Extragonadal germ cell tumors: clinicopathologic findings, staging and treatment experience in 14 patients

Extragonadal germ cell tumors (EGCT) are a rare group of neoplasms histologically identical to testicular counterparts. Fourteen cases of primary mediastinal and retroperitoneal germ cell tumors were treated with chemotherapy and radiotherapy between 1987 and 1999 in Ankara Oncology Hospital. There were 9 (64%) complete remissions (CR),one (7%) partial remission (PR) and 2 (14%) stable diseases (SD). The remaining 2 patients were lost due to dissemination of disease. The median duration of response was 19 months. Our modified chemotherapeutic results were similar to original doses of PVB and BEP but toxicity was less. The neccesity of a uniform staging system and treatment programs are discussed.

Primary mediastinal malignancies in children: report of 22 patients and comparison to 197 adults

PURPOSE

Examine a contemporary series of patients with primary pediatric malignant mediastinal tumors and determine epidemiology, histology, treatment, and survival. Patients and Methods. All malignancies diagnosed between January 1, 1973 and December 31, 1995 were analyzed.

RESULTS

Twenty-two patients, age 18 years or less, with pediatric primary mediastinal malignancies were identified from a database of 110,284 patients with primary malignancies. During the same period, 197 adult patients with primary mediastinal malignancies were identified. Fifty-nine percent of the pediatric patients were male. Median age was 11 years. Lymphoma was present in 55%, neurogenic malignancies in 23%, malignant germ cell tumors in 18%, and sarcoma in 5%. Neurogenic tumors presented in infants and lymphomas and germ cell tumors presented in teens (p = 0.005). In treated children, surgery was used more often in neurogenic tumors and germ cell tumors than in lymphomas (p = 0.002). Five-year survival was 74% for lymphomas, 67% for neurogenic tumors, 25% for germ cell tumors, and 61% overall (p = 0.23). Compared to adults, children had more neurogenic tumors (p < 0.001) and fewer thymomas (p = 0.0499). There were no significant differences in staging or survival between children and adults.

CONCLUSIONS

Pediatric mediastinal malignancies occurred with a frequency of 1/5,013 patients with malignant tumors. Lymphoma, neurogenic tumors, and germ cell tumors predominated. Compared to adults, children had more neurogenic tumors and fewer thymomas. Within the pediatric group, differences were found in age of presentation between histologic groups. These differences between adults and children, and between infants and teens, should be considered when evaluating a patient suspected of having mediastinal malignancy.

Recent developments in the management of testicular germ cell tumors

Testicular germ cell tumors are now generally regarded as a highly curable cancer in the majority of cases, even when patients present with advance disease. However that does not imply that researchers and clinicians have become complacent in their efforts to improve our understanding and the treatment outcome of this disease. This is an overview of recent developments in the management of testis cancer.

[Treatment of stage I germ cell tumors of the testis]

OBJECTIVE

To review the advantages, disadvantages and efficacy of the different therapeutic options for stage I seminoma and nonseminomatous germ cell testicular tumors.

METHODS

The literature on the treatment of stage I germ cell testicular tumors was reviewed.

RESULTS/CONCLUSIONS

Germ cell tumors of the testis constitute 1-1.5% of neoplasms in the male, accounting for 95% of testicular neoplasms, and is the most common solid tumor in men aged 20-35 years. Currently, 70% of the patients with seminoma and 50% of the patients with nonseminomatous germ cell testicular tumors are diagnosed in stage I. Radiotherapy following orchidectomy has classically been utilized in the treatment of stage I germ cell testicular tumors. Postoperative radiation therapy is currently being replaced by close patient follow-up in many centers. Retroperitoneal lymphadenectomy post-orchidectomy is the standard treatment for stage I nonseminomatous germ cell testicular tumors. Today, however, the foregoing approach is also being replaced by close postoperative follow-up.

