIVES

Malignant tumor is a top-ranking cause of pediatric (>1-year) mortality in America and Europe. Among pediatric tumors, germ cell tumors (GCT) and gonadal tumors rank fourth (6%) by the Surveillance, Epidemiology, and End Results (SEER) program (seer.cancer.gov). Continuous research on tumor markers harnesses their full potential in tumor detection and management. We evaluated the effectiveness of beta-human chorionic gonadotropin (β-hCG) and Alpha-fetoprotein (AFP) in Romanian children with (para)gonadal tumors and cysts, determining their accuracy in detecting malignancy, tumor-type, stage, complications, prognosis, and treatment response.

METHODS

A 10-year retrospective study of AFP and β-hCG in 134 children with cysts and (para)gonadal tumors aged one month to 17 years was performed.

RESULTS

AFP/β-hCG was unelevated in patients with cysts and nonmalignant tumors. Forty-eight/86 patients (43 GCT and 5 non-GCT) with malignant tumors had elevated AFP/β-hCG, 3/48 patients had recurrences, and 25/48 had mixed-GCT (68% had elevated AFP + β-hCG). All 30 patients with Yolk sac tumors (YST) or their components had elevated AFP. Area under the curve, sensitivity and specificity for GCT were: AFP + β-hCG- 0.828, 67.2%, 100%; AFP- 0.813, 64.1%, 100%; and β-hCG- 0.664, 32.8%, 100%. Two patients whose AFP/β-hCG levels remained elevated died. Common mixed-GCT components were YST-80% and embryonal carcinoma-72%. Thirty of 34 metastasis cases were GCT, with 26/34 patients having elevated AFP/β-hCG.

CONCLUSIONS

AFP/β-hCG detects malignant GCT and can determine tumor-type. GCT patients with markedly elevated AFP + β-hCG had poor prognosis, especially if recurrence or metastasis was present. Recurrence is unrelated to elevated AFP/β-hCG. The tumor components and quantity present determine AFP/β-hCG values in mixed-GCT.

History of the rare cancer network and past research

Approximately, twenty years ago, the Rare Cancer Network (RCN) was formed in Lausanne, Switzerland, to support the study of rare malignancies. The RCN has grown over the years and now includes 130 investigators from twenty-four nations on six continents. The network held its first international symposium in Nice, France, on March 21-22, 2014. The proceedings of that meeting are presented in two companion papers. This manuscript reviews the history of the growth of the RCN and contains the abstracts of fourteen oral presentations made at the meeting of prior RCN studies. From 1993 to 2014, 74 RCN studies have been initiated, of which 54 were completed, 10 are in progress or under analysis, and 9 were stopped due to poor accrual. Forty-four peer reviewed publications have been written on behalf of the RCN.

Pure seminoma: a review and update

Pure seminoma is a rare pathology of the young adult, often discovered in the early stages. Its prognosis is generally excellent and many therapeutic options are available, especially in stage I tumors. High cure rates can be achieved in several ways: standard treatment with radiotherapy is challenged by surveillance and chemotherapy. Toxicity issues and the patients' preferences should be considered when management decisions are made. This paper describes firstly the management of primary seminoma and its nodal involvement and, secondly, the various therapeutic options according to stage.

[What's new in the treatment of seminomas?]

Pure testicular seminoma is a rare disease with an excellent prognosis. Its management is controversial. In stage I disease, several treatment options are considered. Those are radiation therapy alone, chemotherapy alone or active surveillance, which is becoming increasingly popular. For more advanced stages, treatment is based on chemotherapy with or without radiation therapy. In this article, we review thoroughly the existing literature and recent recommendations the various treatment options, their advantages and disadvantages in different stages of the disease.

Facteurs pronostiques et prise en charge des tumeurs rares

The management of rare cancers is controversial. The role of adjuvant therapies, such as chemotherapy and radiation therapy remains unclear. The limited number of patients included in the studies cannot generally allow any consistent statistical analysis to determine either prognostic factors or the impact of surgery and adjuvant therapies on local control and long-term survival. The Rare Cancer Network is a multi-institutional cooperative group created in 1993 to initiate large retrospective studies on rare cancers with the aim of improving our knowledge in terms of management, outcome, and prognostic factors of such tumors. The network gathers more than 70 institutions from 21 countries. So far, 32 projects have been carried out. In this report we will discuss the most significant data provided by our group in several investigated diseases.

