Pathologic findings and therapeutic outcome of desperation post-chemotherapy retroperitoneal lymph node dissection in advanced germ cell cancer

Increased serum tumor markers after cisplatin-based chemotherapy have usually been considered a contraindication to surgery because of the presence of persistent active germ cell elements. However, a select population of patients with elevated serum tumor markers have undergone post-chemotherapy retroperitoneal lymph node dissection (RPLND) with curative intent. We evaluated the role of surgery to resect retroperitoneal-only marker positive tumor. Long-term survival was observed in 50% of patients. Residual germ cell cancer was identified in 50% of patients, with a third alive at 5 years with no observed benefit from adjuvant chemotherapy. Select patients with increased tumor markers after chemotherapy are cured with surgery.

Significance of elevated preoperative α-fetoprotein in postchemotherapy residual tumor resection for the disseminated germ cell tumors

BACKGROUND AND OBJECTIVES

The purpose of the study is to determine the significance of elevated serum alpha-fetoprotein (AFP) in the setting prior to residual tumor resection (RTR) following chemotherapy for metastatic germ cell tumor in terms of the prediction of histology of the specimen and postoperative survival.

METHODS

We conducted a retrospective review of 68 patients undergoing RTR for metastatic nonseminomatous germ cell tumor or extragonadal germ cell tumor after at least a first-line chemotherapy. Pretreatment and postchemotherapy serum markers were evaluated in association with other clinical findings including results of pathological examination of RTR specimen and surgical outcome.

RESULTS

Of the 68 study patients, 54 (79%) and 45 (66%) had positive AFP and beta-human chorionic gonadotropin (beta-HCG) in pretreatment settings. Rates of presence of residual malignant cell in RTR specimen were similar between patients with normal AFP (7/28 or 25%) and with mildly elevated (10-30 ng/ml) AFP (3/11 or 27%). In 26 patients who had residual viable malignancy in RTR specimen, patients with preoperative positive AFP had significantly better survival (P = 0.02) compared to those with preoperative positive beta-HCG.

CONCLUSIONS

Sole and mild elevation of AFP is not always associated with postoperative poor prognosis. It should be carefully considered individually whether a mild elevation of AFP after chemotherapy represents residual malignancy or benign pathogenesis.

Blood cells with fetal haemoglobin (F-cells) detected by immunohistochemistry as indicators of solid tumours

AIMS

Fetal hemoglobin (HbF) is an established serological indicator of cancer. However, its distribution in tumour tissues is rarely investigated. Therefore, HbF was studied immunohistologically in different cancers characterised by high blood HbF concentrations.

METHODS

Anti-HbF was immunoaffinity purified and used to study HbF immunohistochemically in the following cancers: germ cell tumour (GCT), trophoblastic disease (TD), lymphoma, myelodysplastic syndrome (MDS), multiple myeloma (MM), and ovarian adenocarcinoma (OA).

RESULTS

In GCT a distinction was made between tumours substantially without HbF positive red blood cells (F-RBC) and those with F-RBC. Those without F-RBC were non-metastatic mature teratomas and dermoid cysts. Those containing F-RBC were mainly embryonal carcinomas and metastatic teratomas. HbF positive myeloid cells (F-MLC), HbF positive normoblasts (F-NBS), and F-RBC were common in the bone marrow and in the lymphoid tissues of lymphoma, MDS, and MM. In TD, normal and nucleated F-RBC were seen in the trophoblastic villi in one case with incomplete molar pregnancy (ICM) but not in other cases of ICM and complete molar pregnancy. However, F-RBC and F-MLC were seen in the decidua of both types of TD. Generally, F-cells were observed either within blood vessels or concentrated in certain areas of the neoplastic tissue.

CONCLUSIONS

HbF was evaluated as an inducible marker within different tumour tissue blood cells. The dual distribution of these cells-circulating in the blood or concentrated in areas of the neoplastic tissues-might reflect the two independent serological indicators of HbF: one in whole blood and the other in plasma of patients with cancer.

EPIDEMIOLOGICAL AND CLINICAL BEHAVIOR OF PREPUBERTAL TESTICULAR TUMORS IN KOREA

PURPOSE

To our knowledge there is no multi-institutional report on prepubertal testicular tumors in Korea to date. We obtained demographic data for a better understanding of the biological behavior and optimal management of these tumors.

MATERIALS AND METHODS

The prepubertal testicular tumor registry form was mailed to all 87 hospitals registered in the Korean Urology Association. We retrospectively reviewed recent 5-year medical records.

