Cost-Effectiveness of Chest X-Ray Follow-Up of Patients Treated for Seminoma of the Testis

The authors report on a consecutive series of 253 cases of seminoma of the testis followed with periodic chest X-ray examinations from a minimum of three to a maximum of 27 years. The detection rate of asymptomatic intrathoracic metastases (ITM) was considered together with the costs of the follow-up procedure. Chest X-ray follow-up is not advisable beyond one year from primary treatment, since most (14 of 18) ITM occur in the first year, the detection rate of ITM beyond this date is too low (0.11% patients/year), and the related costs are too high (over $ 130,000 per ITM detected). Chest X-ray follow-up is questionable even in the first year after primary treatment for Stage I cases because of the low detection rate (1.38% patients/year) and the high costs (over $ 14,000 per ITM detected), whereas it appears to be opportune in Stages IIA and IIB.

Paediatric dysgerminoma: Results of three consecutive French germ cell tumours clinical studies (TGM-85/90/95) with late effects study

METHODS

French patients (≤18years) treated for dysgerminoma between 1985 and 2005 in TGM-85, 90, 95 protocols were included. Treatment was based on primary unilateral oophorectomy followed by prophylactic lymph node irradiation (1985-1998) or a wait-and-see strategy (1998-2005) for localised completely resected tumours (pS1) or by platinum-based chemotherapy for advanced diseases.

RESULTS

Forty-eight patients (median age 12.8 years) were included. Six patients had gonadal dysgenesis. Two had bilateral dysgerminoma. Twenty-eight patients had loco-regional dissemination, seven with para-aortic lymph nodes. None had distant metastases. Primary surgery was performed in 47/48 patients. Among the 15 patients with pS1 tumour: seven did not receive adjuvant treatment, six had lymph node irradiation and two received chemotherapy. Among the 32 patients with advanced tumour, 31 received cisplatinum-based (n = 25) or carboplatin-based (n = 8) regimen with lymph node irradiation for one of them and one did not receive adjuvant treatment. With a median follow-up of 14 years, all patients are alive in complete remission. Five events occurred: 2 contralateral dysgerminomas, 1 peritoneal relapse and 2 second neoplasms (teratoma and melanoma). Bilateral oophorectomy was necessary for 12 patients. Desire of pregnancy was expressed for 17/36 patients with unilateral oophorectomy, which succeeded in 13 cases (5 medically assisted). 2/17 had ovarian failure. The renal function was normal in 24/25 evaluated patients treated with platinum, ifosfamide or irradiation. The hearing function was evaluated on 17/36 patients treated with platinum: 12 Brock grade-0, 3 brock grade-1 and 2 grade-4.

CONCLUSION

Dysgerminoma has an excellent prognosis even in advanced cases with conservative surgery and platinum-based chemotherapy. However the disease and/or treatment resulted in a high rate of bilateral oophorectomies and a significant impact on future fertility.

Bilateral poorly differentiated Sertoli-Leydig ovarian tumor associated with dysgerminoma: case report

Sertoli-Leydig cell tumors are rare stromal tumors of the ovary. They account for less than 0.5% of ovarian neoplasms. From a histological point of view, they show large diversity, making their clinical symptoms diverse as well. They are mostly unilateral, with average diameter 13.5 cm at the moment of diagnosis. Histologically, poorly-differentiated Sertoli-Leydig tumors pose a diagnostic problem, often being clinically asymptomatic which makes their detection relatively late, preventing efficient treatment, and resulting in worse prognosis. This article presents a rare case of bilateral poorly-differentiated Sertoli-Leydig ovarian tumor, characterized by heterologous histological structure, without hormonal unbalance, and without signs of defeminization and/or virilization, its diagnostics, and treatment.

[Malignant ovarian germ cell tumors--clinical characteristics and analysis of outcomes]

OBJECTIVES

Presentation of a group of patients with diagnosed malignant ovarian germ cell tumors (MOGCT), determination of prognostic factors and outcome analysis.

MATERIAL AND METHODS

We selected patients with diagnosed malignant ovarian germ cell tumors from the patient registry of Cancer Center in Warsaw from 1990 to 2001. We analyzed clinical and pathological features of the study group, as well as methods and results of treatment.

