Severe spontaneous acute tumor lysis syndrome and hypoglycemia in patient with germ cell tumor

Tumor lysis syndrome has been observed in patients with bulky, treatment-sensitive tumors, in particular hematological malignancies, especially after medical treatment (chemotherapy, corticosteroids, radiation, hormonal agents, and biological response modifiers). Tumor lysis syndrome has been observed also in solid malignancies and it very rarely occurs spontaneously. Tumor lysis syndrome-associated metabolic abnormalities include hyperuricemia, hyperphosphatemia, hyperkalemia, hypocalcemia and uremia. Severe hypoglycemia is another rare metabolic disorder, uncommonly associated with solid malignancies. The case described here is peculiar for the abrupt onset of these two rare conditions in a patient with a metastatic germ cell tumor.

Differences in total human chorionic gonadotropin immunoassay analytical specificity and ability to measure human chorionic gonadotropin in gestational trophoblastic disease and germ cell tumors

OBJECTIVE

To determine the ability of several radioimmunoassays and commercial two-site immunoassays to detect the first World Health Organization International Reference Reagents (IRRs) for 6 defined human chorionic gonadotropin (hCG) variants and to compare their performance in measuring hCG in sera from patients with gestational trophoblastic disease (GTD) and germ cell tumors (GCTs) of the testis or ovary.

STUDY DESIGN

The reactivity of the different assays with the 6 IRRs together with the current fourth International Standard (IS, 75/589) was tested using 5 commercial two-site assays as well as 2 competitive polyclonal radioimmunoassays (RIAs) and a competitive monoclonal immunoassay. Individual samples from 41 patients (19 GCT and 22 GTD) with high circulating levels of hCG (range, 718-6,055,000 IU/L) were diluted and measured using the various immunoassays.

RESULTS

The results of 4 GCT patient samples varied markedly among the assays, including 1 sample that was grossly underestimated by 3 of the commercial assays.

CONCLUSION

Comparison of each assay's reactivity to the variant isoforms revealed that recognition of the isoforms was highly variable, particularly for hCGbeta and hCGbeta core fragment (hCGbetacf).

Matrix metalloproteinases and proangiogenic factors in testicular germ cell tumors

PURPOSE

Testicular cancer is the most frequent solid tumor in young male adults and a disease with elusive pathogenesis. The purpose of this study was to determine the role of matrix metalloproteinases and angiogenic factors in the pathogenesis of testicular germ cell tumors (GCTs).

METHODS

Between 2003 and 2006 we measured the serum levels of matrix metalloproteinase 2 (MMP-2), matrix metalloproteinase 9 (MMP-9), tissue inhibitor of matrix metalloproteinase 2 (TIMP-2), vascular endothelial growth factor A (VEGF-A), basic fibroblast growth factor (bFGF), platelet derived growth factor BB (PDGF-BB) and angiopoietin 2 (Ang-2) in 50 patients with testicular GCTs, at baseline, one month after the completion of the second cycle of chemotherapy and one year after the completion of chemotherapy, and in 16 male age-matched controls at baseline.

RESULTS

At baseline, mean TIMP-2 value was lower in patients than controls, mean MMP-2/TIMP-2 ratio was higher in patients than controls and MMP9/TIMP-2 ratio was also higher. Ang-2 value was higher in patients than controls and bFGF value was also higher. Comparisons of the same parameters were also made among the 3 consecutive serum samples of the patients. All parameters normalized after chemotherapy except Ang-2 which remained elevated.

CONCLUSION

The present study supports the hypothesis that tumor invasion and angiogenesis play a role in testicular GCTs pathogenesis. Also an interesting hypothesis was formed, concerning the role of elevated levels of Ang-2 found in testicular GCTs patients in the pathogenesis of the increased long term cardiovascular morbidity of these patients. Larger prospective studies are needed to confirm our results.

Prediagnostic serum concentrations of organochlorine compounds and risk of testicular germ cell tumors

BACKGROUND

Recent findings suggest that exposure to organochlorine (OC) compounds, chlordanes and p,p'-dichlorodiphenyldichloroethylene (p,p'-DDE) in particular, may increase the risk of developing testicular germ cell tumors (TGCTs).

