VAB-6 as initial treatment of patients with advanced seminoma

Primary seminoma of prostate in a patient with Klinefelter syndrome: A case report

RATIONALE

Klinefelter syndrome (KS) is a sex differentiation syndrome that occurs in men and is characterized by the 47XXY genotype. An association between KS and cancer has also been reported. The occurrence of seminoma of the prostate in KS has not been reported in the literature to date. Primary seminoma should be included in the differential diagnosis of prostate neoplasms in patients with KS.

PATIENT CONCERNS

A 39-year-old man presenting with urinary retention was admitted to our hospital. Physical examination revealed sparse pubic hairs, atrophic testes, and an underdeveloped penis. Hormonal examination revealed significantly lowered serum testosterone levels and markedly higher follicle-stimulating hormone levels. A chromosomal examination was performed. Computed tomography and magnetic resonance imaging imaging showed a neoplasm in the left lobe of the prostate, and immunohistochemical examination of a transrectal needle biopsy of the prostate was performed.

DIAGNOSES

Chromosomal examination was exhibited a 47 XXY genotype. Histopathology and of Immunohistochemistry of the transrectal needle biopsy specimen confirmed a seminoma. No other neoplasm was found on systemic examination; therefore, the patient was diagnosed with primary prostate seminoma and Klinefelter syndrome.

INTERVENTIONS

The patient refused any treatment except catheterization because of religious reason.

OUTCOMES

The patient died 2 years later.

LESSONS

Primary seminoma should be included in the differential diagnosis of neoplasms of the prostate in patients with KS. Transrectal ultrasound-guided prostate needle biopsy is essential for the diagnosis of prostate neoplasms, and cisplatin-based chemotherapy remains the primary treatment for seminoma.

[Role of radiotherapy in stage I testicular seminomas: about 25 cases]

Notre travail se proposait de rapporter les résultats d’une étude rétrospective, descriptive, portant sur 25 séminomes testiculaires de stade I et de préciser la place de la radiothérapie dans la prise en charge de cette entité. Entre janvier 2001 et décembre 2009, 25 patients atteints d'un séminome testiculaire de stade I ont été pris en charge au service de radiothérapie de l’institut national d’oncologie de Rabat. L’orchidectomie première a été réalisée par voie inguinale. Le bilan d’extension initial comportait un dosage de bHCG totale, d’alphafoetoprotéine, et une exploration des aires ganglionnaires sus- et sous-diaphragmatiques par une tomodensitométrie. L’irradiation adjuvante a été délivrée au moyen d’un accélérateur linéaire. L'âge médian est de 33 ans (18-52 ans). La tumeur testiculaire siégeait à droite chez 16 malades et à gauche chez les 9 autres. La radiothérapie était délivrée dans les aires ganglionnaires lomboaortiques pour 18 patients, lomboaortiques et iliaques homolatérales pour les 7 autres et ceci par deux faisceaux antéropostérieurs, délivrant une dose de 20 à 25 Gy en 10 à 14 fractions. La tolérance immédiate était excellente. La durée médiane de surveillance était de 73 mois. Vingt trois patients sont actuellement vivants, en situation de rémission complète. Un patient a rechuté au niveau pulmonaire 22 mois après la fin de sa radiothérapie. Un patient a été perdu de vue. Il n’a pas été observé de toxicité à long terme, en particulier gastro-intestinale. Aucune tumeur ou pathologie hématologique secondaire n’a été rapportée. La radiothérapie prophylactique reste le traitement adjuvant de référence des séminomes de stade I. La tolérance immédiate est satisfaisante et l’augmentation du risque de cancer secondaire est négligeable par rapport au bénéfice thérapeutique. Toutefois une surveillance armée ainsi qu’une chimiothérapie adjuvante avec un cycle de carboplatine sont aussi efficaces.

Management of Low-Stage Testicular Seminoma

Management of testicular seminoma has benefited from numerous advances in imaging, radiotherapy, and chemotherapy over the last 50 years leading to nearly 100% disease-specific survival for low-stage seminoma. This article examines the evaluation and management of low-stage testicular seminoma, which includes clinical stage I and IIA disease. Excellent outcomes for stage I seminoma are achieved with active surveillance, adjuvant radiotherapy, and adjuvant single-agent carboplatin. Current areas of research focus on optimizing surveillance regimens and minimizing the morbidity and long-term complications of adjuvant treatment. Radiotherapy continues to be the primary treatment option for patients with clinical stage IIa disease.

