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Yuen KL, Pandit K, Puri D, Yodkhunnatham N, Bagrodia A. Testicular cancer with small metastatic burden: optimal approach in 2024. Curr Opin Urol 2024; 34:204-209. [PMID: 38305430 DOI: 10.1097/mou.0000000000001162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
PURPOSE OF REVIEW Recent advancements in the management of clinical stage II (CS II) testicular cancer have transformed it into a predominantly curable condition. This success in treatment advancements has markedly extended patient survival. However, these treatments carry risks and morbidities, which is important to consider given the disease's impact on young men and the emerging understanding of long-term treatment consequences. RECENT FINDINGS Emerging data support primary retroperitoneal lymph node dissection (RPLND) for select CS II seminoma patients, with similar short-term outcomes to chemotherapy but less treatment intensity. Recent studies have also challenged the reflexive use of adjuvant chemotherapy for pathologic node-positive disease, as growing evidence shows low relapse rates regardless of nodal stage. Furthermore, novel biomarkers like circulating serum microRNA-371a-3p levels can help predict the presence of viable germ cell tumor at time of RPLND. SUMMARY Advances in risk stratification and therapy enable personalized de-escalation approaches for oligometastatic testicular cancer, optimizing survivorship. Upfront RPLND, reassessing adjuvant systemic therapy for RPLND pN+ disease, and novel biomarkers will shape precision treatment to achieve high cure rates with excellent quality of life. Ongoing trials of reduced-intensity regimens, accurate prognostic models, improved surgical strategy, and emerging biomarkers represent the next frontier in tailored curative therapy.
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Affiliation(s)
- Kit L Yuen
- Department of Urology, University of California San Diego, La Jolla, CA, USA
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Ghosh S, Agrawal A, Rangarajan V, Choudhury S, Maitre P, Purandare N, Shah S, Puranik A, Bakshi G, Joshi A, Prakash G, Menon S, Prabhash K, Norohna V, Pal M, Murthy V. Evaluation of post-chemotherapy residual seminomatous masses by 18F-fluorodeoxyglucose PET/CT using tumor-to-liver ratio - conundrum or solution? Nucl Med Commun 2023; 44:1156-1162. [PMID: 37706256 DOI: 10.1097/mnm.0000000000001762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
OBJECTIVE Assessment of diagnostic accuracy of FDG-PET/CT in the detection of viable disease in post-chemotherapy seminomatous residual masses using visual interpretation, SUVmax, and T/L ratio. METHODS This is a retrospective study assessing the post-chemotherapy seminomatous residual masses of size >3 cm. The PET/CT scan findings were interpreted visually for presence of residual disease which were validated from histopathology reports or imaging follow-up for a maximum of 3 years. SUVmax and T/L ratios were also determined for all the residual lesions. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value NPV were calculated and compared for all three parameters along with ROC analysis to obtain an optimal cutoff value for SUVmax and T/L ratio, respectively. RESULTS Sample size was 49. Out of these 49 patients, 8 had validation of PET results with histopathology. Rest was validated with imaging follow-up. FDG-PET was positive in 30 patients and negative in 19 patients by visual interpretation. The sensitivity, specificity, PPV, and NPV by this method were 100%, 62.5%, 73%, and 100%, respectively. The SUVmax and T/L ratios were also calculated for these lesions. The cutoff for these two variables was 4.56 and 1.21, respectively. The sensitivity, specificity, PPV, and NPV at these cutoffs were 76%, 87.5%, 86%, 77.7%, and 92%, 87.5%, 88%, 91%, respectively. CONCLUSION FDG-PET has a favorable diagnostic value in predicting viable disease in post-chemotherapy seminomatous residual masses and using T/L ratio cutoff of 1.21 will increase the specificity of the test.
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Affiliation(s)
- Suchismita Ghosh
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Homi Bhabha National Institute,
| | - Archi Agrawal
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Homi Bhabha National Institute,
| | - Venkatesh Rangarajan
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Homi Bhabha National Institute,
| | - Sayak Choudhury
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Homi Bhabha National Institute,
| | - Priyamvada Maitre
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute,
| | - Nilendu Purandare
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Homi Bhabha National Institute,
| | - Sneha Shah
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Homi Bhabha National Institute,
| | - Ameya Puranik
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Homi Bhabha National Institute,
| | - Ganesh Bakshi
- Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute,
| | - Amit Joshi
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute and
| | - Gagan Prakash
- Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute,
| | - Santosh Menon
- Department of Pathology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Kumar Prabhash
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute and
| | - Vanita Norohna
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute and
| | - Mahendra Pal
- Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute,
| | - Vedang Murthy
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute,
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Therapy of clinical stage IIA and IIB seminoma: a systematic review. World J Urol 2022; 40:2829-2841. [PMID: 34779882 PMCID: PMC9712301 DOI: 10.1007/s00345-021-03873-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/25/2021] [Indexed: 12/30/2022] Open
Abstract
PURPOSE The optimal treatment for clinical stage (CS) IIA/IIB seminomas is still controversial. We evaluated current treatment options. METHODS A systematic review was performed. Only randomized clinical trials and comparative studies published from January 2010 until February 2021 were included. Search items included: seminoma, CS IIA, CS IIB and therapy. Outcome parameters were relapse rate (RR), relapse-free (RFS), overall and cancer-specific survival (OS, CSS). Additionally, acute and long-term side effects including secondary malignancies (SMs) were analyzed. RESULTS Seven comparative studies (one prospective and six retrospective) were identified with a total of 5049 patients (CS IIA: 2840, CS IIB: 2209). The applied treatment modalities were radiotherapy (RT) (n = 3049; CS IIA: 1888, CSIIB: 1006, unknown: 155) and chemotherapy (CT) or no RT (n = 2000; CS IIA: 797, CS IIB: 1074, unknown: 129). In CS IIA, RRs ranged from 0% to 4.8% for RT and 0% for CT. Concerning CS IIB RRs of 9.5%-21.1% for RT and of 0%-14.2% for CT have been reported. 5-year OS ranged from 90 to 100%. Only two studies reported on treatment-related toxicities. CONCLUSIONS RT and CT are the most commonly applied treatments in CS IIA/B seminoma. In CS IIA seminomas, RRs after RT and CT are similar. However, in CS IIB, CT seems to be more effective. Survival rates of CS IIA/B seminomas are excellent. Consequently, long-term toxicities and SMs are important survivorship issues. Alternative treatment approaches, e.g., retroperitoneal lymph node dissection (RPLND) or dose-reduced sequential CT/RT are currently under prospective investigation.
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Complete testicular remission after chemotherapy in a patient with advanced seminoma: is the testicle a real 'sanctuary'? A case report and review of the literature. Anticancer Drugs 2021; 32:585-588. [PMID: 33595949 DOI: 10.1097/cad.0000000000001042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Testicular cancer is relatively uncommon, but at the same time, it is the most common solid tumor in men between the ages of 20 and 34 years. Seminoma represents the most frequently encountered germ cell tumors. Because orchiectomy is usually performed before chemotherapy, little is known about the effect of systemic chemotherapy on primary testicular tumors. Furthermore, the testis has always been considered a sanctuary site, an immune-privileged site in which inadequate exposure of the tumor to chemotherapy may occur. We report the case of a young patient with advanced seminoma with a complete testicular response after four cycles of cisplatin-based chemotherapy. Then, we performed a systematic review of the literature reporting the studies published to date on the topic.
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Reducing the burden of chemotherapy in stage IIB/C testicular seminoma. CURRENT PROBLEMS IN CANCER: CASE REPORTS 2020. [DOI: 10.1016/j.cpccr.2020.100022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Abstract
There are several treatment approaches for stage II germ cell tumors (GCTs), and a thorough understanding of the staging classification and histologic differences in tumor biology and therapeutic responsiveness is critical to determine an effective, multimodal management strategy that involves urologists, medical oncologists, and radiation oncologists. This article discusses contemporary management strategies for stage II GCTs, including chemotherapy, radiotherapy, retroperitoneal lymph node dissection (RPLND), and surveillance. Patient selection, histology, and extent of lymphadenopathy drive management, and, as both treatment and detection strategies continue to emerge and be refined, the management of patients with stage II GCT continues to evolve.