RESULTS

A total of 209 patients were enrolled in this registry. The incidence was 0.98/100,000 children. Age was 1 to 142 months (median 18). Most patients were diagnosed with a scrotal mass before age 4 years. Serum alpha-fetoprotein and beta-human chorionic gonadotropin increased in as many as 62.9% and 2.7% of patients, including 94.7% and 2.2% in those with yolk sac tumor and 30.4% and 2.7% in those with teratoma, respectively. While potentially malignant tumors accounted for 52.5% of patients, the remainder were benign. Germ cell tumors were the most common (89.4% of cases), mainly with yolk sac tumor (47.8%) or teratoma (39.7%). Management after surgery included surveillance in 71.8% of cases, chemotherapy in 9.1%, combination therapy in 1.4% and other in 17.7%. Of the total patients 10.5% (5.9% of stage I yolk sac tumors) had progression to metastasis. The final results of treatment were complete remission (64.6% of cases), incomplete remission (2.9%), no response or disease progression (1.4%) and unknown (31.1%). Outcomes at the last followup (average 23.5 months) were 76.1% of patients alive, 0.9% dead and 23.0% of unknown status.

CONCLUSIONS

Demographic data on pediatric testicular tumors in Korea will lead to a better understanding of these rare tumors and to optimal therapy in these children.

Outcome of patients with residual germ cell or non-germ cell malignancy after resection of primary mediastinal nonseminomatous germ cell cancer

PURPOSE

To identify prognostic variables and outcomes in patients with primary mediastinal nonseminomatous germ cell tumor (PMNSGCT) with postchemotherapy resection of persistent cancer.

PATIENTS AND METHODS

Forty-seven consecutive patients with residual cancer after resection of PMNSGCT were retrospectively reviewed. Univariate comparisons were performed.

RESULTS

At diagnosis, 43 patients had elevated serum tumor markers (STMs), and 20 had extramediastinal disease. At resection, 21 patients had elevated STMs. After resection, 26 patients had germ cell tumors (GCT), 12 had malignant transformation of teratoma with elements of non-GCT, and nine had both GCT and non-GCT. Sixteen of 47 patients continuously have no evidence of disease (NED). This includes eight of 26 patients with GCT histology and two of 12 patients with non-GCT histology. Of 27 patients with mediastinal-only disease at presentation, 14 have continuously NED. Of 20 patients with extramediastinal disease at presentation, two have continuously NED. Seven of 21 patients with elevated STMs at time of resection have continuously NED. Sixteen patients received adjuvant chemotherapy, and seven have continuously NED. Overall, 16 of 47 patients have continuously NED, an additional four patients have NED with further therapy (currently NED), two patients are alive with disease, 23 patients died of disease, and two patients died postoperatively.

CONCLUSION

The presence of elevated STMs at resection does not appear to alter outcome if residual disease is completely resected. In this poor-risk patient population, surgical resection of persistent cancer, even in the presence of elevated STMs, can still achieve long-term survival.

Extragonadal germ cell tumors in Japan

Extragonadal germ cell tumors (EGCT) represent only 2-5% of adult germ cell malignancies. Some publications from Asia have reported inferior treatment outcomes compared to data from an international study group. To ascertain whether this is generally the case, here we analyze treatment outcomes for 30 Japanese patients with EGCT. The medical records of 30 patients (25 nonseminomas and 4 pure seminomas) treated from 1992 to 2002 were reviewed retrospectively. All patients with seminoma achieved long survival except one who died of chemotherapy-related sepsis. Ten and 11 patients with EGCT presented with mediastinal and retroperitoneal primary sites, respectively. The 5-year overall survival (OS) and progression-free survival (PFS) for nonseminoma was 71% and 42%, respectively. The 5-year OS and PFS was 60% and 44%, respectively, for 10 patients with mediastinal nonseminoma, and 91% and 48%, respectively, for patients with retroperitoneal nonseminoma. Tumor marker values on day 7 were available for 19 patients. Among the 19 patients in whom AFP or beta-HCG were measured on day 7, the values had declined in 12 patients and were transiently elevated in 7 patients compared to pretreatment values. The transient elevations of tumor markers were significantly associated with poor OS (P = 0.02) and PFS (P = 0.008). The treatment outcome of Japanese patients with EGCT seemed to be comparable to that reported from international studies, suggesting no difference between ethnic groups. Transient tumor marker elevations on day 7 predict poor survival in EGCT patients and may be a useful parameter for identifying patients requiring more aggressive treatment.