OBJECTIVE

To further investigate this question, we conducted a nested case-control study of TGCTs within the Norwegian Janus Serum Bank cohort.

METHODS

The study was conducted among individuals with serum collected between 1972 and 1978. TGCT cases diagnosed through 1999 (n = 49; 27-62 years of age at diagnosis) were identified through linkage to the Norwegian Cancer Registry. Controls (n =51) were matched to cases on region, blood draw year, and age at blood draw. Measurements of 11 OC insecticide compounds and 34 polychlorinated biphenyl (PCB) congeners were performed using gas chromatography/high-resolution mass spectrometry. Case-control comparisons of lipid-adjusted analyte concentrations were performed using the Wilcoxon signed-rank test. Odds ratios (ORs) and 95% confidence intervals (CIs) for tertiles of analyte concentration were calculated using conditional logistic regression.

RESULTS

TGCT cases had elevated concentrations of p,p'-DDE (tertile 3 vs. tertile 1 OR (OR(T3)) 2.2; 95% CI, 0.7-6.5; p(Wilcoxon) = 0.07), oxychlordane (OR(T3) 3.2; 95% CI, 0.6-16.8; p(Wilcoxon) = 0.05), trans-nonachlor (OR(T3) 2.6; 95% CI, 0.7-8.9; p(Wilcoxon) = 0.07), and total chlordanes (OR(T3) 2.0; 95% CI, 0.6-7.2; p(Wilcoxon) = 0.048) compared with controls, although no ORs were statistically significant. Seminoma cases had significantly lower concentrations of PCB congeners 44, 49, and 52 and significantly higher concentrations of PCBs 99, 138, 153, 167, 183, and 195.

CONCLUSIONS

Our study provides additional but qualified evidence supporting an association between exposures to p,p'-DDE and chlordane compounds, and possibly some PCB congeners, and TGCT risk.

Serum human chorionic gonadotropin is associated with angiogenesis in germ cell testicular tumors

BACKGROUND

Germ cell testicular tumors have survival rate that diminishes with high tumor marker levels, such as human chorionic gonadotropin (hCG). hCG may regulate vascular neoformation through vascular endothelial growth factor (VEGF). Our purpose was to determine the relationship between hCG serum levels, angiogenesis, and VEGF expression in germ cell testicular tumors.

METHODS

We conducted a retrospective study of 101 patients. Serum levels of hCG, alpha-fetoprotein (AFP), and lactate dehydrogenase were measured prior to surgery. Vascular density (VD) and VEGF tissue expression were determined by immunohistochemistry and underwent double-blind analysis.

RESULTS

Histologically, 46% were seminomas and 54%, non-seminomas. Median follow-up was 43 +/- 27 months. Relapse was present in 7.5% and mortality in 11.5%. Factors associated with high VD included non-seminoma type (p = 0.016), AFP > or = 14.7 ng/mL (p = 0.0001), and hCG > or = 25 mIU/mL (p = 0.0001). In multivariate analysis, the only significant VD-associated factor was hCG level (p = 0.04). When hCG levels were stratified, concentrations > or = 25 mIU/mL were related with increased neovascularization (p < 0.0001). VEGF expression was not associated with VD or hCG serum levels.

CONCLUSION

This is the first study that relates increased serum hCG levels with vascularization in testicular germ cell tumors. Hence, its expression might play a role in tumor angiogenesis, independent of VEGF expression, and may explain its association with poor prognosis. hCG might represent a molecular target for therapy.

[Efficacy of modified retroperitoneal lymph node dissection for testicular nonseminomatous germ cell tumors]

BACKGROUND & OBJECTIVE

Retroperitoneal lymph node dissection(RPLND) is one of the main modalities for nonseminomatous germ cell tumors (NSGCTs). RPLND has achieved relatively high efficacy for stage I/II NSGCTs. Currently, the postoperative complication rate of conventional RPLND is relatively high. This study was to summarize therapeutic efficacy of modified RPLND for stageI/II NSGCTs, thus to explore the reasonable therapy strategy for those diseases.

