Detection of unknown occult primary tumors using positron emission tomography

BACKGROUND

The potential of positron emission tomography (PET) with 18F-fluoro-2-deoxy-D-glucose (FDG) to detect primary tumors after unsuccessful conventional diagnostic workup was assessed in patients with metastatic disease from an unknown primary tumor.

METHODS

Twenty-nine patients with various histologic types of metastases from an unknown primary site were studied after unsuccessful conventional diagnostic workup. The patients received 370 megabecquerels (MBq) (10 millicuries) FDG intravenously and whole body scans were made after 30 minutes after injection onward.

RESULTS

All but one known metastatic tumor sites were visualized. Additional metastases were discovered in five patients. With FDG-PET the primary tumor was identified in 7 patients (24%): in 2 patients with carcinoma of the nasopharynx, in 1 patient with plasmacytoma of the base of the tongue, in 1 patient with carcinoma of the lung, in 1 patient with carcinoma of the colon, and in 2 patients with breast carcinoma. FDG-PET did not identify a primary tumor in the remaining 22 patients (76%). Despite a negative PET study, the primary lesion was identified in a later phase in 3 of these patients (14%). Survival was not altered by discovery of the primary tumor.

CONCLUSIONS

A previously unknown primary tumor was able to be identified with FDG-PET in 7 of 29 patients after an unsuccessful conventional diagnostic workup. However, the clinical relevance of PET information in this setting is limited.

Feasibility and efficacy of external beam radiotherapy after hyperthermic isolated limb perfusion with TNF-alpha and melphalan for limb-saving treatment in locally advanced extremity soft-tissue sarcoma

PURPOSE

Hyperthermic isolated limb perfusion (HILP) with tumor necrosis factor-alpha (TNF-alpha), interferon-gamma (IFN-gamma), and melphalan is associated with a dramatic antitumor effect in locally advanced extremity soft-tissue sarcomas (STS). The aim of this study was to demonstrate the feasibility and efficacy of adjuvant radiotherapy after HILP with TNF-alpha, IFN-gamma, and melphalan and delayed surgical resection.

METHODS AND MATERIALS

Between 1991 and 1995, 34 patients--16 males and 18 females, median age 50 (range 18-80) years--underwent HILP for locally advanced extremity STS. Resection of the residual tumor mass was performed in most patients after 6-8 weeks. Fifteen patients with histopathological viable tumor after resection received adjuvant 60-70 Gy external beam radiotherapy (EBRT) (44%, HILP + EBRT group). Nineteen patients received HILP without adjuvant EBRT (56%, HILP-only group). Five patients in the HILP-only group had also distant metastases (15%) and received HILP as a palliative treatment. Treatment morbidity, local recurrences, and regional and distant metastases were scored.

RESULTS

During a median follow-up of 34 months (range 8-54), limb salvage was achieved in 29 patients (85%): 14 patients after HILP + EBRT and 15 patients after HILP only. None of the patients from the HILP + EBRT group developed local recurrences; however, five patients from the HILP-only did (26%) (p < 0.05). Regional metastases were observed in one patient from the HILP + EBRT group (7%) and in two patients from the HILP-only group who were treated with curative intent (14%). Distant metastases occurred in four patients after HILP + EBRT (27%) and in four patients after HILP only with curative intent (29%). The mean morbidity (subjective, objective, medical management, and analytical evaluation) score in both groups was, respectively, 0.33 for skin and subcutaneous tissue and for muscle and soft tissue, 0.34 (HILP + EBRT group) and 0.33 (HILP-only group).

CONCLUSION

Adjuvant EBRT after HILP with TNF-alpha, IFN-gamma, and melphalan and delayed tumor resection of locally advanced extremity STS is feasible and may increase local tumor control without increasing treatment morbidity.

Induction of tumor necrosis factor-alpha as a cause of bleomycin-related toxicity

BACKGROUND

The application of bleomycin is characterized by acute side effects, such as fever, chills, and sometimes hypotension and tachypnea. Furthermore, bleomycin is known to induce pneumonitis. There are several indications that the induction of cytokines by bleomycin is involved in the development of these side effects.

METHODS

In this study, the authors determined the plasma levels of tumor necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta), and transforming growth factor-beta (TGF-beta) before and after bleomycin infusion in 14 patients treated for disseminated nonseminomatous germ cell tumor.

RESULTS

Compared with the pretreatment value, TNF-alpha was significantly increased 3, 4.5, and 24 hours after bleomycin infusion. For IL-1beta and TGF-beta, no significant alterations were observed within 24 hours after administration of bleomycin.