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Affiliation(s)
- Rashed A Ghandour
- Department of Urology, University of Texas Southwestern Medical Center, 2001 Inwood Road, 4th Floor, Dallas, TX 75390-9110, USA
| | - Nirmish Singla
- Department of Urology, University of Texas Southwestern Medical Center, 2001 Inwood Road, 4th Floor, Dallas, TX 75390-9110, USA
| | - Aditya Bagrodia
- Department of Urology, University of Texas Southwestern Medical Center, 2001 Inwood Road, 4th Floor, Dallas, TX 75390-9110, USA.
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Retroperitoneal Lymph Node Dissection as an Alternative Treatment Strategy for Low Volume, Clinical Stage II Testicular Seminoma: A Survey of Patients and Providers. UROLOGY PRACTICE 2019. [DOI: 10.1016/j.urpr.2018.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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von Amsberg G, Hamilton R, Papachristofilou A. Clinical Stage IIA-IIC Seminoma: Radiation Therapy versus Systemic Chemotherapy versus Retroperitoneal Lymph Node Dissection. Oncol Res Treat 2018; 41:360-363. [PMID: 29763926 DOI: 10.1159/000489408] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 04/19/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Clinical stage II (CSII) seminoma is defined by the presence of pure seminoma accompanied by retroperitoneal lymph node metastases. In patients with bulky disease (lymph nodes > 5 cm in diameter), platinum-based chemotherapy is the widely accepted standard of care. However, the optimal choice of treatment for CSIIA and IIB is more controversial. METHODS We performed a PubMed search using the key words stage II seminoma, BEP (cisplatin, etoposide, and bleomycin), hockey-stick radiotherapy, dog-leg radiotherapy and retroperitoneal lymph node dissection. Most relevant publications were summarized for this review. RESULTS To date, no randomized trials have prospectively compared radiotherapy (RT), chemotherapy (CT) and retroperitoneal lymph node dissection (RLND) for CSII seminoma. Because of the predominantly retrospective analyses and only few prospective trials data interpretation is complex. In CSIIA with lymph nodes of < 2 cm, RT and CT seem to be equally effective, while in CSIIB, a decreased number of relapses were observed in CT-treated patients. In addition, RT seems to be associated with a higher incidence of long-term sequelae when compared with CT. CONCLUSION Prospective clinical trials are needed to systematically compare the different treatment modalities. De-escalation of treatment intensity without loss of efficacy is required to improve long-term outcome for this young patient population.
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Stage II Testicular Seminoma: Patterns of Care and Survival by Treatment Strategy. Clin Oncol (R Coll Radiol) 2016; 28:513-21. [DOI: 10.1016/j.clon.2016.02.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/28/2016] [Accepted: 02/02/2016] [Indexed: 01/06/2023]
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Giannatempo P, Greco T, Mariani L, Nicolai N, Tana S, Farè E, Raggi D, Piva L, Catanzaro M, Biasoni D, Torelli T, Stagni S, Avuzzi B, Maffezzini M, Landoni G, De Braud F, Gianni A, Sonpavde G, Salvioni R, Necchi A. Radiotherapy or chemotherapy for clinical stage IIA and IIB seminoma: a systematic review and meta-analysis of patient outcomes. Ann Oncol 2015; 26:657-668. [DOI: 10.1093/annonc/mdu447] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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Quiñonez MAL. Uso de la quimioterapia en cáncer testicular de células germinales. UROLOGÍA COLOMBIANA 2014. [DOI: 10.1016/s0120-789x(14)50040-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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12
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Hallemeier CL, Pisansky TM, Davis BJ, Choo R. Long-term outcomes of radiotherapy for stage II testicular seminoma–the Mayo Clinic experience. Urol Oncol 2013; 31:1832-8. [DOI: 10.1016/j.urolonc.2012.03.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Revised: 03/17/2012] [Accepted: 03/18/2012] [Indexed: 11/17/2022]
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13
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Domont J, Massard C, Patrikidou A, Bossi A, de Crevoisier R, Rose M, Wibault P, Fizazi K. A risk-adapted strategy of radiotherapy or cisplatin-based chemotherapy in stage II seminoma. Urol Oncol 2013; 31:697-705. [DOI: 10.1016/j.urolonc.2011.04.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 04/11/2011] [Accepted: 04/13/2011] [Indexed: 11/29/2022]
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Pichler R, Leonhartsberger N, Stöhr B, Horninger W, Steiner H. Two Cycles of Cisplatin-Based Chemotherapy for Low-Volume Stage II Seminoma: Results of a Retrospective, Single-Center Case Series. Chemotherapy 2012; 58:405-10. [DOI: 10.1159/000345701] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 11/05/2012] [Indexed: 11/19/2022]
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Abstract
This article highlights relevant aspects of the rare late relapses of malignant germ cell tumors (MGCTs), which by definition occur at least 2 years after successful treatment. In most reports, 1% to 6% of patients with MGCT experience a late relapse. Surgery is the most important part in the treatment of late relapses. Viable MGCT or teratoma with malignant transformation may require multimodal treatment with chemotherapy, radiotherapy, and/or surgery. Salvage chemotherapy should be based on a representative biopsy. Referring patients with late relapse to high-volume institutions ensures the best chances of cure and enables multimodal treatment.
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Affiliation(s)
- Jan Oldenburg
- Department of Oncology, The Norwegian Radium Hospital, Oslo, Norway.
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Boujelbene N, Cosinschi A, Boujelbene N, Khanfir K, Bhagwati S, Herrmann E, Mirimanoff RO, Ozsahin M, Zouhair A. Pure seminoma: a review and update. Radiat Oncol 2011; 6:90. [PMID: 21819630 PMCID: PMC3163197 DOI: 10.1186/1748-717x-6-90] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 08/08/2011] [Indexed: 03/27/2023] Open
Abstract
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.
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Affiliation(s)
- Noureddine Boujelbene
- Department of Radiation Oncology, Centre Hospitalier Universitaire Vaudois (CHUV), Bugnon 46, CH-1011 Lausanne, Switzerland
- Department of Radiation Oncology, Centre Hospitalier Universitaire Habib Bourguiba, 3000 Sfax, Tunisia
- Department of Radiation Oncology, Hôpital de Sion-CHCVs, CH-1950 Sion, Switzerland
| | - Adrien Cosinschi
- Department of Radiation Oncology, Centre Hospitalier Universitaire Vaudois (CHUV), Bugnon 46, CH-1011 Lausanne, Switzerland
| | - Nadia Boujelbene
- Department of Pathology, Institut Gustave-Roussy, 94805 Villejuif, France
- Department of Pathology, Hôpital HabibThameur, 1089 Tunis, Tunisia
| | - Kaouthar Khanfir
- Department of Radiation Oncology, Centre Hospitalier Universitaire Vaudois (CHUV), Bugnon 46, CH-1011 Lausanne, Switzerland
- Department of Radiation Oncology, Hôpital de Sion-CHCVs, CH-1950 Sion, Switzerland
| | - Shushila Bhagwati
- Department of Radiation Oncology, Centre Hospitalier Universitaire Vaudois (CHUV), Bugnon 46, CH-1011 Lausanne, Switzerland
| | - Eveleyn Herrmann
- Department of Radiation Oncology, Centre Hospitalier Universitaire Vaudois (CHUV), Bugnon 46, CH-1011 Lausanne, Switzerland
| | - Rene-Olivier Mirimanoff
- Department of Radiation Oncology, Centre Hospitalier Universitaire Vaudois (CHUV), Bugnon 46, CH-1011 Lausanne, Switzerland
| | - Mahmut Ozsahin
- Department of Radiation Oncology, Centre Hospitalier Universitaire Vaudois (CHUV), Bugnon 46, CH-1011 Lausanne, Switzerland
| | - Abderrahim Zouhair
- Department of Radiation Oncology, Centre Hospitalier Universitaire Vaudois (CHUV), Bugnon 46, CH-1011 Lausanne, Switzerland
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Sneag DB, Ramaiya N, O'Regan KN, Jagannathan JP, Hornick JL, Ho VT, Hayes JH. Peritoneal relapse of testicular seminomatous germ cell tumor treated successfully with salvage chemotherapy and autologous stem cell transplantation. Clin Genitourin Cancer 2011; 9:124-9. [PMID: 21723796 DOI: 10.1016/j.clgc.2011.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 04/14/2011] [Accepted: 05/13/2011] [Indexed: 11/18/2022]
Affiliation(s)
- Darryl B Sneag
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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18
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Abstract
Testicular germ cell tumors and, in particular, seminomas are exquisitely radiation and chemotherapy-sensitive and most presentations are highly curable. In recent years the management focus has been on reducing late sequelae of treatment. For Stage I disease surveillance and adjuvant carboplatin, chemotherapy has become an option. The efficacy of combination chemotherapy has been established for advanced metastatic disease. Through a review of the available literature this article outlines the recent changes in the management of seminoma.