METHODS

Clinical data of 31 patients with stage I/II NSGCTs underwent RPLND from Aug.2003 to Aug.2007 in Sun Yat-sen University Cancer Center, were retrospectively analyzed. All cases received modified RPLND after radical orchidectomy. Four cases received two to three cycles of BEP (bleomycin,etoposide and cisplatin) chemotherapy prior to RPLND. Thirteen cases received one to five cycles of adjuvant cisplatin-based chemotherapy after primary RPLND.

RESULTS

The mean operating time was 147 min (rang 120-200 min) and the mean blood loss was 116 ml (rang 50-300 mL) of modified RPLND. The mean number of dissected lymph nodes sent for pathological examination was 15 (rang 3-40). Retroperitoneal lymph node metastases were confirmed in 15 cases, two of which were fibrosis. According to the pathologic classification after operation, there were 16 cases at stage I, six cases at stage IIA, six cases at stage IIB, and three cases at stage IIC. There was no occurrence of perioperational and postoperational complications. The mean follow-up time was 33 months, ranged eight to 58 months. Twenty-nine patients achieved tumor-free survival, without elevation of blood alpha-fetal protein (AFP) or human chorionic gonadotropin (HCG). One patient developed postoperative recurrence in the retroperitoneum 17 months after operation. After receiving two cycles of salvage therapy, his serum AFP and beta-HCG returned to normal ranges. Another patient had metastasis in the liver and lung six months after operation, but achieved complete response after six cycles of adjuvant cisplatin-based chemotherapy. Antegrade ejaculation was preserved in 96.8% of patients. The mean operative time was 175 vs. 143 min(P=0.002), and the blood loss was 200 vs.104 mL in the group with and without preoperative chemotherapy, respectively(P<0.001).

CONCLUSIONS

Modified RPLND achieves satisfactory results for stageI/II NSGCTs patients. It decreases damages to normal organs as well as causes less perioperative and postoperative complications compared to conventional PRLND.

Elevated serum levels of IGF-binding protein 2 in patients with non-seminomatous germ cell cancer: correlation with tumor markers alpha-fetoprotein and human chorionic gonadotropin

BACKGROUND/AIMS

Alterations of the IGF system have been described in several different types of cancer. However, no information is available about the role of the IGF system in patients with non-seminomatous germ cell cancer.

METHODS

Free IGF-I, IGF-II, acid-labile subunit, and IGF-binding proteins (IGFBPs) 1-4 were analyzed by specific RIAs in 32 patients with untreated non-seminomas and compared with IGFBP levels of 38 healthy controls. Serum IGFBPs were analyzed by western ligand blotting (WLB) and immunoblotting. In 16 patients, IGFBP profiles were measured before, during, and after treatment.

RESULTS

In patients with testicular cancer, IGF-II levels were on average 1.44-fold higher than in the healthy control group (1027+/-48 ng/ml versus 711+/-30 ng/ml, P<0.0001). IGFBP-2 levels were on average 2.6-fold higher (586+/-58 ng/ml versus 226+/-17 ng/ml, P<0.001). During follow-up, a decrease in IGFBP-2 levels was observed in all successfully treated patients, which correlated closely with a decrease in the tumor markers alpha-fetoprotein and human chorionic gonadotropin. Additionally, in all patients with recurrent disease, a significant further increase in IGFBP-2 levels (from 358+/-97 to 976+/-260 ng/ml) was detected. IGFBP-3 levels, as measured by RIA, were not different in patients with testicular cancer compared with controls. However, WLB analysis demonstrated markedly decreased intact IGFBP-3 bands in untreated patients and a significant increase after successful therapy.

CONCLUSION

Our results demonstrate that markedly elevated IGF-II and IGFBP-2 serum levels in patients with non-seminomatous germ cell cancer, showing a significant decrease after successful therapy and an increase in recurrent disease. Additionally, indirect evidence points to an increased proteolytic activity for IGFBP-3 in untreated testicular cancer patients.