2-¹⁸fluoro-deoxy-D-glucose positron emission tomography (FDG-PET) for postchemotherapy seminoma residual lesions: a retrospective validation of the SEMPET trial

BACKGROUND

2-¹⁸fluoro-deoxy-D-glucose positron emission tomography (FDG-PET) has been recommended in international guidelines in the evaluation of postchemotherapy seminoma residuals. Our trial was designed to validate these recommendations in a larger group of patients.

PATIENTS AND METHODS

FDG-PET studies in patients with metastatic seminoma and residual masses after platinum-containing chemotherapy were correlated with either the histology of the resected lesion(s) or the clinical outcome.

RESULTS

One hundred and seventy seven FDG-PET results were contributed. Of 127 eligible PET studies, 69% were true negative, 11% true positive, 6% false negative, and 15% false positive. We compared PET scans carried out before and after a cut-off level of 6 weeks after the end of the last chemotherapy cycle. PET sensitivity, specificity, negative predictive value (NPV), and positive predictive value were 50%, 77%, 91%, and 25%, respectively, before the cut-off and 82%, 90%, 95%, and 69% after the cut-off. PET accuracy significantly improved from 73% before to 88% after the cut-off (P=0.032).

CONCLUSION

Our study confirms the high specificity, sensitivity, and NPV of FDG-PET for evaluating postchemotherapy seminoma residuals. When carried out at an adequate time point, FDG-PET remains a valuable tool for clinical decision-making in this clinical setting and spares patients unnecessary therapy.

Primary seminoma of the prostate

Abstract A 54-year-old gentleman was suspected of having sarcoma of the prostate because of his low serum prostate-specific antigen level (1.9 ng/mL) and an enlarged heterogeneous mass on computed tomography and magnetic resonance imaging scans. Pathological examination of the prostate needle biopsy indicated seminoma, which was confirmed with immunohistochemical staining. There was no evidence of disease in other areas on physical examination or on radiographic tests. Therefore, we diagnosed the case as a primary seminoma of the prostate, which was consequently treated with a total of three courses of bleomycin, etoposide and cisplatin chemotherapy. Complete response was obtained on computed tomography, magnetic resonance imaging and prostate needle re-biopsy. To our knowledge, there have only been five cases of primary seminoma of the prostate reported.

2-18fluoro-deoxy-D-glucose Positron Emission Tomography Is a Reliable Predictor for Viable Tumor in Postchemotherapy Seminoma: An Update of the Prospective Multicentric SEMPET Trial

Purpose

To define the clinical value of 2-18fluoro-deoxy-D-glucose positron emission tomography (FDG PET) as a predictor for viable residual tumor in postchemotherapy seminoma residuals in a prospective multicentric trial.

Patients and Methods

FDG PET studies in patients with metastatic pure seminoma who had radiographically defined postchemotherapy residual masses were correlated with either the histology of the resected lesion or the clinical outcome documented by computer tomography (CT), tumor markers, and/or physical examination during follow-up. The size of the residual lesions on CT, either > 3 cm or ≤ 3 cm, was correlated with the presence or absence of viable residual tumor.

Results

Fifty-six FDG PET scans of 51 patients were assessable. All 19 cases with residual lesions > 3 cm and 35 (95%) of 37 with residual lesions ≤ 3 cm were correctly predicted by FDG PET. The specificity, sensitivity, positive predictive value, and negative predictive value of FDG PET were 100% (95% CI, 92% to 100%), 80% (95% CI, 44% to 95%), 100%, and 96%, respectively, versus 74% (95% CI, 58% to 85%), 70% (95% CI, 34% to 90%), 37%, and 92%, respectively, for CT discrimination of the residual tumor by size (> 3 cm/≤ 3 cm).

Conclusion

This investigation confirms that FDG PET is the best predictor of viable residual tumor in postchemotherapy seminoma residuals and should be used as a standard tool for clinical decision making in this patient group.

Pregnancy outcomes and menstrual function after fertility sparing surgery for pure ovarian dysgerminomas

MATERIALS AND METHODS

The medical records of 23 patients with pure ovarian dysgerminoma treated by conservative surgery at SSK Ankara Maternity Hospital between 1991 and 2001 were reviewed retrospectively. Pregnancy outcomes and menstrual function after conservative surgery were analyzed.