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Affiliation(s)
- Emma J Alexander
- Royal Marsden Hospital, Downs Road, Sutton, Surrey, SM2 5PT, United Kingdom
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Kollmannsberger C, Tyldesley S, Moore C, Chi K, Murray N, Daneshmand S, Black P, Duncan G, Hayes-Lattin B, Nichols C. Evolution in management of testicular seminoma: population-based outcomes with selective utilization of active therapies. Ann Oncol 2011; 22:808-814. [DOI: 10.1093/annonc/mdq466] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Durand X, Avances C, Flechon A, Mottet N. Récidives tardives des tumeurs germinales du testicule. Prog Urol 2010; 20:416-24. [DOI: 10.1016/j.purol.2010.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2009] [Revised: 10/02/2009] [Accepted: 02/09/2010] [Indexed: 12/01/2022]
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Detti B, Livi L, Scoccianti S, Gacci M, Lapini A, Cai T, Meattini I, Mileo AM, Iannalfi A, Bruni A, Biti G. Management of Stage II testicular seminoma over a period of 40 years. Urol Oncol 2009; 27:534-8. [PMID: 18848787 DOI: 10.1016/j.urolonc.2008.07.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Revised: 07/17/2008] [Accepted: 07/22/2008] [Indexed: 10/21/2022]
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Oldenburg J, Wahlqvist R, Fosså SD. Late relapse of germ cell tumors. World J Urol 2009; 27:493-500. [PMID: 19373473 DOI: 10.1007/s00345-009-0411-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Accepted: 03/26/2009] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To assess the main characteristics of late relapsing malignant germ cell tumors (MGCTs). These tumors are rare and occur by definition 2 years or later after successful treatment. METHODS We present relevant literature on relapsing MGCT in order to highlight the following issues: incidence, impact of initial treatment on the subsequent risk of late relapse, treatment, and survival. RESULTS A pooled analysis of 5,880 patients with MGCT revealed late relapses in 119 of 3,704 (3.2%) and in 31 of 2,176 (1.4%) patients with non-seminoma and seminoma, respectively. The retroperitoneal space is the predominant site of relapse in both histological types. The initial treatment is important for the risk and localization of late relapses. Patients with single site teratoma are usually cured by surgery alone, whereas viable MGCT or teratoma with malignant transformation may require multimodal treatment with chemo- and/or radiotherapy as well as surgery. Surgery is the most important part in the treatment of late relapses. Salvage chemotherapy should, if feasible, be based on a representative biopsy. Five-year cancer-specific survival is above 50% in the recent large series and reaches 100% in case of single site teratoma. CONCLUSIONS Treatment of late relapsing MGCT patients is challenging and should be performed in experienced centers only. Referral of late relapsing patients to high-volume institutions ensures the best chances of cure and enables multimodal treatment, and contributes to increased knowledge of tumor biology as well experience with the clinical course of these patients.
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Affiliation(s)
- Jan Oldenburg
- Department of Medical Oncology, The Norwegian Radium Hospital, Oslo, Norway,
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Garcia-del-Muro X, Maroto P, Gumà J, Sastre J, López Brea M, Arranz JA, Lainez N, de Prado DS, Aparicio J, Piulats JM, Pérez X, Germá-Lluch JR. Chemotherapy As an Alternative to Radiotherapy in the Treatment of Stage IIA and IIB Testicular Seminoma: A Spanish Germ Cell Cancer Group Study. J Clin Oncol 2008; 26:5416-21. [DOI: 10.1200/jco.2007.15.9103] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To assess the long-term efficacy and toxicity of front-line cisplatin-based chemotherapy in patients with stage IIA or IIB testicular seminoma. Patients and Methods Untreated patients with pure seminoma of the testis after orchiectomy, with clinical stage IIA or IIB, were considered eligible for this prospective observational study. Chemotherapy consisted of either four cycles of cisplatin and etoposide or three cycles of cisplatin, etoposide, and bleomycin. Results Between April 1994 and March 2003, 72 patients were entered onto the study at 26 participating centers. Eighteen patients had stage IIA disease, and 54 patients had stage IIB disease. Eighty-three percent of patients achieved complete response, and 17% achieved partial response with residual mass. After a median follow-up time of 71.5 months, six patients with stage IIB disease experienced relapse, and one of these patients died as a result of seminoma. Three patients experienced non–seminoma-related deaths (two died from a further esophageal carcinoma, and one died from an upper digestive hemorrhage). The estimated 5-year progression-free survival rates for patients with stage IIA or IIB disease were 100% and 87% (95% CI, 77.5% to 97%), respectively. Five-year progression-free and overall survival rates for the whole group were 90% (95% CI, 82% to 98%) and 95% (95% CI, 89% to 100%), respectively. Severe granulocytopenia and thrombocytopenia were observed in eight and two patients, respectively. Mild to moderate emesis, stomatitis, and diarrhea were the most common nonhematologic effects. Conclusion Chemotherapy is a highly effective and well-tolerated treatment for patients with stage IIA or IIB seminoma and represents an available alternative that could avoid some of the serious late effects associated with radiotherapy. Further studies focusing on long-term toxicities of different treatment modalities are needed.
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Affiliation(s)
- Xavier Garcia-del-Muro
- From the Institut Català d’Oncología, Institut d’Investigació Biomèdica de Bellvitge; Hospital de Sant Pau, Barcelona; Hospital Universitari Sant Joan, Reus; Hospital Universitario San Carlos; Hospital Gregorio Marañón, Madrid; Hospital Marqués de Valdecilla, Santander; Hospital de Navarra, Pamplona; Hospital Clínico, Valladolid; and Hospital La Fe, Valencia, Spain
| | - Pablo Maroto
- From the Institut Català d’Oncología, Institut d’Investigació Biomèdica de Bellvitge; Hospital de Sant Pau, Barcelona; Hospital Universitari Sant Joan, Reus; Hospital Universitario San Carlos; Hospital Gregorio Marañón, Madrid; Hospital Marqués de Valdecilla, Santander; Hospital de Navarra, Pamplona; Hospital Clínico, Valladolid; and Hospital La Fe, Valencia, Spain
| | - Josep Gumà
- From the Institut Català d’Oncología, Institut d’Investigació Biomèdica de Bellvitge; Hospital de Sant Pau, Barcelona; Hospital Universitari Sant Joan, Reus; Hospital Universitario San Carlos; Hospital Gregorio Marañón, Madrid; Hospital Marqués de Valdecilla, Santander; Hospital de Navarra, Pamplona; Hospital Clínico, Valladolid; and Hospital La Fe, Valencia, Spain
| | - Javier Sastre
- From the Institut Català d’Oncología, Institut d’Investigació Biomèdica de Bellvitge; Hospital de Sant Pau, Barcelona; Hospital Universitari Sant Joan, Reus; Hospital Universitario San Carlos; Hospital Gregorio Marañón, Madrid; Hospital Marqués de Valdecilla, Santander; Hospital de Navarra, Pamplona; Hospital Clínico, Valladolid; and Hospital La Fe, Valencia, Spain
| | - Marta López Brea
- From the Institut Català d’Oncología, Institut d’Investigació Biomèdica de Bellvitge; Hospital de Sant Pau, Barcelona; Hospital Universitari Sant Joan, Reus; Hospital Universitario San Carlos; Hospital Gregorio Marañón, Madrid; Hospital Marqués de Valdecilla, Santander; Hospital de Navarra, Pamplona; Hospital Clínico, Valladolid; and Hospital La Fe, Valencia, Spain
| | - José A. Arranz
- From the Institut Català d’Oncología, Institut d’Investigació Biomèdica de Bellvitge; Hospital de Sant Pau, Barcelona; Hospital Universitari Sant Joan, Reus; Hospital Universitario San Carlos; Hospital Gregorio Marañón, Madrid; Hospital Marqués de Valdecilla, Santander; Hospital de Navarra, Pamplona; Hospital Clínico, Valladolid; and Hospital La Fe, Valencia, Spain
| | - Nuria Lainez
- From the Institut Català d’Oncología, Institut d’Investigació Biomèdica de Bellvitge; Hospital de Sant Pau, Barcelona; Hospital Universitari Sant Joan, Reus; Hospital Universitario San Carlos; Hospital Gregorio Marañón, Madrid; Hospital Marqués de Valdecilla, Santander; Hospital de Navarra, Pamplona; Hospital Clínico, Valladolid; and Hospital La Fe, Valencia, Spain
| | - Diego Soto de Prado