RESULTS

We collected documentation of 83 patients. Most were diagnosed with dysgerminoma and immature teratoma in the early stages of development. 73 patients received adjuvant chemotherapy after surgery At the end of the first line of treatment complete response was achieved in 63 patients (75.9%). Time to recurrence ranged from 25 to 518 days (mean 176 days). The most common site of recurrence was the true pelvis. The five-year overall survival was 62.7%. Significant favorable prognostic factor was early stage of disease and the histological diagnosis of dysgerminoma. From the 46 women after fertility-sparing surgery, 8 became pregnant.

CONCLUSIONS

MOGCT are a group of potentially curable, yet very aggressive malignant ovarian tumors. The main condition for obtaining good results is quick diagnosis and appropriate treatment, usually surgery associated with multidrug chemotherapy The stage of the disease remains the most important prognostic factor. Patients diagnosed with dysgerminoma are a separate group with very good prognosis.

Nodular lung schistosomiais lesions after chemotherapy for dysgerminoma

We report an unusual case of pulmonary schistosomiasis in a traveler to Mali that was diagnosed 16 months after primary infection, one month after she finished chemotherapy for a malignant tumor. Serologic analysis showed marked eosinophilia. Our case emphasizes the need to detect parasitic infections in cancer patients with unexplained eosinophilia, particularly in immigrants and travelers to tropical countries.

Expanding the clinical spectrum of Frasier syndrome

Frasier syndrome is an uncommon genetic disorder featuring progressive glomerulopathy, male pseudohermaphroditism, and gonadal dysgenesis with increased risk of gonadoblastoma and malignant germ cell tumors. It is caused by mutations in the donor splice site in intron 9 of the WT1 gene. However, because of its rarity there is limited literature available on the precise spectrum and recommended treatment modalities of this syndrome. We present the clinicopathological findings in 4 patients: 3 phenotypically female adolescents presenting with proteinuria and primary amenorrhea and a 6-month-old baby girl presenting with nephrotic syndrome in whom this very unusual case of early onset was confirmed by molecular studies. The significance of early recognition of Frasier syndrome and its differentiation from Denys-Drash syndrome is reviewed and discussed. Our observation of a case presenting with early clinical manifestations, in contrast with the classical presentation in adolescence, justifies the expansion of the clinical spectrum of Frasier syndrome and contributes to the understanding and appropriate clinical management of these patients.

Dysgerminoma in a patient with a tumor of the neck. Empiric treatment of stage IV dysgerminoma

The evolution of therapy for malignant ovarian germ cell tumors is one of the true success stories in oncology. Treatment outcome has improved greatly thanks to cisplatin-based combination chemotherapy. According to the well-established treatment guidelines for advanced cases, we treated a case of stage IV undifferentiated germ cell tumor in which we were able to preserve the patient's fertility. We concluded that the PEP regimen is an effective treatment for the patient with metastatic germ cell tumor.

Isolated duodeno-pancreatic involvement due to metastatic dysgerminoma ovary and its management by a modified pancreatico-duodenal resection

Dysgerminomas of the ovary rarely metastasize to abdominal viscera and when they do, the involvement is a part of a disseminated disease. A 30-year-old woman developed isolated duodenopancreatic dysgerminoma 14 years after salpingo-oophorectomy. The clinical picture was complicated by the presence of tuberculous lesions in the liver which mimicked metastatic disease. Surgical excision was carried out using a modified pancreatic head resection.

Intracranial metastases from an ovarian dysgerminoma in a 2-year-old dog

A 2-year-old, intact female rottweiler was presented for signs of lethargy. A mass was ultrasonographically observed, cranial and lateral to the left kidney. Exploratory laparotomy revealed a mass in the left ovary that was diagnosed histopathologically as an ovarian dysgerminoma. Two weeks after surgery, the dog was readmitted with signs of peripheral vestibular disease that progressed to central vestibular disease. Magnetic resonance imaging of the brain revealed the presence of a mass in the caudal fossa. The histopathological diagnosis of the mass was metastases from the ovarian dysgerminoma.

Ovarian dysgerminoma with massive metastases to para-aortic lymph nodes

We report on a 15-year-old female with left ovarian dysgerminoma accompanied by massive swelling of the para-aortic lymph nodes which was clearly demonstrated by preoperative magnetic resonance imaging (MRI). Metastasis to the para-aortic lymph nodes from dysgerminoma was confirmed by biopsies obtained during surgery. No study has previously reported dysgerminoma with massive para-aortic lymph node metastases clearly demonstrated by MRI. These preoperative MRI findings are presented here. The patient received six cycles of cisplatin-based combination chemotherapy with the BEP regimen (bleomycin, etoposide and cisplatin) after conservative surgery, and no residual para-aortic lymph nodes were detected by MRI or CT after the chemotherapy.