Para-aortic irradiation for stage I testicular seminoma: results of a prospective study in 675 patients. A trial of the German testicular cancer study group (GTCSG)

A prospective nonrandomised trial was performed in order to evaluate tumour control and toxicity of low-dose adjuvant radiotherapy in stage I seminoma with treatment portals confined to the para-aortic lymph nodes. Between April 1991 and March 1994, 721 patients were enrolled for the trial by 48 centres in Germany. Patients with pure seminoma and no evidence of lymph node involvement or distant metastases received 26 Gy prophylactic limited para-aortic radiotherapy. Disease-free survival at 5 years was the primary end point. With a median follow-up of 61 months, 675 patients with follow-up investigations were evaluable for this analysis. Kaplan–Meier estimates of disease-free and disease-specific survival were 95.8% (95% CI: 94.2–97.4) and 99.6% (95% CI: 99.2–100%) at 5 years and 94.9% (95% CI: 92.5–97.4%) and 99.6% (95% CI: 99.2–100%) at 8 years, respectively. A total of 26 patients relapsed. All except two were salvaged from relapse. In all, 21 recurrences were located in infradiaphragmatic lymph nodes without any ‘in-field’ relapse. Nausea and diarrhoea grade 3 were observed in 4.0 and 1.0% of the patients, respectively. Grade 3 late effects have not been observed so far. The results of our trial lend further support to the concept of limited para-aortic irradiation as the recently defined new standard of radiotherapy in stage I seminoma. There is no obvious compromise in disease-specific or disease-free survival compared to more extensive hockey-stick portals, which were used as standard portals at the time this study was initiated.

Radiotherapy for stages IIA/B testicular seminoma: final report of a prospective multicenter clinical trial

PURPOSE

A prospective multicenter trial was initiated to evaluate the role of modern radiotherapy with reduced treatment portals for stage IIA and IIB testicular seminoma.

PATIENTS AND METHODS

Patients with stages IIA/B disease (Royal Marsden classification) were assessable for the trial. Staging comprised computed tomography of the chest, abdomen, and pelvis as well as analysis of tumor markers alpha-fetoprotein and beta human chorionic gonadotropin. Linac-based radiotherapy was delivered to para-aortic and high ipsilateral iliac lymph nodes. The total doses were 30 Gy for stage IIA and 36 Gy for stage IIB disease.

RESULTS

Between April 1991 and March 1994, 94 patients were enrolled for the trial by 30 participating centers throughout Germany. Seven patients were lost to follow-up. Median time to follow-up of 87 assessable patients was 70 months. There were 66 stage IIA and 21 stage IIB patients. One mediastinal and one field-edge relapse were observed in the stage IIA group. In the stage IIB group, there was one mediastinal and one mediastinal/pulmonary relapse. All patients were treated with a salvage regimen of platinum-based chemotherapy. Actuarial relapse-free survival at 6 years was 95.3% (95% confidence interval [CI], 88.9% to 100%) and 88.9% (95% CI, 74.4% to 100%) for stage IIA and IIB groups, respectively. Maximum acute side effects were 8% grade 3 nausea for stage IIA and 10% grade 3 nausea and diarrhea for stage IIB groups. No late toxicity was observed.

CONCLUSION

Radiotherapy for stages IIA/B seminoma with reduced portals yields excellent tumor control at a low rate of acute toxicity and no late toxicity, which supports the role of radiotherapy as the first treatment choice for these patients.