Insulin-like growth factor 1, insulin-like growth factor-binding protein 3, and testicular germ-cell tumor risk

Studies have consistently shown that taller men are at increased risk of testicular germ-cell tumors. Thus, it is plausible that factors associated with height may also influence risk of these tumors. The authors examined associations between testicular germ-cell tumor risk and circulating concentrations of insulin-like growth factor 1 (IGF-1) and insulin-like growth factor-binding protein 3 (IGFBP-3) among 517 cases and 790 controls from the US Servicemen's Testicular Tumor Environmental and Endocrine Determinants (STEED) Study (2002-2005). Odds ratios and 95% confidence intervals were estimated using logistic regression models, adjusting for age, race/ethnicity, height, and body mass index. All tests of significance were two-sided. Overall, there were no associations between IGF-1 or IGFBP-3 concentrations and risk of testicular germ-cell tumors (p > 0.05). However, when cases were separated by histologic type, there was a suggestion of a reduction in seminoma risk associated with the highest concentrations of IGF-1 as compared with the lowest concentrations (odds ratio = 0.66, 95% confidence interval: 0.40, 1.09). Although there were no overall associations with insulin-like growth factor, contrary to expectation, there was a suggestion that IGF-1 concentrations may be inversely associated with risk of seminoma.

Risk factors for post-treatment hypogonadism in testicular cancer patients

OBJECTIVES

Testicular germ-cell cancer (TGCC) patients are at risk of developing hypogonadism but no risk factors have yet been defined.

METHODS

Blood was collected from 143 TGCC patients (after orchidectomy, prior to further therapy (T0) and 6, 12, 24, 36 and 60 months (T6, T12, T24, T36 and T60) after therapy). Biological hypogonadism (BH) was defined as: serum testosterone below 10 nmol/l and/or LH >10 IU/l; odds ratios (ORs) for BH with BH at T0, age, stage of disease, testicular characteristics, and androgen receptor polymorphism as predictors were calculated as well as the OR for developing BH post-treatment (one to two cycles of adjuvant chemotherapy (ACT) versus three to four cycles of higher dose chemotherapy (HCT) versus adjuvant radiotherapy (RT)).

RESULTS

HCT increased the OR for BH at T6 (OR 22, 95% confidence interval (CI) 4.4-118) and T12 (OR 5.8, 95% CI 1.5-22). RT increased the OR at T6 (OR 10, 95% CI 2.1-47) and at T12 (OR 3.9, 95% CI 1.1-14). Microlithiasis predicted BH at T0 (OR 11, 95% CI 1.2-112), T12 (OR 3.9, 95% CI 1.1-13), T24 (OR 3.0, 95% CI 1.0-8.8), T36 (OR 5.4, 95% CI 1.7-17) and T60 (OR 4.4, 95% CI 1.2-16). BH at T0 was a risk for BH at T6 (OR 53, 95% CI 19-145), T12 (OR 125, 95% CI 37-430), T24 (OR 88, 95% CI 26-300) and T36 (OR 121, 95% CI 32-460).

CONCLUSIONS

It is clinically relevant that BH at T0 and testicular microlithiasis were predictive factors for post-treatment BH. HCT and RT gave temporary BH.

Regression pattern of alpha fetoprotein level changed after treatment of malignant germ cell tumor

OBJECTIVE

To identify the regression pattern of serum alpha fetoprotein in malignant germ cell tumors after initial chemotherapy

MATERIAL AND METHOD

This was a retrospective descriptive study. All patients with malignant germ cell tumor who had elevated serum alpha fetoprotein (AFP) and received adjuvant chemotherapy in Rajavithi Hospital between January 1984 and May 2007 were included.

RESULTS

Sixty patients with malignant germ cell tumor that met the study criteria were included. The median progression free interval (PFI) was 64.3 months and the median overall survival (OS) was 70.9 months. Four courses of chemotherapy was the average. AFP was first negative after a mean of course of three. Two more cycles were given as a maintenance course. The regression of AFP, between its level before the first and second courses was less than 0.015, associated with survival, accuracy about 70%, sensitivity 83.3%. The number of maintenance courses of chemotherapy was statistically affected to PFI and OS (p-value of 0.025, 0.003, respectively).

CONCLUSION

The regression of AFP is an independent prognostic factor in malignant germ cell tumor and may be a useful tool in the therapeutic management of these patients.