Metastatic testicular cancer presenting as spinal cord compression: report of two cases

BACKGROUND

Testicular cancers are heterogenous neoplasms often found in young adults. They tend to metastasize to the chest, retroperitoneum, or neck, but rarely to the long bones or skeleton. However, they can cause neurologic compromise and should be considered in young male patients who present with symptoms of a spine lesion and no known primary cancer.

METHODS

Two patients presented with back pain and a rapid progression of lower extremity weakness. Both underwent radiographic workup and emergency surgery. Metastatic workup revealed testicular cancer and widespread metastases.

RESULTS

Both patients improved neurologically after surgery, but neither regained the ability to ambulate independently. They both underwent chemotherapy. One patient is alive at 1 year follow-up; the other died 9 months after surgery of widespread metastases.

CONCLUSIONS

Vertebral metastases from testicular tumors, although rare, should be considered in young men presenting with spinal cord compression. Work-up should include magnetic resonance imaging (MRI) of the spine and computed tomography (CT) of the chest, abdomen, and pelvis. Urgent intervention may be required, as these two cases show that loss of neurologic function can be rapid and permanent.

Levels of beta-human chorionic gonadotropin in cerebrospinal fluid of patients with malignant germ cell tumor can be used to detect early recurrence and monitor the response to treatment

BACKGROUND

Tumor marker-producing germ cell tumors of the central nervous system are malignant and require radiation and/or chemotherapy. Although serum beta-human chorionic gonadotropin (hCG) has been used to monitor the course of treatment, the levels of beta-hCG in the cerebrospinal fluid (CSF) have not been measured routinely in the clinic. To determine whether they can be used to evaluate parameters of tumor status, such as progression or response to therapy, levels of beta-hCG in the serum and CSF of patients with germ cell tumors were studied.

METHODS

Fifty-four paired samples of CSF and serum were taken from seven patients with germ cell tumor and their beta-hCG levels were measured. Beta-hCG was negative in both serum and CSF in 11 instances and the levels in the other 43 paired samples were analyzed for any correlation or relationship to therapy. They were also compared with the clinical courses.

RESULTS

The mean CSF beta-hCG level was 11.5 mIU/ml, which was significantly higher than the level in serum (3.5, p = 0.002). In all the paired samples except for one time point, the level in CSF was higher than that in serum. Out of 43 instances where the beta-hCG level in CSF was elevated, the level in serum was elevated in only 16 (37.2%). Among cases of recurrent malignant germ cell tumor, there were nine instances of recurrence or progression despite therapy. In all five instances where beta-hCG CSF levels were measured, the levels were elevated prior to any increase or detectability of the serum values.

CONCLUSION

It seems likely that the level of beta-hCG in CSF is a good marker for monitoring tumor recurrence or evaluation of treatment results.

[Treatment decision in advanced testicular germ cell tumors]

OBJECTIVE

To review the classifications of the risk groups of different prestigious institutions and collaborative groups that have had a major impact on our knowledge and therapeutic approach to germ cell tumors of the testis.

METHODS

We reviewed the different classifications of renowned institutions and collaborative groups and the literature published over the last 15 years that provide evidence for the optimal therapeutic approach for each subgroup at risk.

RESULTS/CONCLUSIONS

Germ cell testicular tumors is the paradigm of curable tumors of the adult. Patients with stage I tumors have an excellent prognosis with more than 98% probability of cure. The prognosis for the advanced stage tumors is superior to that of other solid tumors with a similar volume due to their exquisite chemosensitivity. Patients with advanced disease can be divided into two or three groups (low and high, or low, intermediate and high risk) with different probability of cure after treatment with cisplatin-based regimens, according to the location of the primary tumor, extent of the disease and serum levels of the markers. The standard treatment for the advanced disease consists of first line chemotherapy with cisplatin, etoposide and bleomycin (BEP) followed by surgery in cases with residual tumor. Approximately 10% of the patients with good-prognosis factors and 30%-50% of those with poor-prognosis factors will not cure after first line chemotherapy, although rescue with second line chemotherapy can be utilized in some of these patients. The search for more effective chemotherapeutic regimens for high risk patients and regimens with a lower toxicity for the low risk patients has been hampered by the lack of consensus among the working groups on the criteria for the classification of these patients into subgroups according to prognosis. The recent International Germ Cell Consensus Classification will permit studies on homogeneous risk groups of patients and will allow us to obtain reliable and reproducible results.