- From the Institut Català d’Oncología, Institut d’Investigació Biomèdica de Bellvitge; Hospital de Sant Pau, Barcelona; Hospital Universitari Sant Joan, Reus; Hospital Universitario San Carlos; Hospital Gregorio Marañón, Madrid; Hospital Marqués de Valdecilla, Santander; Hospital de Navarra, Pamplona; Hospital Clínico, Valladolid; and Hospital La Fe, Valencia, Spain
| | - Jorge Aparicio
- From the Institut Català d’Oncología, Institut d’Investigació Biomèdica de Bellvitge; Hospital de Sant Pau, Barcelona; Hospital Universitari Sant Joan, Reus; Hospital Universitario San Carlos; Hospital Gregorio Marañón, Madrid; Hospital Marqués de Valdecilla, Santander; Hospital de Navarra, Pamplona; Hospital Clínico, Valladolid; and Hospital La Fe, Valencia, Spain
| | - José M. Piulats
- From the Institut Català d’Oncología, Institut d’Investigació Biomèdica de Bellvitge; Hospital de Sant Pau, Barcelona; Hospital Universitari Sant Joan, Reus; Hospital Universitario San Carlos; Hospital Gregorio Marañón, Madrid; Hospital Marqués de Valdecilla, Santander; Hospital de Navarra, Pamplona; Hospital Clínico, Valladolid; and Hospital La Fe, Valencia, Spain
| | - Xavier Pérez
- From the Institut Català d’Oncología, Institut d’Investigació Biomèdica de Bellvitge; Hospital de Sant Pau, Barcelona; Hospital Universitari Sant Joan, Reus; Hospital Universitario San Carlos; Hospital Gregorio Marañón, Madrid; Hospital Marqués de Valdecilla, Santander; Hospital de Navarra, Pamplona; Hospital Clínico, Valladolid; and Hospital La Fe, Valencia, Spain
| | - Josep R. Germá-Lluch
- From the Institut Català d’Oncología, Institut d’Investigació Biomèdica de Bellvitge; Hospital de Sant Pau, Barcelona; Hospital Universitari Sant Joan, Reus; Hospital Universitario San Carlos; Hospital Gregorio Marañón, Madrid; Hospital Marqués de Valdecilla, Santander; Hospital de Navarra, Pamplona; Hospital Clínico, Valladolid; and Hospital La Fe, Valencia, Spain
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Evidence-based pragmatic guidelines for the follow-up of testicular cancer: optimising the detection of relapse. Br J Cancer 2008; 98:1894-902. [PMID: 18542063 PMCID: PMC2441965 DOI: 10.1038/sj.bjc.6604280] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Testicular germ cell tumours (TGCTs) are the most common cause of cancer in men between the ages of 15 and 40 years, and, overall, the majority of patients should expect to be cured. The European Germ Cell Cancer Consensus Group has provided clear guidelines for the primary treatment of both seminoma and nonseminomatous germ cell tumours. There is, however, no international consensus on how best to follow patients after their initial management. This must promptly and reliably identify relapses without causing further harm. The standardising of follow-up would result in optimising risk-benefit ratios for individual patients, while ensuring economic use of resources. We have identified the seven common scenarios in managing seminomas and nonseminomas of the various stages and discuss the pertinent issues around relapse and follow-up. We review the available literature and present our comprehensive TGCT follow-up guidelines. Our protocols provide a pragmatic, easily accessible user-friendly basis for other centres to use or to adapt to suit their needs. Furthermore, this should enable future trials to address specific issues around follow-up giving meaningful and useful results.
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Krege S, Beyer J, Souchon R, Albers P, Albrecht W, Algaba F, Bamberg M, Bodrogi I, Bokemeyer C, Cavallin-Ståhl E, Classen J, Clemm C, Cohn-Cedermark G, Culine S, Daugaard G, De Mulder PH, De Santis M, de Wit M, de Wit R, Derigs HG, Dieckmann KP, Dieing A, Droz JP, Fenner M, Fizazi K, Flechon A, Fosså SD, Garcia del Muro X, Gauler T, Geczi L, Gerl A, Germa-Lluch JR, Gillessen S, Hartmann JT, Hartmann M, Heidenreich A, Hoeltl W, Horwich A, Huddart R, Jewett M, Joffe J, Jones WG, Kisbenedek L, Klepp O, Kliesch S, Koehrmann KU, Kollmannsberger C, Kuczyk M, Laguna P, Leiva Galvis O, Loy V, Mason MD, Mead GM, Mueller R, Nichols C, Nicolai N, Oliver T, Ondrus D, Oosterhof GO, Paz-Ares L, Pizzocaro G, Pont J, Pottek T, Powles T, Rick O, Rosti G, Salvioni R, Scheiderbauer J, Schmelz HU, Schmidberger H, Schmoll HJ, Schrader M, Sedlmayer F, Skakkebaek NE, Sohaib A, Tjulandin S, Warde P, Weinknecht S, Weissbach L, Wittekind C, Winter E, Wood L, von der Maase H. European Consensus Conference on Diagnosis and Treatment of Germ Cell Cancer: A Report of the Second Meeting of the European Germ Cell Cancer Consensus Group (EGCCCG): Part II. Eur Urol 2008; 53:497-513. [PMID: 18191015 DOI: 10.1016/j.eururo.2007.12.025] [Citation(s) in RCA: 190] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2007] [Accepted: 12/06/2007] [Indexed: 10/22/2022]
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Hinz S, Schrader M, Kempkensteffen C, Bares R, Brenner W, Krege S, Franzius C, Kliesch S, Heicappel R, Miller K, de Wit M. The role of positron emission tomography in the evaluation of residual masses after chemotherapy for advanced stage seminoma. J Urol 2008; 179:936-40; discussion 940. [PMID: 18207171 DOI: 10.1016/j.juro.2007.10.054] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2007] [Indexed: 11/30/2022]
Abstract
PURPOSE Treatment in patients with seminoma who have residual or recurrent masses following chemotherapy is still a matter of debate. Surgical resection is currently the most common recommendation for masses greater than 3 cm, resulting in overtreatment in up to 70% of those affected. We analyzed the accuracy of preoperative positron emission tomography for predicting viable tumor residuals in patients with seminoma. MATERIALS AND METHODS In a prospective, multicenter trial computerized tomography and FDG (2-(F-18)-fluoro-2-deoxy-D-glucose) positron emission tomography were performed before surgical resection for residual or recurrent masses in 20 patients who had undergone chemotherapy for stage IIb, IIc or III seminoma. Histopathological findings were directly correlated with positron emission tomography results. RESULTS Of the patients 18 presented with residual masses and 2 had recurrent masses following chemotherapy. Histopathological assessment revealed viable tumor in 3 patients and benign lesions in 17. All patients with viable tumor were identified correctly by positron emission tomography. No false-negative results were observed but 9 patients had false-positive positron emission tomography results. This resulted in a negative predictive value of 1 (95% CI 0.63-1) and a positive predictive value of 0.25 (95% CI 0.05-0.57) for FDG-positron emission tomography in our patient cohort. CONCLUSIONS Our data indicate that FDG-positron emission tomography is capable of excluding viable disease in residual masses, even those exceeding 3 cm. Therefore, it may be considered an additional tool to improve patient counseling. However, the decision to perform surgical resection of the residual mass should not be based exclusively on a positive positron emission tomography image since false-positive results appear to be common.
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Affiliation(s)
- Stefan Hinz
- Department of Urology, Charité Campus Benjamin Franklin, Universitaetsmedizin Berlin, Berlin, Germany.
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27
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Langenkamp S, Albers P. [Testicular cancer--is there an indication for adjuvant or neoadjuvant systemic therapy?]. Urologe A 2007; 46:1389-90, 1392-4. [PMID: 17874229 DOI: 10.1007/s00120-007-1552-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Testicular cancer represents between 1 and 1.5% of male neoplasms and 5% of all urological tumours. There are indications for adjuvant or neoadjuvant systemic therapy in all stages of seminomatous and non-seminomatous testicular cancer. The treatment decision is strongly stage dependent. The primary treatment of choice for advanced disease is chemotherapy. In earlier stages a risk-adapted treatment should be used and besides chemotherapy, surveillance, radiotherapy and sometimes retroperitoneal lymph node dissection can be considered. In early stages it is important to reduce immediate adjuvant treatment in as many patients as possible to avoid acute and late toxicities. In advanced stages randomized trials have to clarify if there could be a better outcome with adding new agents or with high-dose chemotherapy for patients with "poor prognosis" and adverse features or patients with a chemoresistant relapse.