Foetal haemoglobin-blood cells (F-cells) as a feature of embryonic tumours (blastomas)

Tumour markers are important in the diagnosis and monitoring of many tumours. This study tested the hypothesis that an oncofoetal protein, foetal haemoglobin (HbF) is a potential tumour marker in embryonic tumours, useful for management. An immunohistochemical investigation of HbF blood cell (Fc) distribution was carried out in tumours and in bone marrow samples from 83 children and 13 adults with various embryonic tumours (blastomas), and in bone marrow samples of 24 leukaemia patients. In the three, main blastoma types, nephroblastoma (Wilms' tumour), neuroblastoma and retinoblastoma, where all the patients, except two, were children, around 80% of the tumour samples had Fc within proliferating blood vessels and spaces between tumour cells. In parallel, clusters of Fc, mostly F-erythroblasts (Feb), were distributed in the bone marrow of some of those patients and in the bone marrow of 79% of the leukaemia patients. Foetal haemoglobin, as well as being a potential prognostic cancer marker, is a potential indicator of DNA hypomethylation implicated in the development of these tumours, as well as in others previously noted for the presence of HbF.

Incorporation of TIP (paclitaxel, ifosfamide, cisplatin) into first-line therapy for intermediate to poor risk testicular germ cell tumors with unfavorable marker decline after initial two cycles chemotherapy: A report of three cases

Three patients of advanced-non-seminomatous germ cell tumors (International Germ Cell Cancer Collaborative Group classification: poor risk, 2; intermediate, 1) without evidence of a second primary germ cell tumor were treated. The patients received two cycles of standard BEP (bleomycin, etopside, cisplatin) or VIP/VB (etoposide, ifosphamide, cisplatin/vinblastine, bleomycin) therapy first. All patients in this trial showed unfavorable marker response to these therapies and received four cycles of TIP subsequently. A complete remission was observed in all patients. No patient experienced life-threatening toxicity. During the 34-month observation period, all patients were alive without progression.

Post Chemotherapy RPLND in Patients with Elevated Markers: Current Concepts and Clinical Outcome

Elevated serum tumor markers after cisplatin-based chemotherapy usually contraindicate surgery because of the presence of active germ-cell elements; however, some patients have undergone PCRPLND with curative intent. We evaluated the role of surgery to resect retroperitoneal-only marker positive tumor. Residual germ-cell cancer was identified in 50% of patients with elevated tumor markers with one third alive at 5 years; 5-year survival with residual teratoma or necrosis was 77.5% and 85.7%, respectively. Predictors of retroperitoneal teratoma or fibrosis included declining tumor makers at surgery, betaHCG < 100, and first-line chemotherapy. Predictors of death included rising preoperative betaHCG, elevated AFP, redo RPLND, and active germ-cell cancer in the resected specimen. Select patients with elevated tumor markers after chemotherapy are cured with surgery.

Significance of Primary Tumor Size and Preorchiectomy Serum Tumor Marker Level in Predicting Pathologic Stage at Retroperitoneal Lymph Node Dissection in Clinical Stage A Nonseminomatous Germ Cell Tumors

OBJECTIVES

To determine whether the size of the primary tumor and degree of preorchiectomy serum alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (beta-hCG) elevation predict for retroperitoneal pathologic findings in patients with clinical Stage A nonseminomatous germ cell tumor undergoing primary retroperitoneal lymph node dissection.

METHODS

The testicular cancer database was queried to identify patients with clinical Stage A nonseminomatous germ cell tumor with normalization of serum tumor markers after orchiectomy who had undergone retroperitoneal lymph node dissection. A total of 779 patients were identified. The preorchiectomy serum tumor marker level was recorded and categorized into the following subsets: AFP: less than 20 (normal), 20 to 100, 100 to 1000, and more than 1000 ng/dL; and beta-hCG: less than 5.0 (normal), 5 to 100, 100 to 1000, and more than 1000. The association between AFP, beta-hCG, and primary tumor size and retroperitoneal pathologic findings was determined.

RESULTS

The retroperitoneal pathologic examination revealed metastatic disease in 207 patients (26.6%). The preorchiectomy serum beta-hCG level, as a categorical variable, was not predictive of positive retroperitoneal pathologic findings (P = 0.187). The preorchiectomy serum AFP did predict for positive retroperitoneal pathologic findings, with lower serum AFP levels associated with a greater incidence of retroperitoneal metastasis (P <0.001). The primary tumor size was not predictive of positive retroperitoneal pathologic findings (P = 0.113).