Efficient retrovirus-mediated transfer of the multidrug resistance 1 gene into autologous human long-term repopulating hematopoietic stem cells

Pre-clinical studies indicate that efficient retrovirus-mediated gene transfer into hematopoietic stem cells and progenitor cells can be achieved by co-localizing retroviral particles and target cells on specific adhesion domains of fibronectin. In this pilot study, we used this technique to transfer the human multidrug resistance 1 gene into stem and progenitor cells of patients with germ cell tumors undergoing autologous transplantation. There was efficient gene transfer into stem and progenitor cells in the presence of recombinant fibronectin fragment CH-296. The infusion of these cells was associated with no harmful effects and led to prompt hematopoietic recovery. There was in vivo vector expression, but it may have been limited by the high rate of aberrant splicing of the multidrug resistance 1 gene in the vector. Gene marking has persisted more than a year at levels higher than previously reported in humans.

The relative risk of second nongerminal malignancies in patients with extragonadal germ cell tumors

BACKGROUND

Apart from a recognized association between extragonadal mediastinal germ cell tumors (GCT) and the occurrence of hematologic malignancies, the risk of developing second nongerminal solid tumors after the diagnosis or treatment of extragonadal GCT is unknown.

METHODS

Six hundred thirty-five consecutive patients with extragonadal GCT treated at 11 centers in the U.S. and Europe during the era of cisplatin-based chemotherapy (1975-1996) were included into a large database. These patients were evaluated for the occurrence of second malignancies.

RESULTS

No treatment-related leukemia was observed in 611 patients treated with chemotherapy. In 7 patients, second solid tumors were observed, resulting in a frequency of 1.86% (95% confidence interval [95% CI], 1.79-1.93%) after a median follow-up of 55 months (95% CI, 50-60 months) (annual incidence, 0.30% [95% CI, 0.14-0.59]). Four solid tumors (57%) developed in patients with primary mediastinal and 3 tumors (43%) developed in patients with retroperitoneal GCT. Three patients (43%) had a nonseminomatous and 4 patients (57%) had a seminomatous histology. Six patients had been treated with chemotherapy and one patient with radiotherapy. Six of 7 solid tumors (86%) had developed within 5 years and 7 of 7 solid tumors within 10 years of diagnosis. The median time period to the occurrence of neoplasia was 47 months (range, 9-145 months). Four cutaneous tumors were observed (melanoma, two patients; basal cell carcinoma, one patient; and squamous cell carcinoma, one patient); the other three tumors were angiosarcoma, nonsmall cell lung carcinoma, and colorectal carcinoma. The overall risk for developing a second tumor was not increased compared with an age-matched general population with a standard incidence ratio (SIR) of 1.49 (95% CI, 0.60-3.06). An elevated risk for skin tumors was observed in all extragonadal GCT patients (SIR, 4.00 [95% CI, 1. 09-10.24]), as well as in the subgroup of patients treated with chemotherapy (SIR, 5.33 [95% CI, 1.45-13.65]).

CONCLUSIONS

This analysis excludes an increased biologic risk of developing second solid malignancies in patients with extragonadal GCT except for the previously reported association between primary mediastinal nonseminoma and hematologic disorders. The overall risk of developing second malignancies in extragonadal GCT patients appears to be comparable to that in patients with primary testicular carcinoma. The incremental occurrence of skin malignancies in patients treated with chemotherapy should be investigated further.