RESULTS

Seven patients (30%) were incompletely staged and were assumed to be stage IA due to intraoperative findings. Fifteen patients (70%) were surgically staged. As a result 15 patients (65.2%) were diagnosed to be stage I while 2 patients (8.6%) were staged II and 6 patients (26%) were staged III. Wedge biopsy of contralateral ovary was performed in 17 patients (74%) and tumor was diagnosed in 2 (11.7%). Adjuvant chemotherapy was applied in 16 (70%) of the cases. BEP (bleomycin, etoposide, and cisplatin) was the most frequently used regimen (39%). Recurrences were seen in 3 (13%) patients. The sites of recurrences were contralateral ovary in all cases. Recurrences were treated with surgery and radiotherapy. None of the patients died of disease. Nine patients were sexually active. Five of these patients had prior live births. Three of the primiparous patients delivered after treatment. Five pregnancies occurred in 3 nulliparous patients at the time of primary surgery. Three of these reached term and healthy babies were delivered. One pregnancy was terminated at 18 weeks of gestation due to anencephaly and a dilatation and curettage was performed at 6th week in another patient. Menstrual problems occurred in 4 (17.3%) of the 23 patients.

CONCLUSION

Fertility sparing treatments are safe in patients with pure ovarian dysgerminoma.

Predictive impact of 2-18fluoro-2-deoxy-D-glucose positron emission tomography for residual postchemotherapy masses in patients with bulky seminoma

PURPOSE

To establish the predictive potential of 2-18fluoro-2-deoxy-D-glucose positron emission tomography (FDG PET) for detecting viable tumor tissue in residual postchemotherapy masses of seminoma patients.

PATIENTS AND METHODS

In this prospective multicenter trial, results of FDG PET studies in seminoma patients with postchemotherapy masses > or = 1 cm were correlated with either the histology of the resected lesion or the clinical outcome on follow-up without resection. Negative PET scans of residual lesions that were devoid of viable tumor tissue on resection or disappeared, shrunk, or remained stable in size for at least 2 years were rated as true-negative (TN). Positive scans without histologic or clinical evidence of tumor tissue were classified as false-positive. In patients with histologically positive or progressive lesions, positive PET scans were defined as true-positive (TP) and negative scans, false-negative (FN).

RESULTS

Thirty-seven PET scans of 33 patients were assessable at a median follow-up time of 23 months (range, 2 to 46 months). Histologic data were available from nine patients who had undergone resection. Twenty-eight patients were followed-up clinically and radiologically. Twenty-eight scans were TN, eight were TP, and one was FN. All 14 residual lesions more than 3 cm and 22 (96%) of the 23 < or = 3 cm were correctly predicted by FDG PET. The specificity (100%; 95% confidence interval [CI], 87.7% to 100%), sensitivity (89%; 95% CI, 51.7% to 99.7%), positive predictive value (100%), and the negative predictive value (97%) of FDG PET were superior to data obtained by assessing residual tumor size (< or = or > 3 cm).

CONCLUSION

FDG PET is a clinically useful predictor of viable tumor in postchemotherapy residuals of pure seminoma, especially those greater than 3 cm.

Twelve-year experience with two courses of adjuvant single-agent carboplatin therapy for clinical stage I seminoma

PURPOSE

During the past 30 years, radiation therapy with 28 to 30 Gy for para-aortic and ipsilateral iliac node areas was the standard adjuvant treatment for clinical stage I seminoma after orchiectomy. However, late effects of radiotherapy prompted a search for alternative adjuvant treatment approaches, including surveillance and application of carboplatin. In this retrospective analysis, we evaluated the efficacy and toxicity of two adjuvant single-agent carboplatin courses in 107 patients who were diagnosed with clinical stage I seminoma at our study centers between 1988 and 1999.

PATIENTS AND METHODS

All 107 patients (median age, 39 years; range, 24 to 63 years) received two postoperative adjuvant cycles of carboplatin (400 mg/m(2)). The pathologic tumor stage was pT1 in 84 patients, pT2 in 18 patients, and pT3 in five patients. Whole blood count and serum chemistry were evaluated weekly during treatment to assess hematologic and nonhematologic toxicity.

RESULTS

Six patients died from tumor-unrelated causes. The remaining 101 patients are currently alive and free of disease after a median follow-up of 74 months (range, 5 to 145 months). A detailed analysis of hematologic toxicity showed only World Health Organization (WHO) grade 1 leukocytopenia in 10.7% of all cycles and WHO grade 2 leukocytopenia in 2.1% of all cycles.