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MESH Headings
- Antineoplastic Agents/adverse effects
- Antineoplastic Agents/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biomarkers, Tumor/blood
- Bleomycin/administration & dosage
- Bleomycin/adverse effects
- Carboplatin/administration & dosage
- Carboplatin/adverse effects
- Chemotherapy, Adjuvant
- Cisplatin/administration & dosage
- Cisplatin/adverse effects
- Combined Modality Therapy
- Disease-Free Survival
- Etoposide/administration & dosage
- Etoposide/adverse effects
- Humans
- Lymph Node Excision
- Male
- Neoadjuvant Therapy
- Neoplasm Invasiveness
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/pathology
- Neoplasm Recurrence, Local/radiotherapy
- Neoplasm Recurrence, Local/surgery
- Neoplasm Staging
- Neoplasms, Germ Cell and Embryonal/drug therapy
- Neoplasms, Germ Cell and Embryonal/pathology
- Neoplasms, Germ Cell and Embryonal/radiotherapy
- Neoplasms, Germ Cell and Embryonal/surgery
- Orchiectomy
- Prognosis
- Radiotherapy, Adjuvant
- Randomized Controlled Trials as Topic
- Testicular Neoplasms/drug therapy
- Testicular Neoplasms/pathology
- Testicular Neoplasms/radiotherapy
- Testicular Neoplasms/surgery
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Affiliation(s)
- S Langenkamp
- Klinik für Urologie, Klinikum Kassel GmbH, 34112 Kassel
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Hafeez S, Sharma RA, Huddart RA, Dearnaley DP, Horwich A. Challenges in treating patients with Down's syndrome and testicular cancer with chemotherapy and radiotherapy: The Royal Marsden experience. Clin Oncol (R Coll Radiol) 2007; 19:135-42. [PMID: 17355110 DOI: 10.1016/j.clon.2006.10.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS With a life expectancy similar to the general population, greater numbers of patients with Down's syndrome are being diagnosed with testicular cancer. Learning difficulties and medical co-morbidity are common in this patient population and may lead to non-standard oncological treatment. We aimed to identify and discuss management challenges in the treatment of these patients with chemotherapy and radiotherapy and report their clinical outcome. MATERIALS AND METHODS The Royal Marsden Hospital urology database was searched from 1982 to 2005 to identify all cases of patients with Down's syndrome and histologically confirmed testicular cancer who were referred for consideration of chemotherapy or radiotherapy. RESULTS Nine patients were identified, of whom eight received chemotherapy or radiotherapy. Two patients had bilateral tumours and four had crypto-orchidism. At the time of diagnosis, the patients were 21-50 years of age. Of the 11 tumours identified, nine were seminomas and two were malignant teratoma undifferentiated. Five patients presented with stage I disease, of whom three received carboplatin and one received para-aortic radiotherapy as adjuvant treatment. Three patients presented with stage II disease, of whom two were treated with carboplatin and one received combination chemotherapy followed by radiotherapy. One patient with stage IV disease was treated with carboplatin. Five of nine patients relapsed within 30 months, of whom three were successfully salvaged with radiotherapy and one with combination chemotherapy. CONCLUSION After standard and non-standard therapy for seminoma, the relapse rate for patients in our cohort was high. Since relapsed disease is much more difficult to manage with combination chemotherapy on account of respiratory, cardiac and renal co-morbidity, adequate initial treatment is advised. Consideration of psycho-social issues and the multiple treatment strategies available is vital in delivering optimal care to patients with Down's syndrome and testicular cancer.
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Affiliation(s)
- S Hafeez
- Radiotherapy Department, Royal Marsden Hospital NHS Trust, Downs Road, Sutton, Surrey SM2 5PT, UK
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29
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Oldenburg J, Martin JM, Fosså SD. Late Relapses of Germ Cell Malignancies: Incidence, Management, and Prognosis. J Clin Oncol 2006; 24:5503-11. [PMID: 17158535 DOI: 10.1200/jco.2006.08.1836] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Late relapses of malignant germ cell tumors (MGCTs) are rare and occur, by definition, 2 years or later after successful treatment. They represent a major challenge of today's treatment of MGCTs. Because of the rarity and heterogeneity of late relapses, many aspects of their main characteristics remain obscure. We present relevant literature on relapsing MGCTs to highlight the following issues: incidence, impact of initial treatment on the subsequent risk of late relapse, treatment, and survival. In a pooled analysis, the incidence is 1.4% and 3.2% in seminoma and nonseminoma patients, respectively. The predominant site of relapse is the retroperitoneal space in both histologic types. The initial treatment appears to be important for the risk and localization of late relapses. The treatment of late relapses should be based on a representative presalvage biopsy and includes radical surgery and salvage chemotherapy in most cases. Five-year cancer-specific survival is above 50% in the recent large series and reaches 100% in case of single-site teratoma. Diagnosis and treatment of late-relapsing MGCT patients is challenging and should be performed in experienced centers only. Referral of late-relapsing patients to high-volume institutions ensures the best chances of cure and enables increasing understanding of tumor biology and the clinical course of these patients.
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Affiliation(s)
- Jan Oldenburg
- Department of Clinical Cancer Research, University of Oslo, Rikshospitalet-Radiumhospitalet Medical Center, Oslo, Norway.
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30
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Speight JL, Roach M. Radiotherapy in the management of common genitourinary malignancies. Hematol Oncol Clin North Am 2006; 20:321-46. [PMID: 16730297 DOI: 10.1016/j.hoc.2006.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A continued role for radiation therapy in the multidisciplinary management of genitourinary malignancies seems certain. Treatment outcomes continue to improve, accompanied by diminishing rates of toxicity. With continued technologic advances in the delivery of radiation, including the use of adaptive radiotherapy, the discovery and application of novel treatment agents, and the combined efforts of urologists, medical oncologists, and radiation oncologists, patients who have genitourinary malignancies have an excellent chance of cure.
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Affiliation(s)
- Joycelyn L Speight
- Department of Radiation Oncology, University of California San Francisco Comprehensive Cancer Center, H1031, 1600 Divisadero Street, San Francisco, CA 94143, USA.
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Krege S, Boergermann C, Baschek R, Hinke A, Pottek T, Kliesch S, Dieckmann KP, Albers P, Knutzen B, Weinknecht S, Schmoll HJ, Beyer J, Ruebben H. Single agent carboplatin for CS IIA/B testicular seminoma. A phase II study of the German Testicular Cancer Study Group (GTCSG). Ann Oncol 2006; 17:276-80. [PMID: 16254023 DOI: 10.1093/annonc/mdj039] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The aim was to investigate the use of single agent carboplatin in patients with seminoma stage IIA/B. PATIENTS AND METHODS In a prospective phase II trial, single agent carboplatin at a dose of AUC 7 mg.min/ml every 4 weeks for three cycles in stage IIA (n=51) or four cycles in stage IIB (n=57) was given to 108 patients with previously untreated seminoma stage IIA/B. Patients with residual masses of >or=3 cm were scheduled to receive secondary surgery. RESULTS A complete response (CR) was achieved by 88/108 (81%) patients, 17/108 (16%) achieved a partial response (PR), two of 108 (2%) showed no change, and one patient progressed. In all patients with PR the residual disease was <or=3 cm; yet in two of 17 patients with PR, in two of two patients with NC and in one patient with disease progression residual tumor resection was performed demonstrating vital seminoma. Toxicity was acceptable with grades 3 and 4 myelosuppression, nausea and vomiting in less than 10% of patients each. After a median follow-up of 28 months (range 1-68 months) 14/108 (13%) patients relapsed, all after having achieved a CR. All relapses occurred in the retroperitoneum. One patient died from an unrelated cause. The overall failure rate was 19/108 patients (18%). The overall and disease specific survival was 99% and 100%, respectively. CONCLUSIONS Four cycles of single agent carboplatin AUC 7 do not safely eradicate retroperitoneal metastases in patients with stage IIA/B seminoma.
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Affiliation(s)
- S Krege
- University/Medical School, Urology, Essen, Germany.