CONCLUSIONS

The increase in TNF-alpha after administration of bleomycin suggests a role for this cytokine in the development of the acute side effects and probably also in the occurrence of bleomycin-induced pulmonary toxicity. The involvement of IL-1beta and TGF-beta deserve further study.

External and internal hemipelvectomy for sarcomas of the pelvic girdle: consequences of limb-salvage treatment

The outcome of different limb-saving treatment modalities for pelvic girdle sarcoma is controversial. The oncological and functional results after 11 external and 10 internal hemipelvectomies and the consequences of limb-salvage treatment were studied in 21 consecutive patients with primary bone (19 patients) or soft tissue sarcoma (two patients) of the pelvic girdle. Following external hemipelvectomy, 10 patients (91%) died after a median follow-up of 1.6 years (range: 0.3-7.1). Isolated local recurrences occurred in three patients (27%), with concomitant distant failure in one (9%), while isolated distant failure occurred in six patients (55%). The rate of flap necrosis and wound infection following external hemipelvectomy were both 25%. Following internal hemipelvectomy, nine patients (90%) were alive without evidence of disease after a median follow-up of 6.6 years (range: 2.3-16.0). Concomitant local and distant failures were found in one patient (10%). Reconstruction-related complications necessitated revisional procedures in five of seven patients (72%), leading to external hemipelvectomy in one. Patients with a locally advanced pelvic girdle sarcoma who are unable to undergo an internal hemipelvectomy have a worse prognosis than patients who undergo an internal hemipelvectomy. An internal hemipelvectomy is not attended by an increased risk of local failure, but is by long-term local complications, requiring extensive surgical procedures.

Comparison of the chromosomal pattern of primary testicular nonseminomas and residual mature teratomas after chemotherapy

About 70 to 75% of patients with nonseminomatous testicular germ cell tumors (NSs) present with metastases. When these metastases are treated with chemotherapy, often residual mature teratoma (RMT) is left. RMT is composed of fully differentiated somatic tissue. Untreated metastases of NSs rarely consist exclusively of mature somatic tissue. Apparently, after chemotherapy treatment there is a shift towards higher degrees of differentiation. Investigating tumor progression and the mechanism(s) involved in therapy-related differentiation, we compared the cytogenetically abnormal karyotypes of a series of 70 NSs with those of 31 RMTs. In NSs and RMTs, the modal total chromosome number does not differ and is in the triploid range. Both the frequency and the average copy number of i(12p) are the same, and the pattern of chromosomal over- and underrepresentation and distribution of breakpoints do not differ significantly in these series. So, we found the chromosomal pattern of RMTs as abnormal as those of primary NSs. Based on cytogenetics, we found no indication that specific chromosomal alterations parallel metastasis and therapy-related differentiation of the metastases. The cytogenetic data suggest that both induction of differentiation of (selected) cells or selection of cells with capacity to differentiate are possible mechanisms for the therapy-related differentiation of RMTs.

Isolation limb perfusion with tumor necrosis factor alpha and chemotherapy for advanced extremity soft tissue sarcomas

The unique property of high dose recombinant tumor necrosis factor alpha (rTNF alpha) is to activate and selectively destroy the tumor-associated microvasculature. For the systemic application of rTNF alpha it has been shown that the maximum tolerated dose (MTD) is 10 times less than the effective dose in animals. The main toxicity corresponds to systemic inflammatory response syndrome with a decrease in vascular resistance and hypotension. We found that it is possible to administer rTNF alpha at 10 times the MTD in an isolated limb perfusion (ILP) system with heart-lung machine, for locally advanced extremity soft tissue sarcomas. One hundred forty patients received an ILP with high-dose TNF alpha. In 55 patients treated with the combination of high-dose rTNF alpha + interferon-gamma + melphalan an overall objective response rate of 87% with 36% complete responses was observed; it was 81% and 28%, respectively, in a group treated with TNF alpha and melphalan (n = 85). Angiographic and immunohistological studies showed the selective and early damage of the sarcoma-associated microvasculature preceded by the upregulation of adhesion molecules and intratumoral leak of von Willebrand factor. Tumor invasion by platelets and, in some cases, by polymorphonuclear cells, appeared within hours after the application of rTNFa long before the lysis of the tumor. Thus, ILP with high-dose TNF alpha and chemotherapy seems to act through a dual targeting: TNF hits the tumor associated vasculature, and chemotherapy attacks the tumor cells. Therefore, ILP with TNF is a new option in the management of locally advanced soft tissue sarcoma of the extremities.

Sexual functioning after multimodality treatment for disseminated nonseminomatous testicular germ cell tumor

PURPOSE

We determined sexual functioning after chemotherapy for disseminated nonseminomatous testicular germ cell tumor, and evaluated the impact of resection of post-chemotherapy residual retroperitoneal tumor.

