Nonsurgical treatment of huge suprasellar germinoma

A case describing a huge, suprasellar germinoma with subfrontal extension that produced striking emaciation of the patient as an initial symptom is discussed. Diagnosis of germinoma was made on the basis of a computed tomography scan and cytology of the ventricular fluid. The tumor responded well to radiation treatment, which may indicate that it is not always necessary to reduce tumor bulk by direct surgical intervention before radiation therapy.

Treatment of advanced seminoma with pre-radiation chemotherapy

Seminoma is one of the most radiosensitive of solid tumors. However, the survival rate of patients with clinically advanced stages B3 and C disease is poor. Because of this dismal prognosis we instituted a protocol of pre-radiation chemotherapy in an attempt to improve the survival rates. A chemotherapeutic regimen, consisting of 2 to 3 courses of vincristine, actinomycin D and cyclophosphamide, was administered before radiotherapy. Of 16 patients studied 15 (93.7 per cent) had a complete response to the combined treatment regimen. We believe that pre-radiation chemotherapy is indicated in all patients with advanced seminoma.

Management of primary mediastinal seminoma

Radiation therapy has been the usual initial treatment for mediastinal seminoma in the past. However, 25 to 40 percent of patients are not cured by this therapy, and other therapy is needed. Review of case reports show that vinblastine, bleomycin, and cis-platinum are effective therapy for metastatic disease, advanced disease within the chest, or mixed germ cell tumors with nonseminomatous elements. The use of tumor markers and chemotherapy must be integrated into the staging of and therapy for primary mediastinal seminoma.

Synchronous bilateral primary germ cell tumors of the testis: a case report and review of the literature

Synchronous bilateral primary germ cell tumors of the testis are exceedingly rare. The most common synchronous testicular tumors are seminomas, followed by embryonal carcinomas, teratocarcinomas, and choriocarcinomas. In a series of 385 patients we found nine with bilateral primary germ cell tumors of the testis (2.3%), including one with synchronous involvement of both testes. The treatment of synchronous bilateral primary germ cell tumors of the testis is in principle the same as that of solitary testicular primary germ cell tumors, and is based on tumor histology and tumor metastasis.

The management of metastatic seminoma testis

Clinical details of 85 men presenting with previously untreated metastatic seminoma are presented. In Stage II disease relapse rate was related to the size of metastases. In IIA (32 patients) the relapse rate was 9.4%; IIB (11 patients), 18.2%; and IIC (23 patients), 39.1%. The continuous disease-free survival rate was significantly worse for IIC than IIA and IIB patients (P = 0.023). No instance of first relapse in supradiaphragmatic nodes was observed in 13 men with Stage II disease treated with irradiation limited to infradiaphragmatic nodes. In relapsing Stage IIC patients, extralymphatic metastasis was as frequent as abdominal relapse. On the basis of these observations, together with preliminary data in nine men receiving Cis-platinum-containing chemotherapy, all of whom are in complete remission, it is proposed that patients with Stage IIA and IIB disease should receive infradiaphragmatic irradiation with chemotherapy deferred until relapse. Stage IIC patients should receive chemotherapy initially, followed by irradiation. In Stage III and IV disease chemotherapy should be initial therapy with radiotherapy for bulky disease on an individualised basis. Moderate elevation of blood B-HCG levels is not inconsistent with a diagnosis of pure seminoma and does not appear to influence adversely the outcome of radiotherapy.

Management of radiation ulcers

Despite more efficient and safer technics of radiation therapy, the problem of radiation-induced injury to the skin and soft tissue persists. The problem of adequate coverage of these painful, ischemic, and fibrotic ulcers remains challenging. Split-thickness skin grafts are seldom sufficient coverage, as the graft almost always has areas that do not take. Although these areas may eventually heal by epithelialization, the result is never ideal. Most often flap coverage is required, but elevation of local flaps is jeopardized because the tissue surrounding the ulcer crater frequently has been sufficiently compromised to cause loss of at least part of the flap. In the past, this necessitated use of pedicled flaps, tubed and transposed from a distance. With the development of axial-pattern musculocutaneous and muscle flaps, as well as microvascular free flaps, the difficulty in dealing with these ulcers has been decreased. Surgeons can now recommend earlier use of adequate debridement, many times of the entire irradiated area, and immediate coverage with a well vascularized axial-pattern musculocutaneous flap or revascularized free flap.