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Huddart RA, Kataja VV. ESMO Minimum Clinical Recommendations for diagnosis, treatment and follow-up of testicular seminoma. Ann Oncol 2005; 16 Suppl 1:i40-2. [PMID: 15888748 DOI: 10.1093/annonc/mdi832] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- R A Huddart
- Institute of Cancer Research, 15 Cotswolds Rd, Sutton Surrey, SM7 1DN, England
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Gori S, Porrozzi S, Roila F, Gatta G, De Giorgi U, Marangolo M. Germ cell tumours of the testis. Crit Rev Oncol Hematol 2005; 53:141-64. [PMID: 15661565 DOI: 10.1016/j.critrevonc.2004.05.006] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2004] [Indexed: 11/27/2022] Open
Abstract
Cancer of the testis is a relatively rare disease, accounting for about 1% of all cancers in men. Cryptorchidism is the only confirmed risk factor for testicular germ cell tumour. The majority of GCT are clinically detectable at initial presentation. Any nodular, hard, or fixed area discovered in the testis, must be considered neoplastic until proved otherwise. The appropriate surgical procedure to make the diagnosis is a radical orchidectomy through an inguinal incision. Many GCT produce tumoural markers (AFP, HCG, LDH), who are useful in the diagnosis and staging of disease; to monitor the therapeutic response and to detect tumour recurrence. In 1997 a prognostic factor-based classification for the metastatic germ cell tumours was developed by the IGCCCG: good, intermediate and poor prognosis, with 5-year survival of 91, 79 and 48%, respectively. GCT of the testis is a highly table, often curable, cancer. Germ cell testicular cancers are divided into seminoma and non-seminoma types for treatment planning because seminomatous testicular cancers are more sensitive to radiotherapy. Seminoma (all stages combined) has a cure rate of greater than 90%. For patients with low-stage disease, the cure approaches 100%. For patients with non-seminoma tumours, the cure rate is >95% in stages I and II; it is approximately 70% with standard chemotherapy and resection of residual disease, if necessary, in stages III and IV. Minimum guidelines for clinical, biochemical, and radiological follow-up have been reported by ESMO in 2001.
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Delaney G, Jacob S, Barton M. Estimating the optimal external-beam radiotherapy utilization rate for genitourinary malignancies. Cancer 2005; 103:462-73. [PMID: 15612081 DOI: 10.1002/cncr.20789] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Benchmark radiotherapy utilization rates for genitourinary malignancies are largely unknown, despite the finding that genitourinary cancers comprise approximately 19% of all registered malignancies in Australia. METHODS To develop an evidence-based benchmark of the optimal proportion of patients with genitourinary malignancies who should receive at least one course of radiotherapy at some time during their illness, the authors studied treatment guidelines and treatment reviews regarding genitourinary malignancies. Optimal radiotherapy utilization trees were constructed to show the clinical attributes that indicated possible benefit from radiotherapy based on evidence. Epidemiologic incidence data for each of these clinical attributes were obtained to calculate the optimal proportion of all patients with genitourinary cancer for whom radiotherapy was considered appropriate. RESULTS The proportion of patients with genitourinary malignancies for whom radiotherapy was indicated at some point in their illness, according to the best available evidence, was estimated to be 27% of patients with renal cancer, 58% of patients with bladder cancer, 60% of patients with prostate cancer, and 49% of patients with testicular cancer. The occurrence of ureteric and penile cancers among patients was too rare, and, therefore, these patients were not included in the current study. CONCLUSIONS There was a large discrepancy between actual radiotherapy utilization and the evidence-based optimal rate. The authors recommended strategies to implement the evidence-based guidelines. Evidence-based benchmarks for radiotherapy utilization rates such as the ones described in the current study were important in the evaluation of the appropriate use of radiotherapy.
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Affiliation(s)
- Geoff Delaney
- Collaboration for Cancer Outcomes Research and Evaluation, Liverpool Hospital, Sydney, Australia.
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35
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Schmoll HJ, Souchon R, Krege S, Albers P, Beyer J, Kollmannsberger C, Fossa SD, Skakkebaek NE, de Wit R, Fizazi K, Droz JP, Pizzocaro G, Daugaard G, de Mulder PHM, Horwich A, Oliver T, Huddart R, Rosti G, Paz Ares L, Pont O, Hartmann JT, Aass N, Algaba F, Bamberg M, Bodrogi I, Bokemeyer C, Classen J, Clemm S, Culine S, de Wit M, Derigs HG, Dieckmann KP, Flasshove M, Garcia del Muro X, Gerl A, Germa-Lluch JR, Hartmann M, Heidenreich A, Hoeltl W, Joffe J, Jones W, Kaiser G, Klepp O, Kliesch S, Kisbenedek L, Koehrmann KU, Kuczyk M, Laguna MP, Leiva O, Loy V, Mason MD, Mead GM, Mueller RP, Nicolai N, Oosterhof GON, Pottek T, Rick O, Schmidberger H, Sedlmayer F, Siegert W, Studer U, Tjulandin S, von der Maase H, Walz P, Weinknecht S, Weissbach L, Winter E, Wittekind C. European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG). Ann Oncol 2004; 15:1377-99. [PMID: 15319245 DOI: 10.1093/annonc/mdh301] [Citation(s) in RCA: 380] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Germ cell tumour is the most frequent malignant tumour type in young men with a 100% rise in the incidence every 20 years. Despite this, the high sensitivity of germ cell tumours to platinum-based chemotherapy, together with radiation and surgical measures, leads to the high cure rate of > or = 99% in early stages and 90%, 75-80% and 50% in advanced disease with 'good', 'intermediate' and 'poor' prognostic criteria (IGCCCG classification), respectively. The high cure rate in patients with limited metastatic disease allows the reduction of overall treatment load, and therefore less acute and long-term toxicity, e.g. organ sparing surgery for specific cases, reduced dose and treatment volume of irradiation or substitution of node dissection by surveillance or adjuvant chemotherapy according to the presence or absence of vascular invasion. Thus, different treatment options according to prognostic factors including histology, stage and patient factors and possibilities of the treating centre as well may be used to define the treatment strategy which is definitively chosen for an individual patient. However, this strategy of reduction of treatment load as well as the treatment itself require very high expertise of the treating physician with careful management and follow-up and thorough cooperation by the patient as well to maintain the high rate for cure. Treatment decisions must be based on the available evidence which has been the basis for this consensus guideline delivering a clear proposal for diagnostic and treatment measures in each stage of gonadal and extragonadal germ cell tumour and individual clinical situations. Since this guideline is based on the highest evidence level available today, a deviation from these proposals should be a rare and justified exception.
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Affiliation(s)
- H J Schmoll
- European Germ Cell Cancer Consensus Group, Martin-Luther-University, Department of Hematology/Oncology, Halle, Germany.
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Chung PWM, Gospodarowicz MK, Panzarella T, Jewett MAS, Sturgeon JFG, Tew-George B, Bayley AJS, Catton CN, Milosevic MF, Moore M, Warde PR. Stage II Testicular Seminoma: Patterns of Recurrence and Outcome of Treatment. Eur Urol 2004; 45:754-59; discussion 759-60. [PMID: 15149748 DOI: 10.1016/j.eururo.2004.01.020] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To review treatment outcome and patterns of failure for patients with stage II testicular seminoma and to identify prognostic factors for relapse. METHODS From 1981 to 1999, 126 men with stage II seminoma were treated at Princess Margaret Hospital. Of these, 95 were treated with radiotherapy (RT) and 31 with chemotherapy (ChT). Patient and tumour characteristics were analyzed for prognostic significance for subsequent relapse. RESULTS At median follow-up of 8.5 years, the 5- and 10-year overall survival were both 93%, the 5- and 10-year cause-specific survival were both 94% and the 5- and 10-year relapse-free rates were both 85%. Patients with stage IIA and IIB disease treated with RT and stage IIB treated with chemotherapy had 5-year relapse-free rates of 91.7%, 89.7% and 83.3%, respectively. Seventeen percent of patients treated with radiotherapy and 6% of those treated with chemotherapy have relapsed. Of the RT patients the commonest sites of relapse were left supraclavicular fossa, lung/mediastinum, bone, para-aortics and liver; nine patients had a solitary site of relapse. Two patients treated with chemotherapy had recurrence in the para-aortic and iliac nodes. For RT patients, larger primary tumour size was associated with a reduction in relapse rate. Age, rete testis invasion and lymphovascular invasion were found not to be of prognostic significance. CONCLUSIONS In stage IIA/B seminoma, radiotherapy continues to provide excellent results, as the majority of patients will be cured with this treatment alone. Chemotherapy is the treatment of choice for stage IIC seminoma.
