Recurrence of germ cell tumor after orchiectomy

Long-term clinical outcome in patients with stage-I nonseminomatous germ cell cancer. A critical review of own treatment modalities in a retrospective study

PURPOSE

The optimal management of patients with clinical stage I non-seminomatous germ cell testicular cancer (NSGCT I) was considered controversial until the European Germ Cell Cancer Consensus Group determined unambiguous treatment strategies. In order to assess the long-term outcome we evaluated the data of patients with NSGCT I.

MATERIALS AND METHODS

In a retrospective evaluation, we included 52 patients with a mean age of 26 years (range 15-58) who were treated with different modalities at our department between 1989 and 2003. Mean follow-up was 5.9 years (range 2-14 years). After orchiectomy, 39 patients were treated with chemotherapy, 7 patients underwent retroperitoneal lymph node dissection and 6 men were managed using a surveillance strategy. Survival, recurrence rate and time of recurrence were evaluated. The histological staging and treatment modality was related to the relapse.

RESULTS

Tumor specific overall mortality was 3.8%. The mortality and relapse rate of the surveillance strategy, retroperitoneal lymph node dissection and chemotherapy was 16.7% / 50%, 14.3% / 14.3% and 0% / 2.5% respectively. All relapsed patients in the surveillance group as well as in the RPLND group had at least one risk factor for developing metastatic disease.

CONCLUSIONS

Following the European consensus on diagnosis and treatment of germ cell cancer in patients with NSGCT Stage I any treatment decision must be individually related to the patient according to prognostic factors and care capacity of the treating centre. In case of doubt, adjuvant chemotherapy should be the treatment of choice, as it provides the lowest risk of relapse or tumor related death.

Management and outcome of bilateral testicular germ cell tumors: Twenty-five year experience in Munich

We analyzed characteristics, therapy and outcome of patients with bilateral testicular germ cell tumor (TGCT) at our institutions. Among 1,180 TGCT patients diagnosed and/or treated between 1979 and 2003, 47 (4.0%) developed a second TGCT. Nine of 14 patients (64%) with synchronous TGCT are alive with no evidence of disease (NED) at a median follow-up of 37 months. Thirty-three patients had a metachronous bilateral TGCT. Median time to the 2(nd) TGCT was 71 months. At diagnosis of 2(nd) TGCT 30 patients had stage I, 1 had stage II and 2 had stage III disease. Thirty-two of 33 patients are alive with NED at a median follow up of 41 months. No patient died from second TGCT. As a review of the literature confirms our data we do not recommend a routine biopsy of the contralateral testicle for early detection of testicular intraepithelial neoplasia (TIN).

Bilateral testicular germ-cell tumors--a single centre long-term experience

OBJECTIVES

The incidence of bilateral testicular tumors (BTT) had increased over the preceding decade. The aim of the present study is to analyse a group of patients with BTT and to high-light the need for long-term follow-up of patients treated in a single centre.

MATERIAL AND METHODS

27 (2.8%) out of 960 patients with germ-cell testicular tumors (GCTT), treated between 4/1977 and 8/2001, developed bilateral disease. All of them underwent radical orchiectomy (in one patient was done delayed orchiectomy after primary chemotherapy due to advanced disease). Additional treatment was planned according to the histologic type and clinical stage of the disease, and previous treatment as well. The survival data were reviewed.

RESULTS

24 out of 27 patients (88.9%) developed the 2nd tumor metachronously (median interval 66 months, range, 4-197 months) and three (11.1%) had synchronous BTT. Only 7 patients (25.9%) had identical histological types on both sides (6 of them with pure seminomas, one with embryonal carcinoma). Two of three synchronously developed BTT had different histologic types on both sides. GCTT of one histologic type were observed in respect of the first tumor: 11 seminomas, three embryonal carcinomas, in respect of the 2nd tumor: 10 seminomas, three embryonal carcinomas, in respect of the 2nd tumor: 10 seminomas, three embryonal carcinomas and one mature teratoma. GCTT of more than one histologic type were observed in respect of the first and the 2nd tumors: 6 mixed GCTT with seminoma component and 7 without seminoma component. Majority of BTT was presented in clinical stage I (in respect of the first tumor in 70.4%, in respect of the 2nd tumor in 62.9%). The median duration of the follow-up after the diagnosis of the first GCTT was 149 months (range, 13-288 months) and after the diagnosis of the contralateral GCTT was 68 months (range, 1-167 months). Twenty-five patients (92.6%) were alive with NED at their last follow-up visit. Two patients died by mean of 22.5 months (range, 21-24 months) after the 2nd orchiectomy.

CONCLUSIONS

All patients with unilateral GCTT have an increased risk of developing a contralateral testicular tumor, even decades after diagnosis. Management should be individualised for each patient.

Important factors in the diagnosis and primary staging of testicular tumours

PURPOSE OF REVIEW

In the present review we outline the use of different staging methods and highlight future possibilities in the management of testicular germ cell cancer.

RECENT FINDINGS

The 5-year survival for testicular cancer has improved dramatically over the past 30 years, with cure rates approaching 95%. This success is attributed to the appropriate integration of effective treatments and staging modalities. Staging currently represents the cornerstone on which treatment is based. Because most patients will be cured, attention has shifted toward reducing morbidity of treatment while maintaining high cure rates. This implies that staging must be accurate before any change to the treatment regimen can be instituted.

SUMMARY

Effective management of testicular germ cell cancer continues to pose a major challenge. Early and accurate diagnosis is very important because it will influence the choice of treatment and thus may impact on prognosis.

Familial testicular cancer and second primary cancers in testicular cancer patients by histological type

The Swedish Family-Cancer Database was used to assess familial cancer risks in first-degree relatives and the risks of second primary cancers in testicular cancer patients by the histological type of their testicular cancers. Standardised incidence ratios (SIRs) were employed to estimate cancer risks. Among 4650 patients, 1.3% were familial testicular cancer. Seminomas showed a 10 years later median age of onset than teratomas (30 versus 40 years). The familial risks of testicular cancer were 3.8 for fathers, 8.3 for brothers and 3.9 for sons; they were similar for the two histologies. The fraternal risks were elevated 2- to 2.8-fold for pure histologies compared with the mixed histologies. Significantly increased risks for subsequent cancers were observed in the stomach, pancreas, testis, kidney, bladder, thyroid and connective and lymphatic tissues in the patients. Our data support the contention that genetic predisposition is one of the major contributors to familial and multiple testicular cancers.