Primary spinal germinoma in a patient with concomitant Klinefelter's syndrome

It is known that patients with Klinefelter's syndrome are inclined to develop concomitant malignant tumours, as well as extragonadal germ cell tumours. The association of a primary spinal germinoma in a patient with Klinefelter's syndrome is reported for the first time, and the coincidence of elevated gonadotropin levels and oncogenesis is discussed.

[Testicular embryonal carcinoma with contralateral synchronous intratubular germ cell neoplasia: analysis of a case]

We report the case of a 20-year old male with a right testicular tumor. Bilateral orchidectomy was practised considering the synchronous clinical, ultrasonographical and histological (intraoperative biopsy) findings of the left testis. The definitive pathological report showed a right embryonal carcinoma with wide intratubular germ cell neoplasia (IGCN) of the contralateral testis. IGCN (formerly carcinoma in situ) is present in about 5% of cases in the contralateral gonad of those patients with a testicular neoplasm. More than 50% will develop cancer in that testis. Clinical and physical examination findings are usually unspecific. The diagnosis of IGCN is based on biopsy, although ultrasonography could give some data too, as some authors report. We analyze the therapy options for IGCN: (orchidectomy, chemotherapy, radiotherapy, or "wait and see"). In our case, the first one was made. Chemotherapy was used due to existence of retroperitoneal lymph node metastases, with an excellent follow-up afterwards.

Malignant germ cell tumors of the ovary. Pregnancy considerations

OBJECTIVE

To study the pregnancy association and malignant germ cell tumors of the ovary with regard to its effects on tumor prognosis.

STUDY DESIGN

: Seventy-five patients with malignant germ cell tumors of the ovary treated at the King Faisal Specialist Hospital-Research Center (KFSH-RC) Riyadh, Kingdom of Saudi Arabia between January 1976 and December 1992, were reviewed. Data was retrieved from the medical records and the database of ovarian tumor pathology. Patients with tumor/pregnancy association were identified and correlation with obstetrical outcome and tumor prognosis analyzed. Patients who conceived after treatment were identified and their reproductive outcome described.

RESULTS

Malignant germ cell tumor was associated with pregnancy in a group of ten patients. Possible tumor effects upon pregnancy in this group included operative delivery by caesarean section (n=3), mid-trimester termination (n=2), spontaneous abortion (n=1). Four patients had normal vaginal birth with no apparent tumor effects upon pregnancy. Pregnancy did not seem to influence the tumor prognosis of pure dysgerminoma (n=6), however, two patients with non-dysgerminomatous germ cell tumor (one endodermal sinus tumor and one immature teratoma) died of rapidly progressive disease during the second trimester. Two patients with advanced (stage IIIC) disease concurrent with pregnancy (one pure dysgerminoma and one mixed germ cell tumor), had normal fetal outcomes and achieved long-term survival. Amongst the 22 patients who planned to conceive after conservative surgery, with or without post-operative adjuvant chemotherapy, 12 conceived (12/22) and achieved a total of 20 pregnancies. Their outcomes included normal births (n=18) including one set of twins and hydatidiform moles (n=2).

CONCLUSIONS

Our findings suggest that, (1) The association of pure dysgerminoma and pregnancy did not adversely affect the tumor prognosis or fetal outcome. However, the question remains as to whether pregnancy worsened the prognosis of non-dysgerminomatous germ cell tumors. (2) Recent platinum-based regimens of multiagent chemotherapy for germ cell tumors did not seem to affect fertility potential.

Primary intracranial germinoma in the medulla oblongata

BACKGROUND

Primary intracranial germ cell tumor in the medulla oblongata is very rare; only five cases, including our case, have been reported.

CASE REPORT

Our patient, an 18-year-old woman, was diagnosed with a primary intracranial germinoma in the medulla oblongata by an open biopsy. She was treated successfully with chemotherapy and radiosurgery.

CONCLUSION

All five tumors in this site were histologically diagnosed as germinomas. The finding of female predominance in germ cell tumors in this region is shown.