MATERIALS AND METHODS

A total of 155 consecutive patients treated with chemotherapy for disseminated nonseminomatous testicular germ cell tumor (between 1980 and 1994) was questioned about their sexual functioning. The patients were divided in 2 subgroups: patients treated with or without resection of post-chemotherapy residual retroperitoneal tumor. Volume and location (divided into left para-aortal or right paracaval/interaortacaval) of the resected tumor were related to absence of ejaculation as well as decreased semen amount. In addition, libido, arousal, erection and orgasm were related to ejaculatory dysfunction.

RESULTS

A total of 43 patients (27.7%) was treated with chemotherapy only and 112 (72.3%) had additional resection of post-chemotherapy residual retroperitoneal tumor mass. Overall, 22.4% reported loss of libido, 14.1% decreased arousal, 16% erectile dysfunction, 23.1% decreased orgasmic intensity, 17.4% decreased semen amount and 18.7% complete absence of antegrade ejaculation. With exception of absence of ejaculation, sexual dysfunctions were reported in similar frequencies in both treatment subgroups. In the resection of post-chemotherapy residual retroperitoneal tumor subgroup, 25.9% of the patients had complete absence of ejaculation. The other sexual dysfunctions were related neither to decreased semen amount nor to complete absence of ejaculation. The mean volume of resected tumor was higher (95 cm.3) in patients with absence of ejaculation than in those without (40 cm.3), and patients with right paracaval/interaortacaval tumor (20 of 58, 34.5%) reported more often absence of ejaculation than those with left para-aortal tumor (9 of 54, 16.7%).

CONCLUSIONS

In patients treated for disseminated nonseminomatous testicular germ cell tumor, post-chemotherapy sexual morbidity cannot be neglected. Except for loss of antegrade ejaculation, sexual dysfunctions are not related to resection of post-chemotherapy residual retroperitoneal mass. A high volume of tumor and a right paracaval/interaortacaval location predispose to loss of antegrade ejaculation.

Thoracotomy for postchemotherapy resection of pulmonary residual tumor mass in patients with nonseminomatous testicular germ cell tumors: aggressive surgical resection is justified

In patients with disseminated nonseminomatous testicular germ cell tumors (NSTGCT), a retroperitoneal residual tumor mass (RRTM) and/or a pulmonary residual tumor mass (PRTM) are often present after successful treatment with cisplatin-based polychemotherapy. Results and complications of postchemotherapy resection of PRTM were studied and survival was calculated. In the period 1979 to 1996, 31 patients with a median age of 28 years (range, 17 to 44 years) underwent 32 thoracotomies for the resection of a PRTM. A solitary lesion was encountered nine times (28.1%) and multiple lesions were encountered 23 times (71.9%). The median size was 15 mm (range, 2 to 60 mm). There were only three major postoperative complications (9.6%): prolonged ventilation, pneumothorax, and pneumonia. In 16 patients (51.6%), the resected PRTM showed mature teratoma, while in four patients (12.9%) it showed viable cancer. In 11 patients only necrosis and/or fibrosis were found (35.5%). Resection of an RRTM had been performed prior to thoracotomy in 20 patients. There was dissimilarity between the histologic features of the resected RRTM and PRTM in 10 of the 20 patients (50%). During a median follow-up of 80 months (range, 2.5 to 203 months), five patients died from metastatic disease (16.1%). The 5-year survival rate was 86.8% and the 10-year survival rate was 82.2%. Owing to the dissimilarity between the histologic features of the postchemotherapy resected RRTM and PRTM in 50% of the patients, all sites of pulmonary residual disease must be resected in patients with disseminated NSTGCT, irrespective of the histologic features of previously resected retroperitoneal residual disease. This approach offers minimal morbidity and a high 10-year survival rate.

Residual masses after chemotherapy for metastatic testicular cancer: the clinical implications of the association between retroperitoneal and pulmonary histology. Re-analysis of Histology in Testicular Cancer (ReHiT) Study Group

PURPOSE

We determined the need and sequence of retroperitoneal lymph node dissection and thoracotomy in patients with nonseminomatous testicular cancer, and with residual retroperitoneal and pulmonary masses after chemotherapy.

MATERIALS AND METHODS

We studied 159 patients undergoing retroperitoneal lymph node dissection and a thoracotomy following cisplatin based induction chemotherapy for metastatic testicular nonseminomatous germ cell tumor. Several well-known predictors for residual histology (necrosis, mature teratoma and cancer) were evaluated.

