Testicular cancer

Human chorionic gonadotropin production by the pituitary gland in a premenopausal woman

OBJECTIVE

Our purpose was to investigate the source of human chorionic gonadotropin production in a nonpregnant, premenopausal woman.

STUDY DESIGN

A case of human chorionic gonadotropin production by the pituitary gland in a premenopausal woman is described.

RESULTS

Our results confirm that a biologically active human chorionic gonadotropin-like molecule was secreted in a nonpregnant woman.

CONCLUSIONS

Our results indicate that the pituitary gland was the most likely source of human chorionic gonadotropin production.

Late luteal estradiol patterns are a better prognosticator of pregnancy outcome than serial beta-human chorionic gonadotropin concentrations

OBJECTIVE

Since the corpus luteum (CL) is known to play an important role in early pregnancy, its activity could possibly be a marker for pregnancy outcome.

DESIGN

The late estradiol (E2) concentration in 48 viable pregnancies and 39 pregnancies which resulted in spontaneous abortions after in vitro fertilization and embryo transfer were used to evaluate such predictability.

SETTING

All patients studied were of the Center for Reproductive Medicine at Cornell University Medical College.

PATIENTS, PARTICIPANTS

Eighty-seven patients.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Serum E2 and human chorionic gonadotropin (hCG) concentrations on day +11, +13, +15 (day +1 = day of ovum pick-up) were measured and studied.

RESULTS

The late luteal CL activity after rescue had a positive correlation with the number and quality of the implanted embryos. Reduced CL activity was indicative of abortion. The late luteal E2 pattern when compared with hCG doubling time had a better abortion predictability (37.8% versus 63.9%, respectively).

CONCLUSION

Corpus luteum activity demonstrated to be a better prognosticator of abortion than serial beta-hCG titers.

Testicular seminomas in Saudi Arabia: clinical characteristics, prognostic indicators, and recommendations for management

Thirty Saudi patients with pure testicular seminoma were treated at King Faisal Specialist Hospital and Research Centre in Riyadh, Saudi Arabia, between January 1977 and June 1983. Disease characteristics in Saudi Arabia including clinical findings, response to therapy, and prognosis are described and compared to those in other populations reported in the literature. Symptom durations were 3 to 42 months. Many of the patients presented with an extensive tumor burden and a poor performance status. There was a higher incidence of anaplastic seminoma and of cryptorchidism than in other series and a relatively high incidence of elevated betahuman chorionic gonadotropin (B-HCG). Patients initially underwent funiculo-orchiectomy. Twenty-two patients received radiation therapy and four received chemotherapy. Patients with limited disease responded well to orchiectomy and radiation therapy. However, those with extensive tumor burden had an unsatisfactory response to radiation therapy. Preradiation chemotherapy is recommended for patients with massive retroperitoneal metastases, nodal disease above the diaphragm, or extranodal disease and patients with minimal or moderate sized retroperitoneal nodal disease associated with an elevated B-HCG.

Seminoma of the testis: a 22-year experience with radiation therapy

An analysis is presented of 188 patients with a histological diagnosis of seminoma testis, treated by radical orchiectomy and radiation therapy between 1960 and 1981 at the Cross Cancer Institute. Using the Walter Reed Hospital staging classification, 149 (79%) patients were Stage I, 34 (18%) were Stage II, and 5 (3%) were Stage III. The 5-year survival for all stages was 90%, and for Stage I was 98%, Stage II, 71%, and Stage III, 0%. All were treated primarily with radiation therapy. Prophylactic mediastinal radiation was not employed for Stage I, and was employed in half of Stage II patients. Eleven patients with Stage I relapsed, five in the mediastinum and/or neck nodes. Eight of 11 were cured with further treatment. Stage II patients were subdivided according to the presence or absence of a palpable abdominal mass. Palpable disease (Stage IIB) carried a poorer prognosis. Three of 20 patients without a palpable mass (Stage IIA) died of disease; there was an 82% five-year survival rate. Eight of 14 with a palpable mass (Stage IIB) were cured by radiotherapy; there was a 54% five-year survival rate. All five Stage III patients died within 1 year of diagnosis. Stage I and IIA seminoma is curable by radiation alone. Prophylactic mediastinal radiation is not indicated in either Stage I or IIA disease. Long term toxicity from radiation is not seen. Optimal treatment for Stage IIB disease is undetermined and new treatment regimens should be explored. Stage III disease requires primary chemotherapy.

Current status of adjuvant chemotherapy after radical cystectomy for deeply invasive bladder cancer

Between March, 1976, and December, 1982, 70 of 157 patients (45%) undergoing single-stage radical cystectomy with pelvic lymphadenectomy and urinary diversion with the intent to cure invasive bladder cancer were found to have pathologic Stage P3B, P4 and/or N + disease. Thirty-four of the 70 patients received adjuvant prophylactic chemotherapy after cystectomy and 36 patients were followed expectantly. From 1976 through 1977 adjuvant chemotherapy consisted of cyclophosphamide 1 Gm/M2 each month for six months; from 1978 through June, 1980, adjuvant chemotherapy consisted of cis-platinum 100 mg/M2 each month for four months with the exception of 1 patient treated more aggressively with combination chemotherapy (CISCA). Since July, 1980, a prospective study has been utilized in which patients were randomized into two groups, Group A receiving combination chemotherapy and Group B followed up expectantly; adjuvant chemotherapy appears to result in a slight delay in time to relapse but no influence in overall survival was observed.