[Management of non-seminomatous germ cell tumors of the testes]

Since the advent of cisplatin-based chemotherapy in the 1970s, testicular cancer has become a model for curable cancer. We review the current treatment options for non-seminomatous germ cell tumors (NSGCT) of the testes. Surveillance is considered to be the most widely accepted option for stage I NSGCT in Japan. Because of the high relapse rate of about 30% in this setting, the establishment of a risk-adapted treatment protocol is warranted in stage I NSGCT. In early stage II NSGCT, both the primary RPLND and the primary chemotherapy show equivalent cure rates. These options give different balances of toxicity; namely, ejaculation disorders and drug induced infertility. In the treatment for NSGCT with good prognosis, both three courses of BEP and four courses of etoposide and cisplatin are appropriate and standard chemotherapy regimens.

[Primary mediastinal germ cell tumor: report of a case]

Fourty-seven years old male was admitted to this hospital with the symptoms of worsening cough and chest pain. An anterior mediastinal tumor, 13 cm in diameter, was pointed out on chest X-ray. The tumor was diagnosed as primary mediastinal germ cell tumor with mixed seminomatous and non-seminomatous elements due to elevated serum AFP and beta HCG, and the pathological finding of needle biopsy specimen. He underwent 3 courses of chemotherapy with BEP regimen, and following surgical resection of the tumor, left upper lobectomy and partial resection of pericardium via median sternotomy. Pathological diagnosis of the resected tumor was mature cystic teratoma. For 9 months no recurrence of the tumor has been observed.

[Extratesticular germ cell tumor focusing on treatment and prognosis]

About 3% to 5% of all germ cell tumors are thought to be primary extratesticular tumors, including a small group of benign tumors. Though the testes are clinically normal, diagnosing whether the tumor is primary or metastatic is problematic. Developments in ultrasonography have enabled the detection of tiny testicular lesions, and ultrasonography is applied to determine the biopsy sites. Nevertheless, burned-out tumor and carcinoma in situ are not always easy to find. Extratesticular germ cell tumors are usually treated using methods similar to those for advanced testicular tumors; however, the results are discouraging. Only limited cases are suitable for a monotherapy of surgery, so a combined treatment of cisplatin based chemotherapy and surgery is prevalent. Against seminomas, radiotherapy is effective. In addition to the advent of such pharmaceuticals as G-CSF and serotonin receptor antagonists, recent development of peripheral blood stem cell transplantation is expected to produce improved prognoses among patients burdened with this refractory disease. A prognostic factor-based staging system developed by the International Germ Cell Cancer Collaborative Group is reasonable and useful. Non-seminomas are classified as having good or intermediate prognoses if retroperitoneal tumors having no non-pulmonary visceral metastases show good or intermediate markers. A poor prognosis is associated with extratesticular tumors with mediastinal primary or non-pulmonary visceral metastases or poor markers. Seminomas with normal AFP are classified as having good or intermediate prognoses if no non-pulmonary visceral metastases are seen or discarded. No seminomas are classified in the poor prognosis group.

Metastatic spinal intramedullary germinoma with elevated cerebrospinal fluid chorionic gonadotropin: a case report

We treated a patient whose unusual recurrent germinoma illustrates the diagnostic value of measuring human chorionic gonadotropin beta subunit (HCG-beta) in cerebrospinal fluid (CSF) and serum. A 25-year-old man with a suprasellar germinoma and ventricular dissemination was treated successfully with systemic chemotherapy and cranial irradiation. Six years later he developed progressive numbness and weakness in both upper extremities. Magnetic resonance imaging (MRI) disclosed an intramedullary spinal cord tumor in the cervical region. The CSF concentration of HCG-beta was elevated and exceeded that in serum. After completion of systemic chemotherapy and spinal irradiation, symptoms subsided and the tumor was no longer evident on MRI. Based on the patient's history and the rapid response of the tumor to treatment, the spinal cord tumor was considered a metastatic intramedullary spinal germinoma representing CSF dissemination via the central canal.