Factors that influence the results of salvage surgery in patients with chemorefractory germ cell carcinomas with elevated tumor markers

BACKGROUND

A standard concept for the integration of surgery into the chemotherapy-based treatment of patients with advanced germ cell carcinoma has been that surgery should be avoided in patients with serum tumor markers (alpha-fetoprotein [AFP] and human chorionic gonadotropin [HCG]) that remain elevated. However, some patients may benefit from resection under such chemorefractory conditions. The objective of this retrospective study was to clarify the outcome and clinical prognostic variables of salvage surgery in patients with disseminated (AJCC Stage II or III) testicular germ cell carcinoma or extragonadal germ cell carcinoma who had elevated serum markers.

METHODS

The authors reviewed the clinical records of 24 patients who underwent salvage surgery with elevated serum AFP and/or HCG levels after at least 3 courses of cisplatin-based, systemic chemotherapy between January, 1985 and December, 2000. The survival rates were compared between the subgroups with regard to preoperative and postoperative clinical parameters using the Kaplan-Meier method and a Cox proportional hazards model.

RESULTS

Ten of 24 patients (41.7%) were rendered free of disease and alive without disease after the surgery with or without adjuvant therapy at a median follow-up of 74 months (range, 24-207 months). Among the preoperative parameters, high HCG levels were associated with significantly poorer survival (hazard ratio [HR], 8.321; 95% confidence interval [95% CI], 1.0753-64.553; P = 0.043 and P = 0.016, respectively; log-rank test). In addition, patients who had visceral lesions at resection had a significantly poorer prognosis compared with patients who had retroperitoneal and/or mediastinal lymph node lesions (P = 0.038; log-rank test). Among postoperative parameters, incomplete resection and persistently high HCG levels were associated significantly with poor survival, with a risk of death from disease of 12.516-fold (95% CI, 1.786-87.781) and 9.311-fold (95% CI, 1.796-48.256), respectively.

CONCLUSIONS

Salvage surgery in patients with high serum tumors markers resulted in long-term disease free status in approximately 40% of patients in a small subset with advanced germ cell carcinoma. Patients with elevated AFP levels alone (i.e., normal HCG levels) or with lymph node lesions alone seem to be good candidates for such surgery. Complete resection of target lesions and normalization of HCG levels after surgery are mandatory to achieve long-term disease free status.

Predicting factors for collection of peripheral blood stem cells in patients with advanced germ cell tumors after cisplatin-based combination chemotherapy

The objectives of this study were to identify the predictive factors for the mobilization of CD34 positive peripheral blood stem cells (PBSC) and to determine the optimal timing of PBSC harvest in patients with advanced germ cell tumors after cisplatin-based combination chemotherapy. Thirty-eight patients with advanced germ cell tumors were enrolled in this study. We undertook a retrospective analysis of 124 aphereses performed between March, 1994 and December, 1999. The predictive value for the optimal timing of PBSC harvest was determined by the analysis of the correlation factors between the number of harvested CD34 positive cells and several clinicopathological factors. The mean number of CD34 positive cells obtained at a single apheresis was 5.38 x 10(6)/kg, and the mean cumulative number of CD34 positive cells in each patient was 24.07 x 10(6)/kg. The number of CD34 positive cells were significantly correlated to the number of previously performed chemotherapies before PBSC harvest, leukocyte count and the percentage of immature leukocytes (myelocytes plus metamyelocytes) (p=0.0098, p=0.011, and p<0.0001, respectively). Multivariate analysis revealed that the number of chemotherapies and the percentage of immature leukocytes were independent predictors for the number of harvested CD34 positive cells (p=0.012 and p=0.016, respectively). The present findings suggest that PBSC harvest should be performed during first-line chemotherapy, and that the monitoring of the percentage of immature leukocytes could be a useful predictor for determining the optimal timing of PBSC harvest.

Prognostic value of tumor size, metastases, extension into bone, and increased tumor marker in children with malignant sacrococcygeal germ cell tumors: a prospective evaluation of 71 patients treated in the German cooperative protocols Maligne Keimzelltumoren (MAKEI) 83/86 and MAKEI 89

PURPOSE

To evaluate the prognostic value of metastases, extension into bone, and alpha-fetoprotein (AFP) elevation in children with malignant sacrococcygeal germ cell tumors (GCTs) prospectively collected in two cooperative Maligne Keimzelltumoren (MAKEI) protocols (83/86 and 89).