RESULTS

As expected, necrosis was found more often at retroperitoneal lymph node dissection if the primary tumor was negative for teratoma, the residual mass was small or the decrease in size was great. Contrary, neither residual mass size nor the decrease in size was predictive of the histological status of the residual lung lesion. Histological findings in the retroperitoneum and lung were strongly correlated, such that necrosis at retroperitoneal lymph node dissection was associated with an 89% probability of necrosis in the lung.

CONCLUSIONS

Retroperitoneal lymph node dissection should be performed before thoracotomy is considered, since the histological status at dissection is a strong predictor of that at thoracotomy.

Sexual functioning after treatment for testicular cancer: comparison of treatment modalities

BACKGROUND

This retrospective study evaluates changes in sexual functioning after treatment for testicular cancer and investigates whether there is a relationship with different treatment modalities.

METHODS

A self-reported questionnaire was sent to 337 men who had been treated for testicular cancer at the University Hospital Groningen between 1977 and 1994. Medical information was obtained from the patient records.

RESULTS

A response was received from 287 men (85%); 264 patients were included in this study (78%). The mean patient age at follow-up was 37.7 years (range, 17-71 years). The mean follow-up period was 6.7 years (range, 0.25-18 years). Decrease in sexual functions was reported by 40% of patients (decrease in libido: 19%; arousal: 12% erection: 12.5%; orgasm: 19%; and ejaculation: 26%). Moreover, 23.5% of patients responding reported decreased sexual activity and 12.5% were dissatisfied with their sexual functioning. Patients with Stage II-IV nonseminoma who had been treated with polychemotherapy (PCT) with or without resection of residual retroperitoneal tumor mass (RRRTM) (PCT +/- RRRTM) reported a significantly sharper decrease in sexual functioning than patients who had been followed with a wait-and-see policy (W & S) (Stage I nonseminoma patients). It was noteworthy that patients treated by PCT alone reported more sharply decreased sexual functioning than patients treated by PCT + RRRTM. Patients treated by radiotherapy (Stage I-IIA seminoma) did not report findings significantly different from the W & S group.

CONCLUSIONS

Testicular cancer patients are at risk for reduced sexual functioning, especially when treated by chemotherapy, with or without resection of residual tumor. Although chemotherapy may influence somatic aspects of sexual functioning, it appears that psychologic factors arising from the confrontation with testicular cancer play a strongly mediating (if not determining) role.

Cytogenetics of primary testicular nonseminoma, residual mature teratoma, and growing teratoma lesion in individual patients

Residual mature teratoma (RMT) is often left behind when metastases of primary nonseminomatous germ cell tumors (NSs) are treated with chemotherapy. RMT is composed of fully differentiated somatic tissue. A growing teratoma (GTE) lesion may occur after (incomplete) resection of RMT. To shed light on tumor progression or the mechanism(s) of therapy related differentiation we investigated the chromosomal pattern of the primary NSs and RMTs in twelve patients, of the primary NS, RMT, and GTE lesion in one patient, and of the RMT and GTE lesion in two patients. Although several chromosomal differences are observed between the RMT and NSs and between the GTE and RMTs in the same patient, we obtained no evidence that specific chromosomal alteration(s) play a role in metastasis or differentiation.

Importance of a new tumor marker TRA-1-60 in the follow-up of patients with clinical stage I nonseminomatous testicular germ cell tumors

BACKGROUND

TRA-1-60 is a new tumor marker for embryonal carcinoma-positive nonseminomatous testicular germ cell tumors (NSTGCT). Upper normal reference value (RV) and serum half-life (t1/2) were determined. The value was determined in the follow-up of 154 patients with stage I NSTGCT.

METHODS

TRA-1-60 was measured in normal controls (n = 100) to determine RV and in patients without recurrence for t1/2. In all patients, TRA-1-60 was determined at the time of orchidectomy. In 42 patients with recurrence, values were also evaluated 1 month before and at the time of computed tomography-confirmed recurrence. Predictive values and survival probability were examined and compared with values for alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG).

RESULTS

RV was 230 U/ml and t1/2 9.5 days. Elevated TRA-1-60 at the time of orchidectomy was not associated with recurrence. One month before recurrence, 21 of 42 patients had elevated TRA-1-60 levels (50%); 10 were negative for both AFP and hCG. At the time of recurrence, 24 patients had elevated TRA-1-60 levels (57.1%): 9 were negative for AFP/hCG. Patients with TRA-1-60 levels of > 500 U/ml had a poorer recurrence-free survival probability (p = 0.015).

CONCLUSIONS

TRA-1-60 is useful in the follow-up of stage 1 NSTGCT. The combination of AFP, hCG, and TRA-1-60 may improve the early detection of recurrence.