Paclitaxel and cisplatin as salvage treatment in patients with non-seminomatous germ cell tumour who failed to achieve a complete remission on induction chemotherapy

The purpose of this study was to evaluate the efficacy and toxicity of paclitaxel and cisplatin combination chemotherapy as salvage treatment in patients with non-seminomatous germ cell tumour. Sixteen patients with histologically proven germ cell tumour, measurable disease and/or elevated serum tumour markers were eligible for the protocol. All patients had previously not achieved a complete remission (CR) to platinum-based induction chemotherapy and cytoreductive surgery. The treatment consisted of paclitaxel 175-225 mg/m2 as a 3-hour infusion, followed by cisplatin 100 mg/m2, repeated every 3 weeks for up to four cycles. Seven patients achieved a marker-positive partial remission (PR) by the end of the cisplatin-based induction chemotherapy; the remainder had disease progression at the start of the paclitaxel plus cisplatin treatment. One (6%) CR and 3 (19%) PRs were achieved, with an overall response rate of 25% (90% confidence interval 7-43). The duration of the CR is currently 9+ months; two PRs lasted 2 months. One patient with a PR has been lost to follow-up. During a median follow-up of 8 months (range 1-11), 12 patients died from the disease progression. The median survival for the whole group was 7 months. Toxicity was moderate, with neutropenia grade 3 occurring in 29% of patients, thrombocytopenia grade 1-3 in 29%, creatinine > 130 mmol/l in 36%, peripheral neuropathy grade 1-2 in 50%, and nausea and vomiting in 43%. Paclitaxel plus cisplatin showed modest activity, with an overall response rate of 31% in patients with poor prognosis who had not achieved a CR on induction chemotherapy.

PVB chemotherapy in patients with recurrent or advanced dysgerminoma: a Phase II study of the EORTC Gynaecological Cancer Cooperative Group

Dysgerminoma accounts for 1% of all ovarian cancers and for 50% of all ovarian germ cell malignancies. Low stage patients (50%) can be cured with local treatment. The aim of this trial was to study the objective tumour response rate and toxicity of PVB (cisplatin, vinblastine, bleomycin) chemotherapy in patients with pure advanced or recurrent dysgerminoma. Eighteen eligible patients with advanced dysgerminoma were entered into this study. Three patients had local bulky recurrence only; all the others also had metastatic disease. The median age at entry was 27 years (range 1348). Seventeen patients had had prior surgery and one had undergone prior radiotherapy. The WHO performance status was 0 in 12 patients, 1 in three patients, and 2 in three patients. The treatment consisted of: intravenous or intramuscular bleomycin 30 mg on days 2, 9 and 16, intravenous vinblastine 0.15 mg/kg on days 1 and 2, and intravenous cisplatin 20 mg/m2 on days 1-5. This regimen was given at 3-week intervals for a total of four cycles. Twelve patients obtained a complete response (66%), five a partial response (28%), and one could not be evaluated because radiotherapy was administered immediately after chemotherapy. After a median follow-up of 76 months (range 4-132), 14 (78%) patients were alive and well. Two died of disease progression, one of neutropenic septicaemia and one of lung fibrosis. No unusual toxicity was reported. Alopecia, as well as nausea and vomiting, were common. Leucopenia (78%), thrombocytopenia (17%) and infection (11%) were the other severe (grade 3-4) side effects. The PVB chemotherapy regimen is highly effective in patients with advanced ovarian dysgerminoma. However, the BEP (bleomycin, etoposide, cisplatin) regimen, which is equally as potent and less toxic, is preferred.

An unusual case of urinary incontinence, ataxia-telangiectasia, and metastatic dysgerminoma: case report and review of the literature

Ataxia-telangiectasia (A-T) is a rare autosomal recessive disease notable for neurodegeneration, chromosomal instability, and a predisposition to cancer. It presents in childhood with a variable phenotype. We report the first case of an A-T related tumor presenting as urinary incontinence, and the first case of 2-year survival in an A-T patient with metastatic dysgerminoma.