A clinical review of seventeen patients with ovarian dysgerminoma

This is a retrospective evaluation of 17 patients with the diagnosis of ovarian dysgerminoma who were treated at the University of Iowa Hospitals from January 1938, to December 1976. Not a single patient was lost to follow-up. The majority of patients were between 11 to 30 years old. Seven patients died with disease, 3 during the 1st year, 3 during the 2nd year and 1 during the 4th year after diagnosis. In this series we have 10 patients with no evidence of disease (NED). The duration of follow-up of that group is from 51 months to 444 months with a median of 102 months. Postoperative radiation therapy is a valuable adjuvant to surgical treatment for dysgerminoma.

Patterns of care outcome survey: national outcome data for six disease sites

This paper reports the results of the PCS Outcome Surveys for radiation therapy treatment in six disease sites: cervix, Hodgkin's disease, seminoma of the testis, anterior two-thirds of tongue and floor of mouth, larynx and prostate. The survey reflects data obtained for patients treated in 1973. Results for early stages of disease are generally favorable in cancer of the cervix, prostate, testis, larynx and Hodgkin's disease. Control of disease in anterior two-thirds of tongue and floor of mouth was less favorable, but data suggest that more aggressive radiation therapy may contribute to better outcome for this site.

Recovery from aspermia induced by low-dose radiation in seminoma patients

Gonadal dosimetry and spermatogenic activity was monitored in patients given radiation therapy (RT) after unilateral orchiectomy for seminoma. The RT given was, with minor variations, 3200 rad in 16 fractions in four weeks to the para-aortic and ipsilateral pelvic inguinal lymphatics in order to include the orchiectomy scar. The incidental amount of radiation to the remaining testicle averaged 78.4 +/- 7.4 rad and ranged from 32-178 rad as determined by thermoluminescent dosimetry. Induction of aspermia was documented in ten out of 14 patients who received over 65 rad to the gonad. At lower doses, aspermia may not have occurred or was of short duration. Recovery of sperm in the semen occurred in 12 patients within 30-80 weeks after start of treatment. The data suggest that the time of recovery may be dose dependent within the range of 19-148 rad. During the period of recovery, patients with oligospermic semen may be fertile and should be so advised.

[Tangential pendular cobalt-therapy in the management of malignant testis tumors: a clinical evaluation after 14 years' experience]

129 cases of malignant testis tumors (88 seminoma and 41 carcinomas) treated at Istituto del Radio "O. Alberti" from 1966 to 1979 were statistically reviewed. All patients had inguinal orchiectomy followed by irradiation to iliac and lumbar para-aortic lymph nodes, with an original technique, tangential pendular cobalt therapy, worked out at our Institute in 1966. Results are very good: there is calculated with actuarial method, a 92% of patients with seminoma alive at 5 years and 84% of patients with carcinoma. Earlier or later iatrogenic sequences did not happened. The worth and actuality of tangential pendular cobalt therapy to post-operative irradiation in patients with stage I or II malignant testis tumors is confirmed.

Treatment of children with dysgerminoma of the ovary

The therapeutic approach to dysgerminoma, the most common malignant ovarian tumor in children, has been primarily surgical, with radical excision for tumors extending beyond their capsule. Four children with localized disease were treated with limited surgery only and are free of disease. Five others with extensive disease were treated with chemotherapy as the primary therapeutic modality, with or without adjuvant radiotherapy, and three are alive and remain free of disease. Only the two patients with an admixture of other malignant germ cell tumors had recurrence of the other malignant elements after an initial good response. This experience demonstrates pronounced in vivo tumoricidal activity and supports a therapeutic approach to existence childhood dysgerminoma with an initial chemotherapeutic regimen, resulting in sparing of pelvic and reproductive organs.

[Spermatogenesis after fractionated, low-dose irradiation of the gonads ]

58 patients (50 retrospectively, 8 prospectively) who received post-operative radiotherapy for seminoma, constitute the patient population with which the tolerance dosage for spermatogenesis following low-dose fractionated radiation of the gonads was determined. Field arrangement and caudal field limit were the parameters which determined the amount of the dose to the gonads. Total doses of less than 100cGy, with daily doses of 3 to 5 cGy, permit a complete recovery of spermatogenesis within 14 to 22 months. The occurrence of an azoospermia can be expected 3 to 5 months after initiation of irradiation, lasting for 5 to 6 months. Doses of more than 100 to 150 cGy permit only partial recovery of spermatogenesis and doses of more than 150 cGy can lead to permanent azoospermia. In the absence of evidence of mobile spermatozoa in the ejaculate more than 2 years after radiotherapy, no repopulation of the seminiferous tubules can be expected. After receiving ionizing radiation, the stem cells of the spermatogonia have only a very limited capability for repair, regeneration and compensation. This is the reason for the very high sensitivity of the spermatogenesis to low-dose fractionated radiation of the male gonads.