CONCLUSIONS

Neither the primary tumor size nor the preorchiectomy beta-hCG level was predictive of retroperitoneal metastases. However, a normal preorchiectomy AFP level was associated with a greater incidence of retroperitoneal metastases.

Pre-radiation chemotherapy with response-based radiation therapy in children with central nervous system germ cell tumors: a report from the Children's Oncology Group

BACKGROUND

This Phase II study was designed to determine response to chemotherapy and survival after response-based radiation (RT) in children with CNS germ cell tumors.

PROCEDURE

Children with germinomas and normal markers received cisplatin 100 mg/m(2) + etoposide, alternating with vincristine + cyclophosphamide (CPM) 2 g/m(2)/d, for four cycles. Children with nongerminomatous tumors or with abnormal markers received doubled doses of cisplatin and CPM. For germinoma patients in complete response (CR), RT was decreased from 50.4 to 30.6 Gy. High-risk patients received neuraxis RT: 50.4 Gy local + 30.6 Gy neuraxis in CR; 54 Gy local + 36 Gy if less than CR.

RESULTS

Of 12 germinoma patients, 4 had cerebrospinal fluid (CSF) human chorionic gonadotropin (HCG) 6.9-21 mIU/ml. Of 14 nongerminomatous patients, HCG in serum or CSF was >50 mIU/ml in 9, alpha-fetoprotein (AFP) abnormal in 9. Four germinoma patients attained CR, six PR, one SD, one not evaluable after resection. Two nongerminomatous patients had CR, three PR, three SD, one PD, four not evaluable after resection; one inadequately treated patient had progressive disease (PD). Both PD patients died; one SD patient died during a seizure. Eleven germinoma patients are PF at median 66 months; one patient in CR refused RT, had PD at 10 months, received RT, and was PF at 56 months. Eleven of 14 nongerminomatous patients were PF at median 58 months.

CONCLUSION

Response (germinoma, 91%; nongerminomatous, 55%) and survival are encouraging after this regimen plus response-based RT.

[Chemotherapy for metastatic germ cell tumours of the testis]

The gold standard regimen for metastatic testicular germ cell tumours is a combination of bleomycin, etoposide and cisplatin. The number of cycles is defined by pathology (seminoma or non seminoma) and the prognostic criteria of the international classification (degree of elevation of serum tumour markers and presence or not of non pulmonary visceral metastases). The surgical resection of all residual metastatic masses is mandatory after the normalization of serum tumour markers in non seminoma patients. The cure rates after chemotherapy and surgery are about 90% and 50% in good-risk and poor-risk patients, respectively.

Malignant ovarian germ cell tumors: identification of novel prognostic markers and long-term outcome after multimodality treatment

PURPOSE

Malignant ovarian germ cell tumors are rare and knowledge about prognostic parameters currently is limited. This study was undertaken to evaluate long-term outcome of patients with malignant ovarian germ cell tumors (MOGCTs) after chemotherapy and to assess prognostic parameters.

PATIENTS AND METHODS

A total of 113 patients with stage IC to IV MOGCTs were included into this retrospective study. Patients were treated at two large regional cancer centers between 1977 and 2003.

RESULTS

Ten-year recurrence-free and overall survival rates were 82% and 81%, respectively. A total of 20 patients experienced relapse, all within the first 8 years. Outcome after relapse was poor, with only 10% of patients achieving long-term survival. Univariate and multivariate analyses demonstrated that initial stage of disease (relative risk [RR], 5.96; 95% CI, 3.47 to 10.22; P = .03) and elevation of serum markers beta-human chorionic gonadotropin and alpha-fetoprotein (RR, 3.90; 95% CI, 1.40 to 10.9; P = .009) were significant predictors of overall survival, whereas age at diagnosis was of no prognostic value.

CONCLUSION

This is the first study to identify stage and tumor markers as prognostic parameters for patients with MOGCTs. This might help to select patients for risk-adapted treatment. There is need for improvement of therapeutic strategies after relapse.