Sexual dysfunction in nonseminoma testicular cancer patients is related to chemotherapy-induced angiopathy

PURPOSE

To establish the prevalence of sexual dysfunctions after different treatment modalities for nonseminomatous testicular germ cell tumor (NSTGCT) and to investigate whether treatment-induced angiopathy and neuropathy is related to sexual dysfunction.

PATIENTS AND METHODS

A questionnaire assessing sexual dysfunction was sent to 255 NSTGCT survivors. Polychemotherapy (PCT) regimens (cisplatin, vinblastine, and bleomycin [PVB], vinblastine substituted by etoposide [BEP], or cisplatin substituted by carboplatin [CEB], etoposide combined with cisplatin [EP], or with ifosfamide and cisplatin [VIP] were compared regarding treatment-induced angiopathy and neuropathy. Sexual dysfunctions were related to Raynaud's phenomenon and acral paresthesia.

RESULTS

Among the 215 responders, 56 (26%) had been treated by orchidectomy and surveillance, 42 (19.6%) by PCT, and 117 (54.4%) by PCT and resection of residual retroperitoneal tumor mass (RRRTM). Overall, loss of libido was reported by 19.1%, decreased arousal by 11.2%, erectile dysfunction by 12.1%, decreased intensity of orgasm by 20%, and ejaculatory problems by 28%. Patients treated with PVB suffered more often from Raynaud's phenomenon compared with those treated with other regimens (40.4% v 29%; P < .05) and from paresthesia (31.6% v 14.7%; P < .05). Patients with Raynaud's phenomenon had more often erectile dysfunction (28.8%) compared with those without (8.4%) (P < .05).

CONCLUSION

Compared with orchidectomy alone, PCT, with or without RRRTM, induced more often posttreatment sexual dysfunction. Compared with other chemotherapeutic regimens, signs of angiopathy and neuropathy were most prevalent in those treated with PVB. Erectile dysfunction was related to the chemotherapy-induced Raynaud's phenomenon but not to acral paresthesia.

Cisplatin-based chemotherapy changes the incidence of bilateral testicular cancer

BACKGROUND

The introduction of cisplatin-based chemotherapy has remarkably increased the survival of testicular cancer patients. With this success, the concern for a contralateral testicular tumor has increased. The aim of this study was to investigate whether the risk for contralateral testicular tumor development was influenced by cisplatin-based chemotherapy.

METHODS

The incidence of a contralateral testicular tumor among 365 consecutive patients with a nonseminoma testicular tumor, diagnosed in the period 1980 and 1995, was established and related to previous therapy.

RESULTS

Eleven of 365 men (3%) developed a contralateral testicular tumor. After a total of 2403 person-years at risk, 4 of 225 chemotherapy-treated patients (1.8%) developed a contralateral testicular tumor, and 7 of 140 patients (5%) treated with orchidectomy alone developed a contralateral tumor. In comparison to this surveillance subgroup, patients previously treated with chemotherapy have a relative risk of 0.30 to develop a second testicular tumor.

CONCLUSIONS

In Dutch men with a nonseminoma testicular tumor, the incidence of a contralateral testicular tumor is 3%, which is 60-fold the expected incidence rate of testicular cancer. A three times lower incidence rate of a contralateral testicular tumor was found in the chemotherapy subgroup compared with those on surveillance. This supports the hypothesis that cisplatin-based chemotherapy may eradicate carcinoma in situ or early testicular cancer.

First clinical experience with a noninvasively extendable endoprosthesis: a limb-saving procedure in children suffering from a malignant bone tumor

A modular endoprosthetic system that can be extended noninvasively has been applied for the first time in a growing child who underwent a tumor resection in his leg. The main goal of the study was to test the extendable mechanism that noninvasively corrects leg length differences caused by growth disturbances of the affected leg. The use of this endoprosthetic system resulted in good restoration of function. Six extensions were performed resulting in 19.5 mm of prosthetic growth. Unfortunately, an ingrown toenail caused infection of the endoprosthesis, and the infection necessitated extirpation of the prosthesis 15 months postoperatively. Two months later the patient died of acute leukemia. Analysis of the endoprosthesis revealed some manufacturing shortcomings, none of which impaired the function of the endoprosthesis.

Standardized uptake value and quantification of metabolism for breast cancer imaging with FDG and L-[1-11C]tyrosine PET

The aims of the study were to compare the value of L-[1-11C]tyrosine (TYR) and [IBF]fluoro-2-deoxy-D-glucose (FDG) as tumor tracers in patients with breast cancer, to investigate the correlation between quantitative values and standardized uptake values (SUVs) and to estimate the value of SUVs for the evaluation of therapy.