Management of primary germ cell tumors of the mediastinum

Twenty-eight patients with primary malignant germ cell tumors (GCT) of the mediastinum were treated at the University of California at Los Angeles and The Johns Hopkins Hospital in the past 30 years. Of 11 patients with pure seminomas, nine (82%) are free of disease from 6 months to 15 years following therapy. The primary treatment modality in these patients was mediastinal radiation; one patient with metastatic disease had a complete remission and prolonged survival following combination chemotherapy. Seventeen patients had GCT with nonseminomatous elements. Only three (18%) are alive and free of disease. One patient treated only surgically is alive at 15 years and two patients treated with combination chemotherapy and operation are alive and free of disease at 6 months and 3 years. When analyzed by a Kaplan-Meier actuarial survival estimate, patients with nonseminomatous GCT who were treated with cisplatin-bleomycin-based chemotherapy had a median survival of 14.0 months whereas those treated with chemotherapy regimens not employing these agents had a median survival of 4.0 months (generalized Wilcoxon test, p = 0.0495). Patients with pure seminomas are effectively treated with radiation therapy. Patients with nonseminomatous tumors have a much poorer prognosis and deserve aggressive multimodality therapy with cisplatin-bleomycin-based chemotherapy.

Primary anterior mediastinal seminoma

A review of the Mayo Clinic experience with primary anterior mediastinal seminomas involved 17 patients who had pure anterior mediastinal seminomas and four who had mixed germ-cell tumors containing seminomas. At follow-up, of the 17 patients with pure anterior mediastinal seminoma, nine had no evidence of disease and eight had died of metastatic disease. Of the four patients with mixed germ-cell tumor containing seminoma, two were alive at follow-up and two had died of metastatic disease. In the group with pure anterior mediastinal seminoma, these factors seemed to have been associated with a greater potential for progression of disease: older than 35 years of age, presentation with fever, superior vena caval syndrome, supraclavicular or cervical adenopathy, and roentgenographic evidence of hilar disease.

Mediastinal nonseminomatous germ cell tumors: the role of combined modality therapy

Twelve male patients with mediastinal nonseminomatous germ cell tumors were treated with chemotherapy (with or without operation and radiation therapy) between 1963 and 1980. Eight patients, treated with only chemotherapy and radiotherapy, died with a median survival from diagnosis of 6 months (range, 3 to 12 months). The 4 survivors remain alive at 12, 15, 34, and 56 months from diagnosis; all are without evidence of disease. All surviving patients were treated with surgical resection of disease either before of after chemotherapy. A major problem in the management of mediastinal nonseminomatous germ cell tumors is the persistence of local disease, which may be overcome by vigorous cytoreductive intervention. Multicenter collaboration will be required to define the optimal combined-modality approach.

Seminoma of the testis: results of treatment and patterns of failure after radiation therapy

Four hundred and forty-four patients with the histological diagnosis of pure seminoma were treated at The Princess Margaret Hospital between 1958 and 1976. Using the Walter Reed Hospital staging classification, 338 patients (76.1%) were Stage I, 86 (19.4%) were Stage II, and 20 (4.7%) were Stage III. The 5 year actuarial survival rate (5 yr Sa) for all stages was 87%, and for Stages I, II and III: 94%, 74% and 32% respectively. In Stage II the 5-year Sa was significantly worse when palpable abdominal disease was present (62%, vs 87% when it was absent, p less than .02). Prophylactic mediastinal irradiation was not used for patients with Stage II disease. None of 40 Stage II patients without palpable abdominal disease recurred in the non-irradiated mediastinum. Ten of 46 Stage II patients with palpable abdominal disease recurred in the mediastinum; 7 of the 10 were cured with mediastinal irradiation at the time of relapse. Prophylactic mediastinal irradiation appears unnecessary in Stage II patients. The Stage III category includes a subgroup of patients who were curable with radiation therapy:L 5/6 with supradiaphragmatic nodal disease without palpable abdominal or visceral disease were cured. Exploration of new treatment methods appears indicated for the salvage of patients recurring in sites other than the mediastinum or supraclavicular fossa and for patients presenting with visceral disease.