Stable hematopoietic recovery after peripheral blood stem cell transplantation in patients receiving high-dose chemotherapy for advanced germ cell tumors

AIM

The objective of this study was to evaluate the utility of CD34-positive peripheral blood stem cell transplantation (PBSCT) in the hematopoietic recovery, in patients receiving high-dose chemotherapy (HDCT), for advanced germ cell tumor (GCT).

MATERIALS AND METHODS

This study included 41 patients with advanced GCT, who were treated with HTCT combined with PBSCT. PBSCs were harvested after conditioning chemotherapy followed by the administration of granulocyte colony-stimulating factor. A retrospective analysis of a total of 86 PBSCTs was carried out focusing on the effects of several factors, including age (<35 years versus > or = 35 years), CD34-positive cell dose (<5.0 x10(6)/kg versus > or =5.0 x10(6)/kg), indication of HDCT (first-line versus salvage) and previous history of HDCT before PBSCT (with versus without), on hematopoietic recovery after PBSCT.

RESULTS

The median number of CD34-positive PBSCs collected during a single apheresis and the median cumulative number of CD34-positive PBSCs from each patient were 8.3x10(6)/kg and 23.2x10(6)/kg, respectively. The median number of PBSCT performed in each patient was two and the median number of CD34-positive cells transplanted during a single course was 5.7x10(6)/kg. The median recovery times to white blood cells (WBC) greater than 500/microl, 1000/microl and 2000/microl were 8, 9 and 10 days, respectively, following PBSCT, while that to neutrophils greater than 500/microl and that to platelets greater than 50000/microl were 9 and 13 days, respectively, following PBSCT Only the recovery time to platelet count greater than 50000/microl was significantly affected by age; however, there were no significant differences in the recovery of WBC, neutrophils and platelets in relation to several parameters examined.

CONCLUSION

These findings suggest that CD34-positive PBSCT may facilitate stable hematopoietic recovery after HDCT in patients with advanced GCT, and that HDCT, if combined with PBSCT, could be performed with comparative safety in such patients, irrespective of their individual characteristics.

Testicular Cancer

An estimated 8250 new cases of testicular cancer will be diagnosed in the United States in 2006, with germ cell tumors (GCTs) constituting 95% of the malignant tumors arising in the testes. Although GCTs are relatively uncommon tumors, they are the most common solid tumor in men between the ages of 15 and 34 years. The worldwide incidence of these tumors has more than doubled in the past 40 years. More than 90% of all patients diagnosed with GCTs are cured, including 70% to 80% of patients with advanced tumors who are treated with chemotherapy. Standard therapy has been established at essentially all stages of management and must be closely followed to ensure the potential for cure.

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Spontaneous Regression of Testicular Germ Cell Tumors