Elevated serum angiotensin converting enzyme levels in metastatic ovarian dysgerminoma

A case of a 32-year-old XY genotype female is described, presenting with mediastinal and abdominal lymphadenopathy and associated with an elevated serum angiotensin I converting enzyme (SACE) level. Lymph node histology showed a malignant dysgerminoma of ovarian origin. Combined chemotherapy led to a radiological regression of the lymphadenopathy and coincided with a decrease in SACE concentration. The authors suggest that SACE may be a marker for disseminated germinoma tumours and may be useful for monitoring treatment.

Ascitic positive cytology and intraperitoneal metastasis in ovarian dysgerminoma

OBJECTIVES

To verify the pattern of the spread of tumors in ovarian dysgerminoma, with special reference to intraperitoneal metastasis, and to assess clinicopathologic factors for predicting tumor extension.

METHODS

Detailed data regarding ascitic cytology, macroscopical findings at surgery, and the histopathology of the surgical specimens were retrospectively reviewed in 12 patients with dysgerminoma who were treated at Kyoto University Hospital. The relationships between the tumor extension and the period of symptoms, the serum lactic dehydrogenase (LDH) level, and the operative findings also were analyzed.

RESULTS

Ascitic cytology revealed a high incidence of positivity in 6 of the 10 (60%) cases examined. Extraovarian metastases were present in 4 of the 6 (67%) cases with positive cytology, and in 1 of the 4 (25%) cases with negative cytology. Intraperitoneal metastatic nodules were detected in 5 of the 12 (42%) patients either by inspection during surgery or by postsurgical histological examination. In addition, these metastatic lesions were 5 or fewer in number and 7 mm or less in diameter, except in 1 patient with widespread disease. The presence or absence of extraovarian spread of the tumor was not significantly correlated with the period of symptom, the serum LDH level, the size of the primary tumor, or the volume of the ascitic fluid.

CONCLUSION

The incidence of intraperitoneal spillage and/or metastases of dysgerminoma cells might be higher than previously reported. These findings indicate the importance of ascitic cytology and careful inspection at the time of operation, as well as the rationale of postsurgical chemotherapy for dysgerminoma of an apparently early stage.

Primary chemotherapy for clinical stage II nonseminomatous germ cell testicular tumors: selection criteria and long-term results

OBJECTIVE

To determine the treatment option for patients with low-volume stage II nonseminomatous germ cell testicular tumors (NSGCTT) that yields the best survival, is associated with the least morbidity, and avoids "double therapy"--that is, chemotherapy and retroperitoneal lymph node dissection (RPLND).

DESIGN

We reviewed our institutional experience with 28 patients with stage II NSGCTT who received primary chemotherapy between August 1983 and October 1992.

MATERIAL AND METHODS

The 28 study patients (mean age, 28 years; range, 20 to 52) with low-volume stage II NSGCTT were treated with bleomycin, etoposide, and cisplatin. The correlation of response rates with volume of disease and predominant histologic cell type was determined. The duration of survival was measured from the initiation of chemotherapy to the appearance of progressive disease or death or the date of last follow-up visit.

RESULTS

Of the 28 patients treated, 27 (96%) achieved a complete response--20 (71%) with only chemotherapy and an additional 7 (25%) with chemotherapy plus surgical treatment. Twenty-seven patients (96%) remained free of disease after a median follow-up of 72 months. The most frequent complication was cisplatin-associated paresthesias or tinnitus which was noted in 13 patients (46%). In 11 of 15 patients (73%), attempts to have children have been successful.

CONCLUSION

Excellent long-term survival rates in patients with stage II NSGCTT can be achieved with primary chemotherapy. In this series, 71% of patients were spared RPLND. The need for postchemotherapy RPLND seemed to be related to the initial metastatic tumor volume and possibly the histologic features of the primary tumor. Continued refinement in surgical techniques and chemotherapeutic regimens will necessitate the comparison of these two treatment approaches in a randomized prospective trial.