An adult patient with a mixed germ cell tumor of the spermatic cord

Tumors of the spermatic cord are very rare, and approximately one half of all primary spermatic cord tumors are malignant. We report the presentation and treatment of an adult (36-year-old) patient with a mixed germ cell tumor that originated in the spermatic cord. No similar cases of mixed tumors of the spermatic cord in adults have been reported.

The pathology of late recurrence of testicular germ cell tumors

A total of 91 men had histologically documented late recurrences of testicular germ cell tumors characterized by a complete response to treatment with a subsequent disease-free interval of at least 2 years and no evidence of a second primary lesion. Ninety percent of the patients for whom information was available received chemotherapy shortly after their initial diagnosis of testicular germ cell tumors; most of the other patients were known to have stage I disease initially. Overall, 60% of patients had teratoma in their late recurrences, including 20 patients (22%) in whom teratoma was the only element. Thus, teratoma was the most common type of neoplasm in late recurrences. Excluding teratoma coexisting with other types of neoplasms, yolk sac tumor was the most frequent type of tumor in patients with late recurrence. It occurred in 47% of patients, either alone or with teratoma, another nonteratomatous germ cell tumor type, or a "nongerm cell malignant tumor." Unusual types of yolk sac tumor, including glandular, parietal, clear cell, and pleomorphic patterns, were seen frequently in late recurrences and often raised differential diagnostic problems with "nongerm cell" carcinomas. A smaller number of late recurrences consisted of other types of neoplasms. Twenty percent of patients with late recurrence had a nonteratomatous germ cell tumor other than yolk sac tumor, either alone, with yolk sac tumor, or with a "nongerm cell malignant tumor." Most of these nonteratomatous germ cell tumors other than yolk sac tumor were embryonal carcinoma, although rarely seminoma and choriocarcinoma were encountered. "Nongerm cell malignant tumors," including both sarcomas and carcinomas of various types, occurred in 23% of late-recurrence patients, either alone or with a nonteratomatous germ cell tumor. Late recurrences were seen in many different sites in these patients, including the retroperitoneum, abdomen, pelvis, liver, mediastinum, lung, bone (femur, vertebra, and rib), lymph nodes outside the retroperitoneum and mediastinum (supraclavicular, neck, and axillary regions), scrotum and inguinal regions, adrenal gland, chest wall, and buttocks. Follow-up data were available for 79 of the 91 patients studied. Duration of follow-up ranged from 2 months to 13 years after the patient's first late recurrences; the mean length of follow-up was 4.8 years. Patients whose late recurrences consisted of teratoma only had the most favorable outcomes, with 79% having no evidence of disease at last follow-up. Patients whose late recurrences consisted of pure "nongerm cell malignant tumor" or pure germ cell tumor (yolk sac tumor or other types) had a much worse prognosis: Only 36% to 37% were alive with no evidence of disease. Patients with two different types of nonteratomatous malignancies in their late recurrences had a dismal clinical course: Only 17% with both yolk sac tumor and other nonteratomatous germ cell tumor had no evidence of disease, whereas no patient with both nonteratomatous germ cell tumor and "nongerm cell malignant tumor" was disease free. Late recurrences consisting of teratoma alone often have a favorable outcome, but the prognosis in all other patients is poor. Furthermore, late recurrence is not likely to respond to chemotherapy and is best treated by surgical excision when possible.

Hematologic disorders associated with primary mediastinal nonseminomatous germ cell tumors

BACKGROUND

The association between primary germ cell tumors of the mediastinum (the space between the lung pleura that contains the heart and other chest viscera) and hematologic malignancies has been described by retrospective analysis of patients treated at individual clinical centers. To better characterize the risk of hematologic disorders in patients with extragonadal germ cell tumors and to describe the clinical and biologic features of the disorders, we studied an unselected population in a large, international, multicenter database.

METHODS

Six hundred thirty-five patients treated at 11 centers in the United States and Europe from 1975 through 1996 were evaluated retrospectively.