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Affiliation(s)
- Peter W M Chung
- Department of Radiation Oncology, Princess Margaret Hospital, University Health Network, University of Toronto, 610 University Avenue, Toronto, Ontario, Canada M5G 2M9
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De Santis M, Becherer A, Bokemeyer C, Stoiber F, Oechsle K, Sellner F, Lang A, Kletter K, Dohmen BM, Dittrich C, Pont J. 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. J Clin Oncol 2004; 22:1034-9. [PMID: 15020605 DOI: 10.1200/jco.2004.07.188] [Citation(s) in RCA: 347] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Maria De Santis
- Department of Medical Oncology, Kaiser Franz Josef Spital, Kundratstrasse 3, A-1100 Wien, Austria
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Patel MI, Motzer RJ, Sheinfeld J. Management of recurrence and follow-up strategies for patients with seminoma and selected high-risk groups. Urol Clin North Am 2004; 30:803-17. [PMID: 14680316 DOI: 10.1016/s0094-0143(03)00063-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Seminoma is characterized by high sensitivity to both radiation and chemotherapy. Localized recurrences in the retroperitoneum after surveillance for stage I can be treated with radiotherapy; however, multiple or large bulky retroperitoneal recurrences or systemic metastasis requires cisplatin-based chemotherapy. Salvage chemotherapy for those who recur after initial CR to induction chemotherapy is based on ifosfamide- and cisplatin-containing regimens. Incomplete response or failure after induction chemotherapy requires high-dose chemotherapy and stem cell rescue. Patients with seminoma need long-term follow-up because of the possibility of late recurrence and the risk of a second primary tumor.
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Affiliation(s)
- Manish I Patel
- Department of Urology, Memorial Sloan-Kettering Cancer Center, 353 E. 68th Street, New York, NY 10021, USA
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Lo Curto M, Lumia F, Alaggio R, Cecchetto G, Almasio P, Indolfi P, Siracusa F, Bagnulo S, De Bernardi B, De Laurentis T, Di Cataldo A, Tamaro P. Malignant germ cell tumors in childhood: results of the first Italian cooperative study "TCG 91". ACTA ACUST UNITED AC 2003; 41:417-25. [PMID: 14515380 DOI: 10.1002/mpo.10324] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND AIMS About 20% of patients with germ cell tumor (GCT) are still resistant to therapy. To investigate which features are present in resistant patients, a multicenter study on GCT in children was undertaken to correlate clinical and laboratory parameters with the outcome. METHODS Patients aged less than 16 years, with histologically proven extracranial GCT were included. RESULTS Ninety-five patients (median age 33 months, 45 males) were eligible. The site of the primary tumor was gonadal in 59, extragonadal in 36. The stage was I in 39; II in 5; IIIa (microscopic residue) in 7; IIIb (macroscopic residue) in 16; IIIc (unresectable) in 13; IV in 15. The treatment was surgery alone in 31; surgery plus radiotherapy in 1; chemotherapy +/- surgery in 63. Post-chemotherapy resection in 19 (10 complete, 9 partial). The chemotherapy regimen was carboplatin 400 mg/m2/day on days 1, 2; etoposide 150 mg/m2/day on days 1, 2; ifosfamide 1,500 mg/m2/day on days 21, 22; dactinomycin 1.5 mg/m2/day on day 21; vincristine 1.5 mg/m2/day on day 21. Three patients died because of toxicity and two non-responders (to primary chemotherapy), died of progression; among the remaining 90 patients 20 relapsed, 9 are in second remission, 2 are alive with disease, and 9 died of disease progression (one from progression and intracranial hemorrhage). Overall survival was 82.7% and event-free survival: 71.5%. Survival according to: (a) site: testis: 100%; ovary: 88%; sacrococcyx: 69.6%; other sites: 33.3% (P < 0.001); (b) stage: I and II: 100%; IIIa: 83.3%; IIIb: 84.6%; IIIc: 60.6%; IV: 53.2% (P < 0.001); (c) AFP levels: normal: 85.5%; 42-9,470 ng/ml: 84.6%; >/=10,000 ng/ml: 58.7% (P = 0.02). All the pts who had complete resection of the primary tumor at diagnosis or at delayed surgery, remained in remission. CONCLUSIONS Multivariate analysis showed that the primary site of tumor was the only independent prognostic factor for survival and EFS.
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Gholam D, Fizazi K, Terrier-Lacombe MJ, Jan P, Culine S, Theodore C. Advanced seminoma--treatment results and prognostic factors for survival after first-line, cisplatin-based chemotherapy and for patients with recurrent disease: a single-institution experience in 145 patients. Cancer 2003; 98:745-52. [PMID: 12910518 DOI: 10.1002/cncr.11574] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Advanced seminoma is a rare clinicopathologic entity. To the authors' knowledge, very few sizeable reports published to date have studied the outcome of patients with advanced seminoma after first-line and salvage therapy, and few have dealt with prognostic factors initially or in patients with recurrent disease. METHODS The records of 145 men with advanced seminoma who were treated with cisplatin-based first-line chemotherapy regimens were reviewed. Six patient characteristics, including age, prior radiotherapy, primary tumor site, initial serum lactate dehydrogenase and human chorionic gonadotropin levels, and disease stage, were studied as initial prognostic factors. In patients with recurrent disease, outcome according to the site of recurrence and the salvage treatment was also reviewed. RESULTS A complete response was obtained in 130 patients (90%) after cisplatin-based first-line chemotherapy, and the 5-year overall survival rate was 81% (95% confidence interval [95% CI], 73-87%). Nonpulmonary visceral metastasis at diagnosis was the only initial adverse prognostic factor. Thirty-one patients (21%) developed recurrent disease. Recurrence in the liver or the central nervous system was a major adverse prognostic factor, with a 5-year overall survival rate of 7% (95% CI, 1-32%), compared with 58% (95% CI, 33-79%) in patients who had lymph node, lung, or bone recurrences. The only durable complete remission after a liver recurrence was obtained with high-dose chemotherapy followed by autologous stem cell transplantation. All 12 patients who were treated for primary mediastinal seminoma with cisplatin-based chemotherapy alone were long-term disease free survivors. CONCLUSIONS Overall, the prognosis of patients with advanced seminoma was good after cisplatin-based, first-line chemotherapy. Metastasis in the liver or the central nervous system, initially or at recurrence, is currently the only proven adverse prognostic factor.
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Affiliation(s)
- Dany Gholam
- Department of Medicine, Institut Gustave Roussy, Villejuif, France
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Abstract
Patients diagnosed with germ cell tumors (GCT) are relatively young, and most are rendered disease-free by primary treatment. Also, second-line therapies in nearly all instances are potentially curative. Therefore, the schedule and modalities of follow-up testing are important issues in detecting recurrence of GCT and for detecting secondary malignancies and complications of therapy. Follow-up is usually based on the pattern and probability of recurrence following primary therapy according to stage and histology. The National Comprehensive Cancer Network has outlined guidelines (www.nccn.org/physician_gls/index.html). There is a paucity of randomized data regarding the follow-up regimens most effective in identifying relapsed disease. Optimal means of imaging and frequency of physician visits and serum marker level measurements need to be further addressed.
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Affiliation(s)
- G Varuni Kondagunta
- Department of Genitourinary Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021, USA
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Classen J, Schmidberger H, Meisner C, Souchon R, Sautter-Bihl ML, Sauer R, Weinknecht S, Köhrmann KU, Bamberg M. Radiotherapy for stages IIA/B testicular seminoma: final report of a prospective multicenter clinical trial. J Clin Oncol 2003; 21:1101-6. [PMID: 12637477 DOI: 10.1200/jco.2003.06.065] [Citation(s) in RCA: 179] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Johannes Classen
- Departments of Radiation Oncology and Medical Information Processing, University of Tübingen, Tübingen, Germany.
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Horwich A, Huddart RA. Adjuvant chemotherapy for high-risk low-stage germ-cell tumours. Curr Opin Urol 2002; 12:431-4. [PMID: 12172432 DOI: 10.1097/00042307-200209000-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE OF REVIEW To review the assessment and management of early germ-cell tumours. RECENT FINDINGS A role has evolved for adjuvant chemotherapy in stage I disease postorchidectomy and in the primary management of stage II disease. SUMMARY A range of approaches offer high survival in early germ-cell tumours. Treatment should factor in patient choice and resource issues. More sensitive imaging with Positron Emission Tomography may allow more appropriate treatment decisions.