METHODS

Eleven patients with one or more malignant breast lesions and two patients with one or more benign breast tumors were studied with TYR and FDG. Doses of 300 MBq of TYR and 230 MBq of FDG were given intravenously. All PET sessions were performed using a Siemens ECAT 951/31 camera. Of 10 malignant tumors and the 3 benign lesions, glucose consumption and protein synthesis rate were quantified. All lesions were studied using SUVs based on body weight, body surface area and lean body mass, with and without correction for plasma glucose or tyrosine levels.

RESULTS

All malignant tumors were visualized with both FDG and TYR, but the visual contrast was better with FDG. Increased uptake of the tracers was seen in patients with fibrocystic tissue and complicated the visual assessment and the outlining of tumor tissue. Uptake in fibrocystic disease was more prominent with FDG than with TYR. No difference in tumor/nontumor ratio between the two tracers could be established. FDG showed a false-positive result in one benign lesion. No major differences between the SUVs as defined above were found, although the best correlation between glucose consumption and the SUV was observed when the SUV was based on body surface area and corrected for plasma glucose level (r = 0.85-0.87). The SUV based on lean body mass was found to correlate best with protein synthesis rate (r = 0.83-0.94).

CONCLUSION

In this group of patients, TYR appears to be a better tracer than FDG for breast cancer imaging, because of lower uptake in fibrocystic disease. SUVs correlate well with quantitative values, but future studies must determine whether treatment evaluation is also reliable with SUVs.

Effects of hyperthermic isolated limb perfusion with tumor necrosis factor-alpha and melphalan on pulmonary function assessments

High doses of tumor necrosis factor-alpha (TNF) seem to be effective in the treatment of solid tumors in the extremities. By applying current intensive care technology, systemic administration of high doses of TNF levels might be feasible for the treatment of cancer in other localizations. To establish the early and late effects of high systemic TNF levels on the lungs, we determined lung function parameters in 12 patients before and after hyperthermic isolated limb perfusion (HILP) with TNF and melphalan. Because of leakage during perfusion, mean maximum systemic TNF levels of 60.0 ng/ml (range, 0.3-356 ng/ml) were obtained. Significant alterations in the vital capacity (VC), the capillary blood volume (Vc), the diffusing capacity of the alveolocapillary membrane (Dm), and the transfer capacity of the lungs for carbon monoxide per unit alveolar volume (KCO) were observed 1 week after HILP. Eight weeks after HILP, they returned to pretreatment value. Alterations in lung functions were not related to the maximum systemic TNF level. In conclusion, disturbances in pulmonary functions are observed in patients after HILP with TNF and melphalan. These disturbances, which are probably partly caused by high systemic TNF levels, are reversible and would not preclude administration of systemic TNF in high doses.

Sexual functioning in testosterone-supplemented patients treated for bilateral testicular cancer

OBJECTIVE

To determine the effects of intramuscular injections with testosterone (Sustanon) on sex-hormone levels, sexual functioning and general well-being in patients treated with orchidectomy for bilateral testicular cancer.

PATIENTS AND METHODS

The study comprised seven men (median age 38 years, range 25-46) who had undergone orchidectomy for bilateral testicular cancer. Patients received intramuscular injections with testosterone every 3 weeks and blood samples for hormone analysis were collected from each patient at three times: one day after testosterone injection (t1), halfway between subsequent injections (t2) and just before injection (t3). Plasma hormone levels were then related to sexual function, as assessed by self-reported data on sexuality and general well-being, measurements of nocturnal penile tumescence and rigidity (NPTR) and erectile function elicited by visual erotic stimulation (VES), determined at t1, t2 and t3.

RESULTS

During the 3-week interval between injections, there was a sixfold decrease in plasma testosterone level (mean testosterone 35.8, SD 7.8, and 6.0, SD 2.5 nmol/L, at t1 and t3, respectively). At t1, five of the men had a plasma testosterone level above the upper normal limit (> 35 nmol/L) and at t2 and t3, testosterone levels were below the reference range (< 10 nmol/L) in three and six men, respectively. Oestradiol (E2) levels showed the same pattern: at t1 the mean (SD) E2 level was 0.17 (0.07) nmol/L and at t3 0.07 (0.01) nmol/L. In contrast to follicle-stimulating hormone, luteinizing hormone (LH) mirrored the decline in plasma testosterone after injection, with the lowest levels at t1 and the highest at t3. Other hormone levels remained unchanged. Three patients reported loss of libido, decreased arousal, erectile dysfunction, fatigue and mood depression. However, neither the arousal nor the erectile problems could be verified by VES. There was no relationship between plasma testosterone levels, the reported sexual dysfunctions and the results of NPTR and VES measurements. Although unrelated to a specific testosterone level, three patients reported increased irritability, excessive sweating, hot flushes and heat intolerance at the end of the injection interval. These adverse effects of declining plasma testosterone were related to loss of libido and other sexual problems.