PATIENTS AND METHODS

Between October 1983 and October 1995, 76 of 210 registered patients with sacrococcygeal primaries presented either with pure yolk sac tumor, embryonal carcinoma (EC), or yolk sac tumor and EC mixed with immature and mature teratoma elements. Stages T1 and T2 disease were diagnosed in 15 and 61 children, respectively, 41 patients had metastases, and 35 children presented with extension into bone. At diagnosis, 22 children had an AFP elevation of less than 10,000 ng/mL. Thirty-six children showed an AFP level between 10,000 and 100,000 ng/mL, and 12 patients had values of greater than 100,000 ng/mL. Five patients died of complication during treatment and were excluded from further evaluation. Seventy-one patients could be analyzed.

RESULTS

The 5-year relapse-free survival rate (RFS, Kaplan-Meier) was 0.76 +/- 0.03 (54 of 71 patients; median observation time, 54 months after diagnosis). The RFS of patients with and without metastases was different, but not significantly so (0.71 v 0.82). The outcome of patients with extension into bone (n = 31) and without this extension (n = 40) was 0.71 versus 0.80 (RFS, 5 years). Above-normal AFP level had no prognostic significance (P =.52).

CONCLUSION

In children with malignant sacrococcygeal GCTs treated with an intensive, short-interval, platinum-based regimen, the stage, extent of metastases, extension into bone, and AFP level had no prognostic significance.

Serum levels of basic fibroblast growth factor reflect disseminated disease in patients with testicular germ cell tumors

The potential role of angiogenesis stimulators in the pathogenesis of different tumor entities has been confirmed in several studies. We measured the serum levels of basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF) and platelet derived growth factor (PDGF) in 51 patients with testicular germ cell tumors and in 39 healthy volunteers. Serum concentrations of bFGF, VEGF and PDGF-AB were determined by enzyme-linked immunosorbent assay. The median serum bFGF level for tumor patients was 3.46 pg/ml (range 0-61.6) compared to 0.7 pg/ml (0-11) in the control group (P<0.01). In patients with metastatic disease, the median serum bFGF level was 10.3 pg/ml (0-61.6) in contrast to 2.8 pg/ml (0-50) in patients with localized disease (P<0.01). The median serum VEGF and PDGF levels were 270 pg/ml (0-1,903) and 37,837 pg/ml (9,075-108,800), respectively, for tumor patients and 200 pg/ml (44-585) and 23,000 pg/ml (4,250-70,650) in the control group ( P<0.05). Our data suggest that angiogenesis, as reflected by serum concentrations of bFGF, VEGF and PDGF, plays a functional role in the growth and progression of testicular germ cell tumors.

The lack of long-term effect of Cisplatin based combination chemotherapy on serum cholesterol for treatment of testicular cancer

PURPOSE

Cisplatin based combination therapy is curative in most patients with advanced testicular cancer. Previous reports have suggested that hypercholesterolemia is a common complication in this patient group. We performed a cross-sectional study to assess further the relationship of cisplatin based chemotherapy and serum cholesterol in long-term survivors of testicular cancer.

MATERIALS AND METHODS

Fasting lipid profiles were obtained from 106 men previously treated for testicular cancer, of whom 34 had received cisplatin based combination chemotherapy and 72 were chemotherapy naive.

RESULTS

Mean total cholesterol in the chemotherapy and nonchemotherapy groups was 5.50 +/- 0.20 and 5.36 +/- 0.13 mmol./l., respectively (p = 0.55). Mean high density lipoprotein cholesterol in the chemotherapy and nonchemotherapy groups was 1.09 +/- 0.04 and 1.09 +/- 0.03 mmol./l., (p = 0.94), while mean low density lipoprotein cholesterol was 3.49 +/- 0.17 and 3.40 +/- 0.11 mmol./l. (p = 0.67) respectively. The mean total-to-high density lipoprotein cholesterol ratio was 5.26 +/- 0.27 in the chemotherapy group and 5.12 +/- 0.16 in the nonchemotherapy group (p = 0.67). Body mass index was not significantly different in the 2 groups.

CONCLUSIONS

Administering cisplatin based chemotherapy was unrelated to lipid profiles in long-term survivors of testicular cancer. Chemotherapy treated and chemotherapy naive patients had mean cholesterol levels in the borderline elevated range and body mass index in the overweight range. These potentially reversible cardiovascular risk factors have considerable importance in the overall testicular cancer population.