Spontaneous regression of testicular germ cell tumors (GCTs) is a well-recognized phenomenon but has been incompletely characterized. Many pathologists are not familiar with the findings that support a diagnosis of a "burnt-out" primary in a patient with metastatic GCT. We therefore report the clinical, gross, and histologic findings in 42 cases of testicular GCT that showed either complete (26) or greater than 50% scarring (16). Thirty-seven patients (88%) had either known GCT metastasis or some residual testicular GCT, and none had treatment before orchiectomy. The patients were 17 to 67 years old, with a median of 32. Thirty presented with symptoms of metastasis, 7 with a testicular mass, 2 with elevated human chronic gonadotropin, and 1 with testicular pain. In 2 patients the presentation was unknown. Two patients had prior orchiopexy; another had an intraabdominal testis, and 2 others had prior contralateral seminoma (20 and 42 years previously). Gross descriptions in 37 cases identified white to tan scars, 0.6 to 2.4 cm, in 33. These were circumscribed in 16, with 15 of these having nodular or multinodular configurations and 1 a band-like appearance. In 9 cases the scar was ill defined or stellate, and in 8 cases no further details concerning the scar configuration were available. In 4 cases no scar was apparent; 2 of these had received intraoperative biopsy. Microscopically, all cases showed circumscribed to irregular foci of scarring, distinct from the adjacent parenchyma, in association with widespread testicular atrophy. Other common features were lymphoplasmacytic infiltrates in the scars (37/42) and "ghost" tubules in scars (31/42). Less common features in the scars included angiomatous foci (22/42), siderophages (15/42), and coarse intratubular calcifications (6/42); in the surrounding testis they included intratubular germ cell neoplasia, unclassified (IGCNU) (22/42), Leydig cell prominence (18/42), and necrosis (5/42). Tubular microliths occurred in 13 cases, 12 peripheral to the scar and 1 within it. Metastases in 31 cases were: pure seminoma (17, 3 with residual testicular seminoma), mixed GCT with seminoma (4, 3 with residual testicular seminoma), mixed nonseminomatous GCT (4, 3 with residual testicular GCT), pure embryonal carcinoma (2), pure teratoma (2, 1 with residual testicular teratoma), and pure yolk sac tumor (2). In 5 cases with clinically diagnosed metastases, there was no histologic documentation of the nature of the metastatic tumor. Testicular tumors in the remaining 6 cases having residual primaries without concomitant metastases were pure seminoma (3), mixed GCT with seminoma (2), and pure embryonal carcinoma (1). The most specific histologic findings of a regressed GCT are a distinct scar in association with either IGCNU or coarse intratubular calcifications; however, many cases lack the latter 2 features. In such cases additional features supportive of regressed GCT include testicular atrophy, microlithiasis and, in the scar, lymphoplasmacytic infiltrates and prominent vascularity. Ghost tubules in many scars are not evidence of a non-neoplastic process but likely reflect regression of tumors with intertubular growth. Intertubular growth is a common finding in seminoma, which is the single most frequent type of regressed GCT, occurring either in pure or mixed form in the metastases of 68% (21/31) of the cases and identifiable in 62% (10/16) of persistent testicular tumors. We conclude that regression of testicular GCTs shows a distinctive constellation of findings that usually permits its recognition. In contrast, nonspecific atrophy lacks distinct scars, and scars from non-neoplastic causes lack most of the associated findings seen in our cases.

Retroperitoneal metastatic squamous cell carcinoma of the tonsil (with elevated beta human chorionic gonadotrophin): a misdiagnosis as extra-gonadal germ cell tumour

Head and neck cancers usually spread first to the regional lymph nodes but rarely may metastasize to distant sites. Metastasis to distant lymph node groups is a rare event. Furthermore, delayed multiple metastases without local recurrence is relatively uncommon. A case of retroperitoneal metastasis from a squamous cell carcinoma of the tonsil, secreting beta human chorionic gonadotrophin (beta-hCG), is reported. A 58-year-old man had undergone a tonsillectomy and chemo-radiotherapy for squamous cell carcinoma of the left tonsil and 13 months later presented with non-specific abdominal pain. The serum beta-hCG levels were high and an abdominal ultrasound scan revealed hydronephrosis on the left side. A computed tomography scan demonstrated para-aortic retroperitoneal lymphadenopathy. The patient underwent an open lymph node biopsy. The initial pathological analysis was interpreted as extra-gonadal germ cell tumour and the patient received chemotherapy. A subsequent review was consistent with a metastatic squamous cell carcinoma of the tonsil, as immunohistochemical studies showed positive staining for epithelial membrane antigen and cytokeratins 5/6 but a negative reaction to placental alkaline phosphatase. Following this, the chemotherapy regimen was changed; however, a restaging scan demonstrated progression, and the patient died from aspiration pneumonia secondary to alcohol intoxication. To our knowledge, this is the first reported case of retroperitoneal metastasis from a squamous cell carcinoma of the tonsil, secreting beta-hCG and causing hydronephrosis. This case highlights the necessity of using clinical, histological, immunohistological and ultrastructural examination to establish precise diagnosis and to avoid inappropriate treatment.

[Antibodies to stuctural proteins of endogenous retrovirus of the HERV-K/HTDV family as markers of human germ cell tumors]

Human germ cell tumors (GCT) have been found to be closely associated with the expression of HERV-K/HTDV proviruses and most patients with GCT produce antibodies to the major HERV-K/HTDV Gag and Env proteins. The findings have shown a strong association of the level of HERV-K/HTDV antibodies with the clinical course of the disease and therapy success, which makes it possible to confirm the fact that viral protein antibodies may be used as an additional marker of GCT.