CONCLUSION

In most patients castrated for bilateral testicular cancer and receiving intramuscular injections with testosterone, plasma testosterone levels were outside the normal range. After injection, there was a rapid decline of plasma testosterone to levels below the lower normal limit. With the exception of oestradiol, sex-hormone levels were not correlated to testosterone levels. Sexual functioning was not affected by the fluctuations of plasma testosterone level. However, at the end of the injection interval, adverse psychological and physical effects had a significant impact on libido and arousal.

Complications of the post-chemotherapy resection of retroperitoneal residual tumour mass in patients with non-seminomatous testicular germ cell tumours

OBJECTIVE

To evaluate the resection of the retroperitoneal residual tumour mass (RRTM) for histological examination after chemotherapy in patients with disseminated non-seminomatous testicular germ cell tumours (NSTGCTs), with particular attention to surgical morbidity.

PATIENTS AND METHODS

From 1979 to 1995, 112 patients (mean age 28 years, range 16-53) with NSTGCT had residual disease after chemotherapy for which surgical evaluation was indicated; the histology of the residual tumour and the surgical complications were assessed. Possible associations between the occurrence of surgical complications and the age of the patient, size of the residual tumour, operative duration, previous laparotomy and pathological findings were evaluated.

RESULTS

The median size of the residual tumour was 4 cm (range 0-18); histological examination revealed viable tumour in 9%, mature teratoma in 44% and necrosis/fibrosis in 44% of the patients. In three patients (2.8%) no residual tumour mass was found at laparotomy. There were 26 complications in 20 patients (18%); urinary tract infection was the most common, occurring in nine patients (8%). One patient died during the induction of anaesthesia. There were no significant relationships between the occurrence of complications and age, size of the residual tumour, operative duration, previous laparotomy or pathological findings.

CONCLUSION

The resection of RRTM after polychemotherapy treatment for disseminated NSTGCT is a safe surgical procedure, with low treatment morbidity consisting mainly of urinary tract infection. Knowledge of the potential complications may help to prevent morbidity. However, the surgical evaluation of the ultimate effect of polychemotherapy remains the gold standard.

PET with L-[1-carbon-11]-tyrosine to visualize tumors and measure protein synthesis rates

We studied the potential of PET with L-[1-11C]-tyrosine (TYR) to visualize tumors outside the central nervous system and to quantify their protein synthesis rates (PSRs).

METHODS

Twenty-two patients suspected of having a malignant tumor underwent a PET study with TYR before biopsy. The PSR in nanomoles per milliliter tumor tissue per minute as well as the PSR in contralateral normal tissue, standardized uptake values (SUVs) and tumor-to-nontumor-ratios (T/N ratios) were calculated.

RESULTS

Fifteen of the 16 malignancies (94%) were correctly visualized as a hot spot. A chondrosarcoma of the sacrum was not visualized. Of the six patients with benign lesions, cold spots were correctly identified in four (67%). A benign schwannoma and an intramuscular hemangioma of the forearm were visualized as hot spots. PSR in tumor tissue was higher than in the corresponding contralateral normal tissues. PSR and SUV in malignant tumors were higher than in benign tumors.

CONCLUSION

TYR appears to be a good tracer for imaging malignancies. The PSR, which was higher in malignant tumors than in normal tissue and the studied benign lesions, could be quantified and correlated with the SUV.

Residual pulmonary masses after chemotherapy for metastatic nonseminomatous germ cell tumor. Prediction of histology. ReHiT Study Group

BACKGROUND

After chemotherapy for a metastatic nonseminomatous germ cell tumor, pulmonary masses may be seen on a computed tomography scan. These residual masses may contain one of three histologic elements: necrosis, mature teratoma, or cancer. Because surgical resection of masses containing only necrosis is unnecessary, the authors aimed to predict the histology of these residual masses.

METHODS

Six study groups contributed patient data on a total of 215 patients undergoing thoracotomy after cisplatin-based induction chemotherapy for metastatic testicular nonseminomatous germ cell tumors. Logistic regression analysis was used to estimate the probability of necrosis, mature teratoma, and cancer in relation to predictors known before thoracotomy.