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Affiliation(s)
- Alan Horwich
- The Academic Unit of Radiotherapy and Oncology, The Royal Marsden NHS Trust and The Institute of Cancer Research, Sutton, Surrey UK
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Shahidi M, Norman AR, Dearnaley DP, Nicholls J, Horwich A, Huddart RA. Late recurrence in 1263 men with testicular germ cell tumors. Multivariate analysis of risk factors and implications for management. Cancer 2002; 95:520-30. [PMID: 12209744 DOI: 10.1002/cncr.10691] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Testicular germ cell tumors are highly curable. However, 10-30% of patients have recurrence after initial treatment. The time-course of recurrence has implications for the duration of follow-up. This study was undertaken to assess the risk and time-course of recurrence and to identify patients at higher risk of late recurrence. METHODS The records of 1263 patients with primary testicular germ cell tumors presenting to the Royal Marsden Hospital between December 1979 and December 1993 were reviewed. In all, 255 episodes of recurrence were documented (including 44 patients with multiple recurrences) and used to calculate recurrence-free survivals. RESULTS Fifty-three patients (15 seminomas; 38 nonseminomatous germ cell tumors [NSGCT]) had recurrence more than 2 years after initial presentation. A multivariate analysis of risk of recurrence after 2 years identified positive markers at presentation and the presence of differentiated teratomas in postchemotherapy surgical specimens as significant predictors. Very late recurrence (> 5 years) occurred mainly in patients with metastatic NSGCT (12 of 14 patients) with a 1% annual risk of recurrence between 5 and 10 years. Very late recurrence was also seen in one case of metastatic seminoma and one case of Stage I NSGCT managed by surveillance. Most late recurrences (n = 9) were detected at routine annual follow-up visits but five had recurrences with symptoms leading to an unscheduled clinic visit. CONCLUSION Late recurrences are rare in patients with testicular germ cell tumors and follow-up to detect recurrence may not be needed after 5 years, except in those presenting with metastatic NSGCTs.
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Affiliation(s)
- Mehdi Shahidi
- Academic Department of Radiotherapy and Oncology, The Royal Marsden NHS Trust, Institute of Cancer Research, Downs Road, Sutton, Surrey SM2 5PT, United Kingdom.
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Abstract
PURPOSE To compare the outcome of patients with Stage II seminoma treated with prophylactic mediastinal irradiation, without any supradiaphragmatic irradiation, and with prophylactic left supraclavicular irradiation (PLSCI). METHODS AND MATERIALS Between 1960 and 1999, 73 men with Stage II seminoma received postorchiectomy radiotherapy. Before 1984, 36 received prophylactic mediastinal irradiation (Series I); between 1984 and 1992, 17 received no supradiaphragmatic irradiation (Series II); and after 1992, 20 received PLSCI (Series III). The outcomes in these series were compared. RESULTS The abdominal tumor sizes were as follows: Series I, <or=2 cm, n = 4; >2 and <or=5 cm, n = 12; >5 and <or=10 cm, n = 16; Series II, <or=2 cm, n = 1; >2 and <or=5 cm, n = 12; >5 and <or=10 cm, n = 4; and Series III, <or=2 cm, n = 1; >2 and <or=5 cm, n = 14; >5 and <or=10 cm, n = 5 (p = 0.75). The median duration of follow-up was 14.4, 9.3, and 4.5 years for Series I, II, and III, respectively. The 6-year freedom from relapse was 94%, 71%, and 95% for Series I, II, and III, respectively. The differences between Series I and II (p = 0.014) and between II and III (p = 0.042) were significant. Three patients in Series II had a relapse in their left supraclavicular fossa-a failure pattern abrogated by PLSCI. CONCLUSIONS PLSCI significantly diminishes the likelihood of relapse for Stage IIA, IIB, and IIC seminoma (mass <or=10 cm).
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Affiliation(s)
- G K Zagars
- Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
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Abstract
The treatment of low-stage testis cancer (defined as clinical stage I or low-volume clinical stage II disease) varies, depending on whether or not the orchiectomy specimen reveals seminoma or nonseminoma. Treatments for clinical stage I seminoma include radiotherapy to the retroperitoneum, surveillance, or two courses of carboplatin chemotherapy. Until the results of an ongoing randomized study comparing radiotherapy with two courses of carboplatin are known, standard accepted treatments currently include radiotherapy or surveillance. In nonbulky clinical stage II seminoma, therapeutic options include radiotherapy or cisplatin-based chemotherapy. For clinical stage I nonseminoma, equivalent short-term survival rates are obtained with either nerve-sparing retroperitoneal lymph node dissection (RPLND), surveillance, or two courses of BEP (bleomycin, etoposide, and platinum) chemotherapy. However, minimization of toxicity of treatment would argue that the two preferred treatments in clinical stage I nonseminoma are nerve-sparing RPLND or surveillance. For low- volume clinical stage II nonseminoma, options include three courses of BEP or primary RPLND. The overall chance for cure is essentially the same for either of these options. Therefore, in each clinical stage of early-stage testis cancer, therapeutic options exist that, based upon current data, are therapeutically equivalent in the short term. Therefore, the ultimate choice of therapy is also dependent upon the short- and long-term toxicity of therapy and the likelihood of late recurrence of disease.
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Affiliation(s)
- R S Foster
- Department of Urology, Indiana University Medical Center, 535 North Barnhill Drive, Suite 420, Indianapolis, IN 46224, USA.
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ESMO Minimum Clinical Recommendations for diagnosis, treatment and follow-up of testicular seminoma. Ann Oncol 2001. [DOI: 10.1023/a:1012416707128] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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von der Maase H. Do we have a new standard of treatment for patients with seminoma stage IIA and stage IIB? Radiother Oncol 2001; 59:1-3. [PMID: 11295199 DOI: 10.1016/s0167-8140(01)00344-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Patterson H, Norman AR, Mitra SS, Nicholls J, Fisher C, Dearnaley DP, Horwich A, Mason MD, Huddart RA. Combination carboplatin and radiotherapy in the management of stage II testicular seminoma: comparison with radiotherapy treatment alone. Radiother Oncol 2001; 59:5-11. [PMID: 11295200 DOI: 10.1016/s0167-8140(00)00240-1] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE To assess the results of treatment in 33 patients with stage IIA/B seminoma who were treated with carboplatin and radiotherapy (RT) between January 1989 and December 1996. PATIENTS AND METHODS Thirty patients received single course single agent carboplatin (400 mg/m2 or area under curve (AUC 7), two patients received two courses carboplatin, and one patient received single course carboplatin and etoposide, all 4-6 weeks prior to infra-diaphragmatic RT. Results were retrospectively compared with those obtained for 80 patients treated from 1970 to 1998 with radiotherapy alone. RESULTS There was minimal toxicity associated with the use of carboplatin prior to RT. With a median follow-up of 4 years (range 2-70 months) 2/33 patients treated with chemotherapy and RT have relapsed, 5-year relapse free survival (RFS) = 96.9% (95% confidence interval (CI) 72.9-99.4%), and one patient has died of progressive disease, 5-year overall survival (OS) = 96.7%. With a median follow-up of 11.2 years (range 6 months to 25.8 years) 15/80 patients treated with RT alone have relapsed, 5-year RFS = 80.7% (95% CI 70.1-87.9%), including 13/61 patients treated with infra-diaphragmatic RT, 5-year RFS = 77.9%, and 2/19 treated with additional supra-diaphragmatic RT, 5-year RFS = 89.5% (P = 0.277). Eleven out of 80 patients have died, 5-year OS = 94.7%. For stage IIA, 1/14 patients treated with chemotherapy and RT have relapsed, 5-year RFS = 92.3%, compared with 5/34 treated with infra-diaphragmatic RT alone 5-year, RFS = 84.9% (P = 0.527). For stage IIB, 1/19 patients relapsed (at 69 months) following chemotherapy and RT (5-year RFS = 100%), whereas 8/27 relapsed following infra-diaphragmatic RT alone, 5-year RFS = 69.4% (P = 0.0595). CONCLUSION Infradiaphragmatic RT alone cures the majority of patients with stage II seminoma, but the relapse rate remains high particularly for patients with stage IIB disease. As compared with historical controls, carboplatin with RT appears to reduce the relapse rate in stage II seminoma with minimal additional toxicity and the results approach statistical significance for stage IIB patients. Confirmation would require a phase III randomized comparison.
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Affiliation(s)
- H Patterson
- Academic Radiotherapy Unit, Institute of Cancer Research and The Royal Marsden NHS Trust, 15 Cotswold Road, Belmont, Sutton, SM2 5NG, Surrey, UK
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