CONCLUSION

Regarding the absence of tumor recurrences in our retrospective analysis and the favorable toxicity profile with no episodes of long-term toxicity, we suggest that two adjuvant courses of single-agent carboplatin for clinical stage I seminoma patients might be equivalent to radiotherapy.

Management of testicular seminoma

Testicular seminoma is highly curable with currently available treatments. Today, there is good evidence that patients with Stage I disease can be treated equally well with either immediate adjuvant para-aortic and ipsilateral pelvic radiotherapy or close surveillance with treatment at the time of relapse. The decision as to which of these management strategies is adopted in an individual case is a complex function of physician preference, and the emotional, social, and economic circumstances of the patient. Ongoing research in Stage I seminoma is focused at reducing the side-effects of treatment either by modifying the radiation treatment plan or by using adjuvant chemotherapy in lieu of radiation. Stage II patients with small bulk retroperitoneal lymphadenopathy have a high probability of long-term disease control with radiotherapy. Patients with bulky Stage II disease or Stage III disease should be treated with cisplatin-based chemotherapy.

Outcome and reproductive function after chemotherapy for ovarian dysgerminoma

PURPOSE

To review the outcome for all patients with ovarian dysgerminoma treated at the M.D. Anderson Cancer Center who received bleomycin, etoposide, and cisplatin (BEP) and to assess the menstrual and reproductive function of those who received conservative treatment.

PATIENTS AND METHODS

Clinical information was abstracted from the medical record. Patients completed a detailed questionnaire about menstrual and reproductive function; those who did not return the questionnaire were interviewed by telephone.

RESULTS

Twenty-six patients were identified as having been treated with BEP chemotherapy for pure ovarian dysgerminoma from January 1984 to January 1998. Their median age was 19.5 years (range, 7 to 32 years). Sixteen patients underwent fertility-sparing surgery in the form of unilateral salpingo-oophorectomy. At a median follow-up time of 89 months, 25 (96%) of the 26 patients remained continuously disease-free. One patient apparently developed a second primary dysgerminoma in her remaining ovary after BEP and was clinically disease-free after further treatment. Of the 16 patients who underwent fertility-sparing surgery, one was lost to follow-up when she was pregnant, and one was still premenarchal. Of the remaining 14 patients, 10 (71%) maintained their normal menstrual function during and after chemotherapy, and 13 (93%) had returned to their prechemotherapy menstrual pattern at the time of the questionnaire. Five pregnancies have occurred thus far, and two patients have had difficulty conceiving.

CONCLUSION

Most patients with metastatic dysgerminoma can expect cure with maintenance of normal reproductive function when treated with conservative surgery and BEP chemotherapy.

Single-agent carboplatinum for advanced seminoma. A phase II study

BACKGROUND

To reduce the side effects of cisplatin-based combination chemotherapy, the activity of carboplatinum was evaluated in patients with advanced seminoma.

METHODS

Forty-two evaluable patients with advanced seminoma (defined as abdominal lymph nodes > 5 cm or supradiaphragmatic or visceral disease) received single-agent carboplatinum at a dose of 400 mg/m2 intravenously every 4 weeks for a maximum of six cycles. The median follow-up was 31 months (18-67 months).

RESULTS

Thirty patients (71%) achieved a complete remission (CR; 21 chemotherapy alone, 9 with additional surgery), 8 patients (19%) a partial remission (PR), and 4 patients had disease progression (10%). Patients with metastases confined to the lymph nodes had a significantly higher remission rate than patients with visceral metastases (97% versus 50%; P < 0.002). Elevation of lactate dehydrogenase or human chorionic gonadotropin before radiation therapy had no influence on response rate. Eight patients have relapsed (five from CR and three from PR). All 12 patients failing carboplatinum therapy received cisplatin-based combination regimens. Ten patients achieved a stable favorable response (eight CR, two PR), whereas two patients died of their disease. Currently, 30 patients (71%) are continuously free from progression (25 CR, 5 PR), and 40 patients are alive (survival 93%). Toxicity was mild with no neurotoxicity or nephrotoxicity.

CONCLUSIONS

The use of up-front carboplatinum therapy appears not to compromise the ultimate curability of patients with advanced seminoma. Randomized trials, however, will have to demonstrate the effectiveness of carboplatinum with regard to survival, and help to identify prognostic subgroups of patients who require up-front cisplatinum-based combination chemotherapy.