[Clinical presentation of testicular germinal cancer]

OBJECTIVE

To review the clinical features in our series of patients of germ-cell testicular cancer.

METHODS

The charts of 73 patients with diagnosis of germ-cell testicular tumours were reviewed. Age, history of cryptorchism, time to diagnosis, main symptoms, and serum markers values (alpha- fetoprotein and beta-HCG) were analysed. All cases underwent orchiectomy and extension study with abdominal CT-scan and either chest X-ray or Thoracic CT-scan. We follow the AJCC-UICC 1997 stage classification. Histological cell line, size, and clinical stage at presentation (local, regional and distance) have been analysed also.

RESULTS

Among 73 germ-cell testicular tumours 34 were seminomas (46.6%) and 39 were non-seminomatous (54.4%). Clinically, 58.9% of the patients had localised stage I tumours. On presentation 85.7% seminomas were stage I compared to 35.9% non-seminomatous tumours. The remaining tumours were diagnosed in advanced phases (stages II and III). Inguinal orchiectomy was performed in all patients except 5 in whom tumours were incidentally diagnosed (atrophic testis orchiectomy, hydrocoelectomy, trauma) and needed a second operation including ipsilateral scrotal excision. When size, cell line and primary tumour T category were reviewed we found that 32.3% seminomas and 20.5% non seminomas were smaller than 4 cm. 50% seminomas and 49.7% non seminomas were pT1; 41.2% seminomas and 28.2 non seminomas were pT2; finally 8.8% seminomas were pT3 compared to 23.1% non seminomas. Vascular infiltration, also evaluated in this chapter, was present in 38.2% seminomas compared to 38.5% non seminomas. Elements of embryonal carcinoma were found in 37 non seminomatous tumours, either isolated (14) or associated with other components. Teratoma appeared in 18 non seminomatous tumours, 16 of them associated to embryonal carcinoma alone or together with other components. Elements of choriocarcinoma and endodermal sinus were evident in 5 and 4 cases respectively, always associated with other elements.

CONCLUSIONS

Seminomas clinical presentation substantially differs from that of non seminomatous testicular tumours in age, clinical features, stage and histological aggressiveness.

No association between human parvovirus B19 and testicular germ cell cancer

The incidence of testicular germ cell cancer, which is the most common cancer among young male adults, is increasing. The aetiology remains unknown, although a virus has been proposed. A previous study has shown a high prevalence of human parvovirus B19 (B19) DNA in the testes of patients with testicular germ cell tumours (85%) and suggested that B19 may play a role in tumour development. To address this question of causality, seroreactivity to B19 was studied among cases (n=80) and controls (n=241) using serum samples drawn before the onset of disease, in addition to an elucidation of the frequency of virus DNA in a retrospectively collected 2-year testicular carcinoma series. No association was found between B19 seropositivity and the risk of testicular cancer (odds ratio=1.03; 95% confidence interval=0.60-1.77) nor was there any dose-response relation (P for trend=0.53). This study did, however, confirm the observation that B19 DNA can be detected in testicular carcinoma tissue, as 4 of 24 cases were found to be positive, while no B19 DNA could be detected in the control cases. It is speculated that this finding may be due to susceptibility of the carcinoma cells to B19 virus owing to high-level expression of the viral receptor glycosphingolipid (Gb4) and possible other putative cellular factors resulting in a localized persistence initiated after the development of cancer.

Serum lactate dehydrogenase isoenzyme 1 and prediction of death in patients with metastatic testicular germ cell tumors