Radiotherapy for stages I and IIA/B testicular seminoma

Radiotherapy is generally accepted as a standard treatment for early-stage testicular seminoma. Relapse rates of 2% to 5% in clinical stage I and 10% to 20% in stage IIA/B (according to the Royal Marsden classification) can be achieved. Disease-specific survival reaches 100%. With such excellent cure rates, treatment-related side effects gain particular importance. Therefore, a prospective multicenter trial was initiated for radiotherapy of testicular seminoma with limited treatment portals and low total doses of irradiation. In clinical stage I, 483 patients were treated with 26 Gy to the para-aortic region only. In stage IIA, 42 patients and, in stage IIB, 18 patients received irradiation to the para-aortic and high iliac lymph nodes with 30 and 36 Gy, respectively. With a median time to follow-up of 55 months for stage I and 55.5 months for stage IIA/B, there were 18 (3.7%) and 4 (6.7%) cases of relapse in both treatment groups. Disease-specific survival was 99.6% in stage I and 100% in stage IIA/B. Acute toxicity was dominated by moderate gastro-intestinal side effects. No major late toxicity has been observed to date. Limited volume pure para-aortic treatment for stage I and para-aortic/high iliac irradiation for stage IIA/B with 26, 30 and 36 Gy, respectively, yields excellent cure rates with only moderate acute toxicity and is therefore recommended as standard treatment.

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.

Testicular seminoma with human chorionic gonadotropin production

Testicular seminoma with elevated serum human chorionic gonadotropin level (hCG-positive seminoma) is regarded as more malignant than marker-negative seminoma, although its prognosis is still unclear. To clarify the malignant potential of seminoma with hCG production, the serum levels of the beta subunit of hCG (beta-hCG) and lactic acid dehydrogenase (LDH) were examined in 35 and 40 patients, respectively, and the immunohistochemical expression of beta-hCG examined in 45 tumors. The elevation of the LDH serum level correlated to the invasive status, metastatic status and poor outcome, while that of the serum beta-hCG level correlated only to the metastatic status. Immunohistochemical expression of beta-hCG was observed in syncytiotrophoblastic giant cells in 11 tumors and a few mononuclear seminoma cells in 36 tumors. Expression was not associated with the malignancy potential, except where the expression in mononuclear cells inversely correlated to the invasive status. These results suggest that most seminomas produce a slight amount of hCG; that an elevated hCG serum level indicates the presence of metastatic tumors and mainly reflects an increase in tumor volume but not in cellular malignancy potential; and that the LDH serum level, rather than hCG, is more useful as a prognostic indicator for patients with seminoma.

Radiotherapy in stage IIA and IIB testicular seminoma with reduced portals: a prospective multicenter study

PURPOSE

A prospective multicenter study was carried out to estimate the treatment outcome of radiotherapy in Stage II seminoma after the application of modern staging and radiotherapy techniques. The lower margin of the iliac field was positioned on the upper rim of the acetabulum to reduce the amount of scattered irradiation to the remaining testicle.

METHODS AND MATERIALS

The study was carried out in 25 centers in Germany. Patients with pure seminoma, negative AFP-values, and retroperitoneal lymph node metastases of less than 5 cm in diameter were entered into the study. All patients received a ventrodorsal opposed field irradiation of the para-aortic and the ipsilateral iliac lymph nodes. The fields extended from the top of the 11th thoracic vertebra to the top of the acetabulum. Patients in Stage IIA (lymph nodes <2 cm ) received 30 Gy, and patients with Stage IIB (lymph nodes between 2 and 5 cm) 36 Gy total dose.

RESULTS

39 patients in Stage IIA and 19 patients in Stage IIB were evaluated. After a median observation time of 37 months all patients are alive and disease free. Recurrence free survival in stage IIA was 100%. Two patients in Stage IIB experienced a recurrence 10 and 17 months after the end of radiotherapy. The actuarial recurrence free survival estimate in Stage IIB was 94.1% for 1 year and 87.4% for 2 years. One recurrence in Stage IIB occurred in the mediastinum, one in the mediastinum, and one the lung. Both patients could be salvaged by chemotherapy. There were no pelvic recurrences. The treatment was well tolerated, with nausea being the most common side effect (56.9% Grade 1, 15.5% Grade 2, and 8.6% Grade 3). Diarrhea occurred in 15.5% (Grade 1), 15.5% (Grade 2), and 5.2% (Grade 3) of the patients.

CONCLUSIONS

The outcome of para-aortic and ipsilateral iliac irradiation in Stage IIA/B testicular seminoma is excellent with the currently available staging methods and treatment facilities. The treatment is well tolerated. The lower margin of the iliacal field can be placed at the acetabulum.

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.