Analysis of a non-ras 21-kDa protein in patients with metastatic testicular germ-cell tumors

A novel protein of 21 kDa (p21) has been detected in the sera of patients with different solid tumors. The serum levels of this p21 protein were measured in seven patients with metastatic testicular germ-cell tumors before and after chemotherapy using an enzyme-linked immunosorbent assay. In five out of six patients who responded to chemotherapy a concomitant decrease of p21 serum levels was found. The decrease of p21 was in accordance with the decline of the established tumor markers alpha-fetoprotein, human chorionic gonadotropin beta-subunit and lactate dehydrogenase in three patients with non-seminomatous tumors and with the decline of lactate dehydrogenase and the clinical response in two patients with seminoma. In one patient the predicted decline of p21 did not occur despite the patient's clinical response to chemotherapy. In the seventh patient, who relapsed directly after chemotherapy, no decline of either p21 levels or tumor markers was observed. The absolute amount of the p21 protein prior to chemotherapy did not correlate with the patients' tumor burden. Elevated levels of p21 were found in patients with seminomatous and non-seminomatous germ-cell tumors. Since seminoma patients do not secrete tumor markers like alpha-fetoprotein or human chorionic gonadotropin beta, the determination of p21 levels may help to evaluate the efficacy of chemotherapy in patients with seminomatous as well as in patients with marker-negative non-seminomatous germ-cell tumors. The biological role of p21 and its clinical significance will be further investigated.

Brain metastasis as the site of relapse in germ cell tumor of testis

BACKGROUND

Brain metastases occur in approximately 8-15% of patients with testicular germ cell tumors and invariably are associated with relapse at other sites, most commonly the lungs, or as a terminal event.

METHODS

The authors, from the Institute Rotary Cancer Hospital, a regional cancer center in northern India, did a retrospective analysis to determine how many previously treated patients had isolated cerebral metastasis develop.

RESULTS

Three of 123 patients with testicular germ cell tumor seen during a 6-year period starting in January 1986 had isolated cerebral metastasis develop during remission after initial treatment. Two patients who had pure seminoma were treated with radiation therapy and are alive and symptom free at 15 and 18 months. The third patient had a combined tumor, the major component of which was embryonal cell carcinoma, that required debulking surgery and radiation therapy, and the patient died with recurrent cerebral metastases.

CONCLUSIONS

Review of the literature reveals that although cerebral metastasis is well recognized in testicular cancer, particularly nonseminomatous germ cell tumor (NSGCT), it is invariably preceded by systemic metastasis. Cerebral metastasis is extremely rare as the sole and presenting feature of relapse. This complication must be recognized and treatment defined because it may become more frequent as patients survive for longer periods with modern disease management.

[A case of complete response with radiation and chemotherapy using cisplatin, etoposide and bleomycin]

A 37-year-old man, who had been treated with inguinal orchiectomy and radiotherapy of retroperitoneal and iliac lymph node for r-testicular tumor 6 months earlier, was admitted with a complaint of left leg pain in May 1992. CT scan of pelvic bone revealed osteolytic change of left pubic bone with soft tissue mass. Bone scintigram showed significant uptake of radioisotope on left pubic bone. Biopsy of left pubic bone confirmed histologic findings compatible with that of previous testicular cancer. He was treated with PEB chemotherapy (CDDP, Etoposide and Bleomycin) and radiation therapy. After treatment, the majority of the tumor mass disappeared on CT scan. On repeat biopsy specimens, significant fibrotic change was observed and no cancer cells were recognized. He is alive with no evidence of disease.

Chest staging in testis cancer patients: imaging modality selection based upon risk assessment as determined by abdominal computerized tomography scan results

We compared chest computerized tomography (CT) to chest x-ray as chest staging modalities in testis cancer patients on the basis of abdominal CT findings. We identified 92 patients who presented with negative staging abdominal CT scans and 52 with abnormal abdominal CT scans. Of these patients 42 and 32, respectively, underwent a chest x-ray and chest CT concurrently as part of the initial staging evaluation. Dictated x-ray reports were used to compare study findings. Findings on chest x-ray and chest CT were considered concordant if both studies identified similar chest abnormalities. Findings were considered discordant if either study failed to identify an abnormality noted on the other test. Patient outcome during followup, response to therapy or chest pathology was used to discriminate benign from malignant radiological abnormalities. Radiographic chest abnormalities (chest x-ray and/or chest CT) were identified in 12 of the 42 patients with negative abdominal CT scans. Three of these 12 studies represented metastasis with the remainder being benign. Imaging results were concordant in all 3 patients with chest metastasis and 5 of 9 with benign chest disease. Chest x-ray identified abnormalities not observed on chest CT in 1 patient, with chest CT identifying abnormalities not observed on chest x-ray in 3. Radiographic chest abnormalities (chest x-ray and/or chest CT) were identified in 15 of 32 patients who had a positive abdominal CT. All chest lesions identified in these patients were believed to represent metastatic disease. Chest x-ray failed to identify abnormalities present on chest CT in 4 of the 15 patients. The use of chest CT as a staging modality in abdominal CT negative patients failed to increase diagnostic sensitivity relative to chest x-ray alone. However, in 32 patients with abnormal abdominal CT scans the use of chest x-ray alone would have missed intrathoracic metastatic disease in 4. These data suggest that chest x-ray may be the preferred initial chest staging study for testis cancer patients with negative abdominal CT, while chest CT is mandated in patients with abnormal abdominal CT.