Value of retroperitoneal lymph node dissection in advanced testicular seminoma

Seven patients with advanced seminoma of the testis (stages II C and III) were treated with 3 induction cycles of VAB-6 chemotherapy. Three patients had complete remission after chemotherapy and are alive disease free at 32, 38, and 40 months with no additional treatment. Four patients were subjected to retroperitoneal lymph node dissection for residual retroperitoneal masses measuring 2-4 cm after chemotherapy, which revealed fibrosis in 2 patients and metastatic seminoma in the other 2. Patients with metastatic residual masses were given postoperative radiation therapy to the retroperitoneum and are alive disease free at 33 and 34 months, while those with fibrosis are alive disease free at 30 and 52 months, respectively, with no additional treatment.

Treatment of stages B3 and C seminoma with chemotherapy followed by irradiation therapy. Southwest Oncology Group Study

Beginning in 1981, 28 patients with advanced seminoma were treated with combination chemotherapy followed by irradiation to evaluate the possibility of improved survival using both modalities. The treatment protocol consisted of two courses of vincristine, actinomycin-D, and cyclophosphamide followed by reassessment. Those initially presenting with Stage B3 disease who achieved a complete response to two cycles of chemotherapy then underwent irradiation. All others were given a third course of chemotherapy before undergoing irradiation. The pre-radiation portion of this protocol produced a complete response rate of only 25 percent, substantially less than other, more recent, protocols. Radiation therapy produced a complete response in 69 percent of those who did not achieve a complete response from chemotherapy, increasing the complete response rate from 25 percent to 64 percent. Given this response rate to radiation therapy and the difficulty of dissection and associated morbidity with the surgical excision of postchemotherapy residual masses, the best option at this time may be observation with salvage chemotherapy and/or radiation reserved for those with disease progression.

VAB-6 and cisplatin-cyclophosphamide combinations in the treatment of metastatic seminoma patients: the U.S.S.R. experience

In a non-randomized study the treatment results of 59 patients with disseminated seminoma were evaluated: 21 patients were treated with a VAB-6 combination and 38 with a CP (cyclophosphamide and cisplatin) combination. After VAB-6 CR was observed in 8 patients and 6 achieved CR with additional treatment: 1 with chemotherapy (PVB) and 5 with radiotherapy (RT). The final CR rate was 67%. At a median follow-up of 38 (11-70) months 15 (71%) are alive, and 11 of them (52%) are NED; 6 have died. Of the 38 patients treated with CP alone only 18 achieved CR and 9 had a CR after additional RT and 1 chemotherapy (VAB-6), the overall CR rate was 72%. The median follow-up is 24 (4-55) months, 28 (74%) are alive, 24 (66%) are currently NED, and 9 have died. Both regimens were well tolerated, the main toxicity being leukopenia: 48% (WHO grade 111-1V-5%) for VAB-6, and 59% (13%) for CP. Hearing loss was registered in 8 patients receiving CP and in 2 receiving VAB-6. There were no fatal toxicities. Thus, VAB-6 and CP regimens seem to have compatible and high activity in disseminated seminoma.

Cisplatin, etoposide, ifosfamide, vincristine and bleomycin combination chemotherapy for far advanced testicular carcinoma

Forty-eight patients with advanced testicular cancer, defined as abdominal mass greater than 10 cm, mediastinal mass greater than 5 cm, more than 20 lung metastases, or visceral organ involvement were treated with an intensive, alternating five-drug regimen consisting of cisplatin 50 mg/m2 d 1-3, etoposide 170 mg/m2 d 1-3, ifosfamide 5 g/m2 d 15, vincristine 2 mg weekly, bleomycin 15 mg/m2 weekly, q d 28. Thirty-four (71%) of the patients attained tumor-free status. This was achieved by chemotherapy alone in 14 patients and by surgical resection of residual disease in the remaining 20 patients (histology of resected tissue: necrosis 12, mature teratoma 7, viable carcinoma 1). Patients with pure seminoma responded better than patients with nonseminoma (CR 100% vs. 67%, respectively). In a univariate analysis only the value of HCG (less than vs greater than 10,000 U/L) and the number of involved organ sites (less than or equal to 2 vs greater than to 2) had significant influence on the response rate. After a minimum follow-up of 24 months 3 patients (9%) have relapsed. The survival rate is 76% after 36 months, with 61% remaining disease-free. Though this intensive regimen might bestow some of the therapeutic advantages of standard three-drug protocols in far advanced testicular cancer, the results are still less than optimal and warrant the exploration of new therapeutic strategies.