Suprasellar germinoma. Unresolved problems in diagnosis, pathogenesis, and management

A suprasellar germinoma, initially thought to be granulomatous diencephalitis of uncertain cause, responded following chloramphenicol and methicillin treatment both by clinical and radiographic criteria and was not diagnosed until a third biopsy was performed. Analysis of this case and review of the literature lead to the conclusion that adequate diagnostic workup of such lesions requires that biopsy be extensive enough to include the central core as well as the granulomatous reaction that surrounds such tumors. Furthermore, since the degree of inflammation may fluctuate, regression does not mean that the lesion is not neoplastic in origin. In the present instance, the correct diagnosis could have been made earlier if the beta-chain of human chorionic gonadotropin had been measured in spinal fluid.

Radiation therapy in bulky seminoma

Between 1969 and 1980, 17 patients with bulky retroperitoneal seminoma and 1 patient with bulky mediastinal seminoma were treated with radiation therapy. One patient had resection of gross retroperitoneal disease, and 1 patient had resection of gross mediastinal disease. Fifteen patients received adjuvant irradiation to the mediastinum and paraclavicular lymph nodes, and 1 patient received adjuvant chemotherapy. At last follow-up, 17 of 18 patients (94%) remain free of disease. No patient has sustained treatment-related morbidity or mortality.

Resection of pulmonary metastases from nonseminomatous testicular tumors. Correlation of clinical and histological features with treatment outcome

Clinical and histological correlates of survival in patients undergoing complete resection of pulmonary metastases from nonseminomatous testicular carcinoma were determined in 25 Stage C patients aged 17-38 years treated from 1969-1978. All patients had orchiectomy and retroperitoneal lymphadenectomy. Nineteen patients received combination chemotherapy before resection, and all received chemotherapy after resection. Three patients had four additional thoracotomies for pulmonary recurrence. Survival was measured from time of first thoracotomy to time of last followup or death. Actuarial survival for the entire group at one, two, and five years was 80, 63, and 59%, respectively. Median follow-up of the survivors was 3.5 years. Patients in low tumor burden groups such as those with no tumor in retroperitoneal nodes, with unilateral metastases, or with single metastases had better prognosis, as did patients whose primary tumors were moderately well differentiated. Characteristics of pulmonary metastases that favorably influenced the prognosis were the presence of mature teratoma, presence of few mitoses, lack of mononuclear infiltrate, and lack of desmoplastic response. These findings confirm the effectiveness of multimodality therapy which includes the resection of pulmonary metastases for Stage C nonseminomatous carcinoma of the testes. In addition, they suggest that consideration should be given to the stratification of prospective clinical trials on the basis of tumor burden and histologic characteristics of the primary and metastatic lesions.

Advanced metastatic testicular cancer: the need for reporting results according to initial extent of disease

During an 8-year period 63 consecutive patients were treated for the first time for extensive metastatic nonseminomatous testicular cancer. Four patients did not respond sufficiently to chemotherapy to be considered surgical candidates, while 59 underwent surgical resection of retroperitoneal disease. Of these 59 patients 19 had concomitant wedge resection of associated pulmonary disease and 9 had a planned subsequent resection of residual pulmonary disease. Of the 63 patients 16 had stage B3 disease alone and 47 presented with pulmonary metastases associated with varying degrees of retroperitoneal disease. The most important determinant for survival was extent of pulmonary disease. Of 17 deaths 14 occurred among patients presenting with extensive pulmonary disease. Patients with minimal to moderate pulmonary disease have done well regardless of the extent of coexistent abdominal disease, 24 of 27 (89 per cent) remaining in sustained complete remission. Of 16 patients with massive palpable abdominal disease (B3) without coexistent pulmonary metastases 15 (94 per cent) survived free of tumor. The combination of extensive pulmonary and abdominal disease with or without liver involvement has a poor prognosis, with only 35 per cent of these patients remaining in sustained complete remission. Preoperative combination chemotherapy with platinum, vinblastine sulfate and bleomycin has improved survival free of tumor in this group compared to other combinations not including platinum (47 compared to 20 per cent) but the results in this selected group of patients are significantly worse than those seen for all other patients with lesser extent of disease. Tumor recurrence more than 9 months after achieving complete remission has not been noted during following to 10 years. A plea is made for cases of advanced disease (B3 and/or C) to be reported according to the extent of pulmonary disease as well as the associated abdominal disease, since analysis of these data reveals striking differences in patient survival, ranging from 100 to 35 per cent according to subgrouping.