[Current status of therapy of CNS metastases of germ cell tumors]

The incidence of CNS metastases in germ cell tumors is 2-5% and in very advanced disease over 20%. We report on 37 patients in whom CNS metastases were diagnosed with the CAT scanner. Twenty-nine patients were subsequently treated. In 19 cases, treatment consisted of radiotherapy, 1 patient was only operated on, and in 9 cases patients received combined surgery and radiotherapy. Two patients had seminomatous germ cell tumors, 27 patients non-seminomatous tumors. HCG levels were high in 11 cases. In 31 patients the disease was in the advanced stages; in 6 the disease was at the early stage. If there was just a solitary tumor, operation was the preferred mode of treatment. Radiotherapy consisted of 50 GY whole-brain irradiation, with a tumor saturation up to 60 GY. In 2 cases we suspected radiogenic necrosis. There were no other severe side effects. Of the 37 patients, 4 obtained a long-term cure (observation time 34-90 months). Therapy must take all methods of treatment into consideration and should only be carried out in fully equipped medical centers. Only then can we hope to obtain long-term cures in individuals with this usually fatal disease.

Inguinal lymph node metastasis from contralateral testicular origin

A twenty-eight-year-old man had a testis tumor eighteen years after orchiopexy and inguinal lymph node metastasis in the contralateral side. It is suggested that scrotal surgery may lead to the formation of new lymph channels and alter the pattern of nodal metastases.

Differential expression of a human sperm-specific isozyme in seminoma cells transplanted in Scid-nu(str) mice

An isozyme of human sperm-specific lactate dehydrogenase, LDH-X (C4) (EC 1.1.1.27), which is expressed only in differentiated germ cells (spermatozoa, spermatids and primary spermatocytes after midpachytene), appeared in the xenografted tumor cells of human seminoma and its metastatic lesions (lymph node and kidney) in scid (severe combined immunodeficiency)-nude(streaker) double mutant mice, though it was not expressed in the original tumor of the patient. The morphological pattern of seminoma cells also changed in the xenografts and metastatic lesions as in normal spermatogenesis. Thus, the human seminoma cells showed differential expression of the sperm-specific isozyme in parallel with their morphological changes. However, the sperm-specific isozyme disappeared in the mitotically dividing seminoma cells which were newly established from the LDH-X positive xenograft.

Surveillance in stage I seminoma of the testis

In a health care system with adequate personnel and resources, careful surveillance, rigorously performed, following guidelines set out in the prospective trials is an appropriate alternative to adjuvant irradiation for patients with stage i seminoma of the testis.

Skip metastases from testicular seminoma

A unique case of metastatic testicular seminoma which did not initially involve the retroperitoneal lymph nodes is presented. Modern treatment, with cis-platinum based chemotherapy and involved-field irradiation, resulted in cure.

Testicular seminoma metastasizing to palatine tonsil

Patients presenting with Stage I seminoma of the testis have an excellent prognosis after treatment by orchidectomy and prophylactic radiotherapy to the paraaortic and pelvic lymph nodes. Only 2% subsequently recur but relapse in these cases has been reported in unusual sites such as the prostate and mesentery. We report a case of Stage I seminoma relapsing in another rare site for secondary malignant deposits, the palatine tonsil. This case further illustrates the favourable prognosis for this tumour even in cases of distant recurrence.