The importance of prognostic factors in the individual treatment of patients with disseminated germ cell tumours

Following chemotherapy for disseminated testicular cancer, 55 patients underwent surgery because of residual tumour. The histological findings were viable tumour in 12 patients, mature teratoma in 12 and fibrosis and/or necrosis in 31. Retroperitoneal abdominal masses were evaluated radiographically before and after chemotherapy. The reduction in size of these masses after chemotherapy appeared to have prognostic significance. A decrease of more than 70% was always associated with fibrosis. A residual mass over 50 mm indicated viable tumour or mature teratoma. Seminoma or embryonal carcinoma was more likely to result in fibrosis/necrosis in the resected tissue. Both the Indiana and the EORTC classification models can be used for prognosis. Radiographic measurements before and after chemotherapy are of considerable prognostic significance. These objective indicators help in planning treatment and so diminish the side effects of therapy and maintain or even increase the high cure rate in disseminated testicular cancer.

Modern radiotherapy results with bulky stages II and III seminoma

We treated 20 patients with stage II seminoma by primary radiotherapy from 1971 to 1982. Median patient age was 38 years (range 26 to 52 years) and median disease width in the transverse plane was 11 cm. (range 5 to 25 cm.). Four tumors were 5 to 9 cm., 9 were 10 to 14 cm. and 7 were 15 cm. or more wide. Tumor was palpable in 13 patients. Generous radiation ports (such as wide hockey stick or whole abdomen) often followed by a boost to the area of bulky disease were used as primary therapy in all patients. Median tumor dose was 37.5 Gy. (range 13.3 to 56.7 Gy.). Supradiaphragmatic prophylactic radiation was given to 16 patients (median dose 26 Gy., range 12 to 37.3 Gy.). Median followup was 56 months, and all patients currently are free of disease except for 1 who died without disease more than 10 years after completion of all therapy. Mediastinal failure occurred in 2 of 4 patients without and 1 of 16 with mediastinal prophylaxis. All 4 patients with relapse are currently free of disease after salvage therapy. Five patients 16 to 42 years old (median age 30 years) received primary radiation therapy for stage III disease. The median size of abdominal disease was 10 cm. (range 5 to 17 cm.). Of the 5 stage III cancer patients 3 had supradiaphragmatic disease demonstrated only in supraclavicular lymph nodes and all 3 were continuously free of disease 115 to 136 months after therapy. The remaining 2 stage III cancer patients had supradiaphragmatic disease by virtue of bulky mediastinal disease with or without supraclavicular involvement. Both patients had relapse in-field and distantly, and they died of disease despite salvage chemotherapy. A total of 30 fields with bulky disease (greater than 5 cm.) was treated either primarily or at relapse among the 25 stages II and III cancer patients. In-field relapse occurred in 3 of 21 patients receiving less than or equal to 36 Gy. and 0 of 9 who received greater than 36 Gy. These results justify radiation therapy as an acceptable initial primary treatment modality for typical bulky stage II seminoma. Disease greater than 5 cm. should receive greater than 36 Gy. Prophylactic radiation to the mediastinum is effective. However, patients who have mediastinal failure often can be salvaged with chemotherapy and/or radiation, and prophylactic mediastinal radiotherapy may be associated with poor tolerance to salvage chemotherapy and other significant late effects.(ABSTRACT TRUNCATED AT 400 WORDS)

The case for relevant staging of germ cell tumors

Successful treatment of germ cell tumors arising in the testes or extragonadal sites has become routine. The therapeutic approaches available for patients with germ cell tumor are determined by stage, histology, and site of tumor origin. Staging systems have played an important role in the development of therapy for patients with germ cell tumors. Staging systems must address not only the prognostic variables that determine survival but also the correct therapeutic approach available for such patients (surgery, chemotherapy, surgery plus chemotherapy). Trials are under way in many centers with the intention of reducing the intensity of therapy for patients with a good prognosis and increasing the intensity for those with a poor prognosis. The ability to compare data and, more importantly, to select safely and appropriately those patients to be placed at risk by reduced or increased intensity of therapy will require clinically relevant staging systems. Histologic type and the site of tumor origin markedly determine the clinical dilemmas existing for each group of patients. The subgroup with pure seminoma has tumors with a unique spectrum of sensitivity and toxicity to chemotherapy. A staging system for such patients must be necessity be designed specifically to meet their needs. Patients with nonseminomatous germ cell tumors have benefitted most from the introduction of chemotherapy. Tumor volume, histologic types, and site of origin greatly influence the results of treatment. Staging systems must be developed that meticulously evaluate tumor volume, secretion of serum biomarkers, and site of origin of tumor. The results of the M.D. Anderson Cancer Center experience treating germ cell tumors support the use of such clinically relevant staging systems. The therapeutic dilemmas outlined for each of the histologic subtypes will serve as the basis of future studies.