RESULTS

The pulmonary mass histology was necrosis in 116 patients (54%), mature teratoma in 70 (33%), and cancer in 29 (13%). Necrosis was found at thoracotomy in 89% of those patients with necrosis at retroperitoneal lymph node dissection (RPLND). Other predictors included the primary tumor histology, prechemotherapy tumor marker levels, change in mass size during chemotherapy, and the presence of a single, unilateral mass. Multivariate combination of predictors yielded reliable models (goodness-of-fit tests, P > 0.20), which discriminated necrosis well from other histologies, especially if RPLND histology was available (area under the receiver operating characteristic curve, 0.86).

CONCLUSIONS

This analysis indicated subgroups of patients with a high probability of necrosis and a low risk of cancer for whom close follow-up of the residual pulmonary mass might be considered. In most patients, a RPLND should be performed before a thoracotomy is considered, because the probability of necrosis is generally higher at thoracotomy than at RPLND and the histology at RPLND is a strong predictor of the histology at thoracotomy.

Aneurysmal bone cysts treated by curettage, cryotherapy and bone grafting

We treated 26 patients with 27 aneurysmal bone cysts by curettage and cryotherapy and evaluated local tumour control, complications and functional outcome. The mean follow-up time was 47 months (19 to 154). There was local recurrence in one patient. Two patients developed deep wound infections and one had a postoperative fracture. We compared our results with previous reports in which several different methods of treatment had been used and concluded that curettage with adjuvant cryotherapy had similar results to those of marginal resection, and that no major bony reconstruction was required. We recommend the use of cryotherapy as an adjuvant to the surgical treatment of aneurysmal bone cysts. It provides local tumour control. Combination with bone grafting achieved consolidation of the lesion in all our patients.

Angiographic response of locally advanced soft-tissue sarcoma following hyperthermic isolated limb perfusion with tumor necrosis factor

BACKGROUND

Hyperthermic isolated limb perfusion (HILP) with tumor necrosis factor-alpha (TNF-alpha), interferon-gamma (IFN-gamma), and melphalan is associated with a dramatic anti-tumor effect in which the neo-vascularization of the tumor is supposed to be the major target. The aim of the present study was to correlate the angiographic findings with the pathological response in patients undergoing HILP for locally advanced soft-tissue sarcoma.

PATIENTS AND METHODS

Twenty-five patients, 14 male and 11 female, mean age 47 years (range 18-80) were studied. Angiographies were performed before and a median period of 7 weeks (range 4-14 weeks) after HILP. Eight weeks after perfusion, the residual tumor mass was resected and pathologically examined. The changes in tumor vascularization after treatment were scored and compared with the pathological response.

RESULTS

All baseline angiograms showed a hypervascular tumor. After HILP, a normal angiography result (NA) was observed in 18 patients (72%) and an abnormal angiography result (AA) was observed in seven patients (28%). All patients with an NA showed a pathologically complete response (pCR) or a pathological partial response with > 90% necrosis of the tumor. Of seven patients with an AA, pathological examination showed a pCR in one patient, 10-50% viable tumor volume in four patients, and no pathological response after perfusion in two patients. A good correlation was seen between angiographic and pathological classification (p < 0.001).

CONCLUSION

An angiography performed after hyperthermic isolated limb perfusion with TNF-alpha and melphalan provides a good indication, regardless of whether a good pathological response is expected.

Detection of local recurrence of soft-tissue sarcoma with positron emission tomography using [18F]fluorodeoxyglucose

BACKGROUND

It is often difficult to detect a local recurrence of soft-tissue sarcomas due to disturbance of the normal anatomy by previous surgery and radiotherapy. The aim of this study was to assess the value of positron emission tomography (PET) with [18F]fluoro-2-deoxy-D-glucose (FDG) for detecting local recurrences.

METHODS

In the period 1992-1995, 17 patients with proven or suspected local recurrence of soft-tissue sarcoma were examined using FDG-PET. Fifteen of these patients were ultimately proven to have a recurrence.

RESULTS

Recurrence was visualized in 14 patients (93%). Small tumors (maximum diameter 0.5 cm) were as easily visible as large lesions (maximum diameter 20 cm). In one patient the PET scan was positive, but the recurrence could not be proven histologically. Recurrence was proven 1 year later. A recurrent low-grade liposarcoma was not visualized. The two patients with benign lesions had a negative PET scan. The mean glucose metabolic rate was calculated to be 13.2 mumol/100 g/min (range 1.9-28.4). A correlation was found between the histological malignancy grade and the metabolic rate (p < 0.05; Kruskal-Wallis).

CONCLUSION

PET with FDG is a useful addition to the diagnostic armamentarium for detecting local recurrence of soft-tissue sarcomas and provides an indication of the malignancy grade of the recurrent lesion.