Combination chemotherapy with cisplatin and etoposide for hematogenous spinal metastasis of intracranial germinoma--case report

A 24-year-old male presented with a metastatic germinoma in the thoracic vertebra 7 years after irradiation of a pineal germinoma. Combination chemotherapy with cisplatin and etoposide was highly effective. No recurrence has appeared in the 2 years since chemotherapy.

Bone metastasis in ovarian cancer

Bone involvement in carcinoma of ovary occurs rarely. In a review of 103 patients over last 3 years we have seen 4 such patients (serous-2, mucinous-1, mixed germ cell tumour-1). Patients presented with severe localized bone pain, bony swelling and difficulty in walking. The common sites of involvement were vertebrae, pelvic bones and skull. Radiologically the osteolytic lesions were commonest. Bone lesions were associated with abdomino-pelvic disease in 3 patients. Cisplatinum based chemotherapy in addition to local radiation resulted in significant response in 2 patients; one complete and one partial response. The median survival was 7.5 months (range 6-39 months) after bone metastasis. We conclude bone involvement in cancer ovary is associated with poor prognosis.

Treatment of Metastatic Testicular Tumours with Bleomycin, Etoposide, Cisplatin and Vincristine (BEPV)

Between August 1983 and December 1988, 47 patients with metastatic testicular tumours (44 non-seminomatous, three seminomas) were treated with two to six courses of bleomycin, etoposide, cisplatin and vincristine (BEPV). Five stage I tumours were included, three because of raised tumour markers following orchidectomy, one with vascular invasion of spermatic cord vessels and the other with both these features. Forty-four patients (93.6%) are alive and disease free 12–75 months (median 39 months) after completion of BEPV. Further treatment was necessary in 12 of the survivors. Eight had residual disease excised, one of whom received radiotherapy, one additional chemotherapy and one both radiotherapy and chemotherapy. Of the remaining four, two had radiotherapy and two second line chemotherapy. Thirty-one non-seminomatous and the three seminoma patients had small volume disease and all are in complete remission. Ten of the 13 patients with bulky disease are alive. It is concluded that BEPV is a well-tolerated, effective, first line therapy for patients with metastatic testicular tumour.

Metastatic testicular seminoma of the cervicothoracic spine

A case of metastatic testicular seminoma affecting the cervico-thoracic spine is reported along with its clinical and radiographic findings. Case progression is discussed.

A late manifestation of testicular seminoma in the bladder in a renal transplant recipient: a case report

An unusual case is presented of a renal transplant recipient on immunosuppressive medication who underwent orchiectomy for a testicular seminoma. Since the surgical resection plane showed seminoma cells, radiotherapy was applied to the para-aortic and inguinal regions. Tumor recurred in the bladder 3 years later as demonstrated by urine cytology and later by bladder biopsies. After chemotherapy, repeated bladder biopsies were normal and a complete remission was achieved. The possible metastatic pathways are discussed.

Ovarian dysgerminoma metastatic to the breast

A 16-year-old girl underwent a right salpingo-oophorectomy for a pure dysgerminoma limited to the right ovary. One month later, she developed a right pelvic mass along with abdominal lymphadenopathies, peritoneal carcinomatosis, left breast mass, and left axillary node. Cytology of the breast mass was suggestive of a pure dysgerminoma. Breast metastases of epithelial ovarian carcinoma are uncommon. In the literature, this is the first case of a breast metastasis of an ovarian dysgerminoma.

Sites of relapse in seminoma treated with single agent carboplatin chemotherapy: implications for further management

Between 1983 and 1990, 66 patients were treated with single agent carboplatin for advanced seminoma, and sites of relapse have been analysed with respect to sites involved before chemotherapy. Fourteen relapses were evaluable, and relapse was confined to node groups affected before chemotherapy, or those immediately adjacent, in seven patients. At present it is unclear whether single agent carboplatin should be the initial chemotherapy for seminoma, but if it is employed there may be a role for local adjuvant radiotherapy after carboplatin chemotherapy.

Late metastases in seminoma: incidence, localization, and therapeutic implications

Late metastases of seminoma testis were found in 2 patients thirty and nine years after orchiectomy and radiotherapy. Metastases involved retroperitoneal lymph nodes and lung in 1 case and obstruction of the sigmoid colon and left ureter in the other. Cases of late, atypically localized metastases of seminoma described in the literature are reviewed. Therapy includes surgical removal of the metastases, radiation therapy, and systemic chemotherapy. Therapeutic considerations must include toxicity of preceding radiotherapy.