Combination chemotherapy with vinblastine, ifosfamide and cisplatin in bulky seminoma

Since 1982, 24 patients with bulky seminoma were treated with the VIP-regimen consisting of vinblastine 6 mg/m2 days 1+2, ifosfamide 1.5 g/m2 days 1-5, cisplatin 20 mg/m2 days 1-5. One patient showed primary progression, another patient partial remission, and one patient died during the first cycle. All the other patients had complete remission (21/24 = 87%), which was documented histologically in 9 patients. One patient relapsed but obtained complete remission after repeated treatment. Thus 21 patients are currently living without disease after a median observation time of 30+ months. Bone marrow toxicity was severe, leading to dose reduction in more than 50% of the patients. No other severe side effects were observed. We conclude that the regimen is highly effective in bulky seminoma. Reduction of the vinblastine dose is recommended because of bone marrow toxicity.

Bone disease in testicular and extragonadal germ cell tumours

Of 297 patients with metastatic testicular and extragonadal germ cell tumours (GCT), bone involvement was detected clinically in 3% (7/251) of those at first presentation and in 9% (4/46) of relapsed cases. This difference was not statistically significant (95% confidence limits -2%; +14%). Concurrent systemic metastases, commonly involving lung (7/11 cases) and para-aortic lymph nodes (6/11), were present in all patients with bone disease. All affected patients had localized bone pain and lumbar spine was the most frequent site involved (9/11). Spinal cord compression occurred in two patients while a third developed progressive vertebral collapse after chemotherapy and required extensive surgical reconstruction. At median follow-up of 4 years, survival among patients presenting with bone disease (6/7) was similar to overall survival in the whole group (84%) and appeared better than in those with liver (18/26, 69%) or central nervous system (6/9) metastases at presentation. Back pain in metastatic germ cell tumours is often due to retroperitoneal lymphadenopathy but lumbar spine osseus metastases must be recognized early if severe potential complications, such as spinal cord compression, are to be avoided. In this series, bone metastases were not seen in the absence of widespread systemic disease suggesting all solitary bony lesions in GCT patients should be biopsied.

Management of seminoma with bulky abdominal disease

Thirty-three cases of seminoma with palpable abdominal disease were treated at the Cancer Control Agency of B.C. between 1948 and 1983. Twenty-three had disease confined to the abdomen (Stage IIB), eight had simultaneous involvement of mediastinal and supraclavicular nodes (Stage IIIB) and two had bone or pulmonary metastases (Stage IV). Five and 10-year disease-specific actuarial survivals for the whole group were 87% and 81%, respectively. Corresponding relapse-free survival was 64%. Of the twenty-three IIB cases, 15 had primary treatment with abdominal radiation only, and eight had prophylactic mediastinal/supraclavicular radiation. Although relapse in IIB was more common in the group receiving abdominal radiation only, survival was unchanged. For the entire IIB group, 5- and 10-year disease-specific actuarial survivals were 91% and 84%, respectively, and corresponding relapse-free survival was 74%. The eight IIIB patients were treated primarily with radiation. Four patients relapsed, all in extranodal sites. Two of these died of disease. Both Stage IV patients required radiation and chemotherapy for long-term disease control. Stage IIB disease can be treated primarily with abdominal radiation, but radiation alone is inadequate when bulky abdominal disease is associated with supradiaphragmatic lymphatic spread or hematogenous metastases.

Cyclophosphamide and sequential cisplatin for advanced seminoma: long-term followup in 52 patients

Fifty-two patients with advanced seminoma were treated with primary chemotherapy: 44 received cyclophosphamide and weekly cisplatin, and 8 received sequential weekly cisplatin alone. Of the patients treated with chemotherapy alone only 44 achieved a complete remission and 4 were salvaged with further therapy (1 chemotherapy and 3 radiation therapy). These 48 patients (92 per cent) remained free of disease at a followup of 30 to 471 weeks. Six prognostic factors were tested by univariate analysis (chi-square) and only the use of previous chemotherapy predicted for a lower complete remission rate (p equals 0.02). Renal toxicity (greater than 0.4 mg. per dl. increase in serum creatinine) occurred in 2 patients (4 per cent). Neurotoxicity occurred in 16 patients (31 per cent). No fatal toxicity occurred. Cyclophosphamide and weekly cisplatin were well tolerated in patients previously treated with radiation therapy and is the treatment of choice for patients with disseminated seminoma.