RESULTS

A hematologic disorder was observed in 17 patients with germ cell tumors. All cases developed among the 287 patients with primary mediastinal nonseminomatous germ cell tumors, giving an incidence rate in this group of 2.0% (95% confidence interval [CI] = 1.1%-3.1%) per year over a median follow-up time of 3 years. The risk of developing hematologic disorders was statistically significantly increased in patients with primary mediastinal nonseminomatous germ cell tumors in comparison with the age-matched general population (standardized incidence ratio = 250; 95% CI = 140-405). The median time to onset of hematologic neoplasia was 6 months (range, 0-47 months), and the median survival after diagnosis of the hematologic disorder was 5 months (range, 0-16 months) (two-sided P<.0001, comparing survival from the time of diagnosis of the germ cell tumor of patients with and without hematologic disorders).

CONCLUSION

In our study, approximately one in 17 patients with primary mediastinal nonseminomatous germ cell tumors was affected by a hematologic disorder, whereas no cases were seen among 334 patients with other extragonadal germ cell tumors. The hematologic disorder had a statistically significant impact on prognosis, with none of the 17 reported patients surviving for more than 2 years.

Rethinking nonseminomatous testicular cancer in U.S. Air Force pilots: case presentation and literature review

A U.S. Air Force F-15 pilot presented with a painless testicular mass. Nonseminomatous germ cell tumor (NSGCT) of the testis was diagnosed at orchiectomy. Retroperitoneal lymph node dissection (RPLND) yielded pathology stage IIa disease when 2 of 21 abdominal lymph nodes were positive. The patient immediately underwent adjuvant chemotherapy consisting of etoposide and cisplatin. Follow-up tumor markers, abdominal and chest CT scans were negative. Randomized, prospective studies have shown excellent response rates to low volume metastatic disease. This pilot's risk of sudden incapacitation due to this tumor following orchiectomy, RPLND, and immediate adjuvant chemotherapy is below the 1% threshold set forth by the U.S. Air Force for unrestricted flying waiver. Chemotherapy for testicular cancer carries significant morbidity risks that may complicate a pilot's return to status and these are reviewed. The overall recovery from chemotherapy is poorly quantified and needs to be further evaluated to optimize a pilot's return to flying status.

[Kinetics of peripheral blood CD34-positive cells and the optimum timing for harvesting peripheral blood stem cells during BEP chemotherapy in patients with testicular germ cell tumor]

PURPOSE

Recently, high-dose chemotherapy with peripheral blood stem cell (PBSC) rescue has been developed for poor risk testicular germ cell cancer. In this study, we investigated the optimum timing for harvesting PBSCs with the use of bleomycin + etoposide + cisplatin (BEP) chemotherapy, which is a well known first-line regimen for the testicular cancer.

MATERIAL AND METHOD

Peripheral blood CD34-positive cell ratios were measured during a total of 10 courses of BEP chemotherapy in 6 patients with metastatic germ cell cancer between 1996 and 1998. We performed 4 apheresis in 3 patients during this period. Recombinant human granulocyte-colony stimulating factor (rhG-CSF) was administrated from the day on which the neutrophil count decreased less than 1,000/microliter.

RESULTS

The peripheral blood CD34-positive cell ratios became maximum (3.0-24.6%; average 10.0%) on the day 18 to 21 (median day 19) of BEP chemotherapy with rhG-CSF administration. The maximum ratios of peripheral blood CD34 positive cells were achieved when the number of leukocyte were 6,880-23,600/microliter and exceeded 6,000/microliter after the 18th day of BEP chemotherapy. The average number of collected CD34 positive cells was 9.5 x 10(6)/kg at a single apheresis, and 12.6 x 10(6)/kg per patient.

CONCLUSION

Efficient hematopoietic progenitor cells were mobilized by BEP chemotherapy with rhG-CSF administration of first-line setting. Our results suggest that the optimum timing of PBSCs harvest is the day when the numbers of leukocyte exceed 6,000/microliter after the 18th day of BEP chemotherapy and the following day.