Subtle bone marrow edema assessed by frequency selective chemical shift MRI

Subtle edema in yellow bone marrow from tumors (14 subjects) and osteomyelitis (9 subjects) were examined by selective nonexcitation (SENEX) water imaging using a short five pulse frequency selective excitation with lipid suppression greater than 96%. Standard spin-echo (SE) proton density-, T1- and T2-weighted images, and fat suppression methods such as short inversion time inversion recovery and also the chemical shift selective Dixon method are discussed in comparison with SENEX. Application of the SENEX method is described and images from four typical cases are demonstrated. Sensitivity to edema is obviously better using the SENEX chemical shift selective method than using other imaging techniques. Improved delineation of abnormal areas in yellow bone marrow is provided by SENEX water imaging in one slice after multislice standard imaging. After shimming, only one SE scan with frequency selective excitation is necessary to get a pure water image.

Retroperitoneal seminoma secondary to 'burned out' testicular tumor in an acromegalic patient

We report a case of an acromegalic patient with a retroperitoneal seminoma secondary to a testicular tumor which had completely disappeared. Testicular ultrasonography did not show any pathological mass and histological examination indicated that the normal testis had been totally replaced by fibrous tissue, without neoplastic cells. Our patient had high levels of growth hormone (GH) and prolactin (PRL), both hormones with high immunostimulating effect, and an increase of interleukin-2 receptor-positive lymphocytes, a finding supporting enhanced immunological activity. Thus, we cannot exclude that the immunological pattern of this acromegalic patient may have played some role in the tumoral destruction.

[Late pulmonary changes following bleomycin administration in computed tomography. Nodular fibrosis mimicking a seminoma metastasis]

This is a case report of a patient with multiple metastases to the lung due to a seminoma, treated with a chemotherapeutic regimen containing bleomycin. The typical subpleural fibrosis of the lung related to bleomycin damage disappeared 6 months after the start of chemotherapy. 4 weeks later, a solitary nodule at a prior unchanged site of the lung appeared, mimicking recurrent metastasis. Explorative thoracotomy revealed a nodular fibrosis of the lung, representing a late reaction of the lung to chemotherapy damage.

Single agent activity of carboplatin in patients with previously untreated non-seminomatous germ cell tumours

The response to a single course of carboplatin has been investigated in 12 patients with previously untreated non-seminomatous testicular germ cell tumours. Patients received one course of carboplatin at a dose calculated to achieve a target area under the free carboplatin plasma concentration versus time curve (AUC) of 7 mg/ml x mins using the formula: dose (mgs) = target AUC x (GFR + 25). Response to carboplatin was assessed after a single course and treatment was then continued on the POMB/ACE schedule. Ten of 12 patients had either a greater than 50% decrease in serum HCG and/or AFP levels or a greater than 50% decrease in tumour volume after a single course of carboplatin. No patient had evidence of disease progression after carboplatin. This study demonstrates that single agent carboplatin is highly active in patients with non-seminomatous testicular germ cell tumours and thus provides evidence to justify its inclusion in chemotherapy combinations.

The activity of single-agent carboplatin in advanced seminoma

Between 1982 and 1990, 70 patients with advanced metastatic seminoma were treated with 4-6 courses of single-agent carboplatin (SAC) administered at 400 mg/m2 every 3-4 weeks. Treatment was of low toxicity and no patients suffered neurotoxicity, ototoxicity or significant renal damage. There was only one episode of neutropenic sepsis and no thrombocytopenic bleeding. The median follow-up of surviving patients was 3 years. 16 patients have relapsed and 4 of these 16 have died, thus the actuarial 3-year relapse-free survival was 77% (95% CI 65-86%), cause-specific survival was 94% (95% CI 82-99%) and overall survival was 91% (95% CI 80-96%). The risk of relapse was reduced by post-chemotherapy irradiation (PCRT) to involved nodes, occurring in 1/20 patients treated with PCRT compared with 11/31 who could have been treated but were not (P = 0.04). Of the 16 patients who relapsed, 12(75%) have been salvaged with combination chemotherapy and remain free from further relapse with a median follow-up of 18 months. Though this level of survival is equivalent to that obtained with initial cisplatin-based combination chemotherapy, the recurrence rate indicates that SAC remains an investigative treatment, except for unfit patients.