Chemotherapeutic complete remission in patients with metastatic ovarian dysgerminoma. Potential for cure and preservation of reproductive capacity

Two patients with metastatic dysgerminoma of the ovary were treated with a combination of etoposide, bleomycin, and cisplatin at The University of Texas M.D. Anderson Hospital and Tumor Institute at Houston. Both patients achieved a complete remission. Patient 1 developed a massive recurrence in the para-aortic lymph nodes 21 months after diagnosis and treatment with right salpingo-oophorectomy alone. She received four cycles of chemotherapy and is free of disease 21 months from the start of chemotherapy. Patient 2 had Stage III dysgerminoma and a lymphangiogram positive for tumor in the para-aortic lymph nodes. After surgery she received three cycles of chemotherapy and is free of disease 20 months from the start of chemotherapy. Both complete remissions were documented with second-look laparotomy. Chemotherapy may be an alternative to radiotherapy for the treatment of metastatic dysgerminoma and should also be considered for selected patients with Stage I disease. A literature review further supports the conclusion that additional clinical trials might expand the indications for chemotherapy in patients with this disease.

Vinblastine-ifosfamide-cisplatin treatment of bulky seminoma

Eighteen patients with pure seminoma in advanced Stages IIC-IV of disease were treated with VIP combination chemotherapy consisting of vinblastine (6 mg/m2, days 1 and 2), ifosfamide (1.5 g/m2, days 1 to 5), and cisplatin (20 mg/m2, days 1 to 5). Eleven patients had Stage IIC, four had Stage III, three had Stage IV, and two had primary extragonadal seminoma. Primary histologic diagnoses were typical seminoma in 15 patients and anaplastic seminoma in three patients. Human chorionic gonadotropin (HCG) levels were elevated to 350 U/1 in eight patients; alpha-fetoprotein (AFP) levels were always normal. No primary lymphadenectomy was carried out. Seven of 18 patients had prior radiotherapy and were treated because of relapse or progression. There was one early death and one patient has not yet completed therapy. Of 16 evaluable patients, 14 reached complete remission (CR) (88%), which was documented surgically in six cases, whereas in the non-pretreated group, all nine patients reached CR and in the pretreated group, CR could be induced in five of seven patients (71%). The remission duration ranged from 6+ to 41+ months (median, 29+ months). No relapse has occurred. The bone marrow toxicity of VIP was remarkable. Because of leukopenia below 1000/mm3 and/or thrombopenia below 50,000/mm3, dose reduction and interval prolongation were necessary in 10 of 16 patients, especially in all those who were pretreated. Even though it is not superior to other platin-based regimens, VIP chemotherapy is highly effective in bulky seminoma with and without prior radiotherapy.

Cisplatin combination chemotherapy in advanced seminoma

Thirty-one patients were treated with cisplatin combination chemotherapy for advanced seminoma (26 Stage III or bulky Stage II testicular, and five disseminated extragonadal). Seventeen (89%) of 19 patients not previously pretreated and four (80%) of five who had received only abdominal irradiation entered continuous complete remission (CR), versus only two (28%) of seven patients who had received extensive infra- and supradiaphragmatic radiotherapy. Results were not significantly influenced by stage, human chorionic gonadotropin (HCG) titers and histologic subgroups, whereas patients with lactic dehydrogenase (LDH) values exceeding 500 mIU/ml did worse (50% continuous CR rate in 12 cases) than those with normal or less elevated titers (89% continuous CR rate in 19 cases). After a median follow-up period of 34 months (range, 12+ to 77+ months), 23 patients (74.5%) remain alive in continuous CR, two (6%) died in CR and another one (3%) entered CR after deferred treatment of residual disease. Five patients (16%) died of cancer. Toxicity was severe in extensively irradiated patients, but it was acceptable in those not pretreated and in those who had received only subdiaphragmatic radiotherapy. Cisplatin combination chemotherapy can be successfully and safely used as the primary treatment of choice in patients with advanced seminoma. It is also an excellent salvage therapy for patients who had received subdiaphragmatic irradiation only. On the contrary, it is very difficult to treat with chemotherapy extensively irradiated patients.