The International Germ Cell Cancer Collaborative Group study of patients with metastatic testicular germ cell tumors showed that catalytic concentration of serum lactate dehydrogenase (S-LD), serum alpha-fetoprotein concentration (S-AFP), and serum human chorionic gonadotropin concentration (S-hCG) predicted death from tumor. The recent international TNM classification (T primary tumor, N lymph node metastasis, M distant metastasis) is based on these results. The aim of our study was to evaluate whether catalytic concentration of S-LD isoenzyme 1 (S-LD-1) was a better predictor than the criteria used for the international classification. In an evaluation series of 44 patients from Odense University Hospital, Denmark, a raised S-LD-1 (>1.0 x upper limit of reference values) had a predictive value for death from tumor in 5-years observation of 46%. The predictive value was 46% for S-LD, 25% for S-AFP, and 40% for S-hCG. A normal SLD-1 had a predictive value for survival over 5-years observation of 100%. It was 81% for S-LD, 75% for SAFP, and 77% for S-hCG. The fraction of the patients who died of tumor and had a raised tumor marker value was 100% for S-LD-1, 46% for S-LD, 9% for S-AFP, and 18% for S-hCG. The fraction of patients with a normal serum tumor marker value among those who survived was 61% for S-LD-1, 81% for S-LD, 94% for SAFP, and 94% for S-hCG. A validation series of 37 patients treated at the University of Texas MD Anderson Cancer Center showed similar findings. Combining the patients in the two series, a raised value of SLD-1 classified more patients into a subgroup with an impaired survival (53%) than S-LD (35%), S-AFP (6%), or S-hCG (11%), and the high risk subgroups based on the international classification (40%). The findings have implications for the staging and treatment of patients with metastatic testicular germ cell tumors.

Detection of germ-cell tumor cells in peripheral blood progenitor cell harvests: impact on clinical outcome

Our study was conducted to evaluate the impact of tumor cell contamination in peripheral blood progenitor cell (PBPC) harvests on the clinical outcome of patients with germ-cell tumors undergoing high-dose chemotherapy (HDCT) and autologous PBPC reinfusion. Samples of mononuclear cells from progenitor cell harvests of 57 patients with advanced or recurrent germ-cell tumors were retrospectively screened for contaminating tumor cells using immunocytochemical staining for cytokeratin filaments and reverse transcription-PCR (RT-PCR) testing for germ-cell alkaline phosphatase mRNA. The results were correlated to clinical prognostic variables as well as to the overall and event-free survival of these patients. Tumor cell contamination was detected in PBPC harvests of 16 of 57 enrolled patients (28%), and, among these, in 14 of 51 (27%) who underwent HDCT. The presence of contaminating tumor cells as detected by either immunocytochemical staining, RT-PCR, or both was strongly associated with a reduced overall survival (43% versus 71%, P = 0.0037) and event-free survival (0% versus 52%, P = 0.0005) after 1 year. In multivariate analysis, the demonstration of contaminating tumor cells had a higher predictive value for a poor event-free survival than other known prognostic variables. The presence of contaminating tumor cells in PBPC harvests of patients with germ-cell tumors seems to predict a poor overall and event-free survival in patients undergoing HDCT and autologous PBPC reinfusion.

The course of long-term toxicity in patients treated with cisplatin-based chemotherapy for non-seminomatous germ-cell cancer

BACKGROUND

The prognosis of advanced testicular cancer has improved considerably after the introduction of cisplatin-based combination chemotherapy. The improved prognosis of testicular cancer has brought the long-term toxicity of the treatment into focus.

PATIENTS AND METHODS

Long-term toxicity was investigated prospectively until more than 10 years after after treatment in a group of 22 patients treated with six series of cisplatin based chemotherapy (PVB) for testicular cancer. We have focused on nephro-, neuro-, pulmonary-, and gonadal toxicity.

RESULTS

Glomerular filtration rate (GFR) decreased significantly during treatment but increased during follow-up and all the patients had normal values of GFR 10-15 years after treatment. Carbon monoxide diffusion capacity (TLco) decreased during PVB treatment in smokers. TLco remained unchanged during the first years after PVB treatment, but improvement of TLco was seen in some patients more than 43 months after treatment. Paresthesia was reported by 83% of the patients immediately after treatment, 50% at follow-up 4-9 years after chemotherapy and 14% prevalence 11-15 hears after treatment. The reported decline in neurotoxicity was verified by normalisation of vibration perception. Gonadal toxicity was severe and persistent although improvement was seen in a few patients even many years after treatment.

CONCLUSIONS

The patients treated with PVB were physically and socially well-being at follow-up investigation 11-15 years after treatment. Improvements in pulmonary- and renal function, and recovery from neurotoxicity was seen during the long-term follow-up period. Gonadal toxicity was severe and persistent.

Detection of circulating testicular cancer cells in peripheral blood

Patients who receive peripheral blood stem cell transplants are at risk of developing cancer recurrence due to the presence of malignant cells in the transplants. We investigated a sensitive method to detect malignant cells in the peripheral blood and peripheral blood stem cells of patients with testicular cancer using nested, reverse transcription-polymerase chain reaction (RT-PCR) to measure alpha-fetoprotein gene expression. Using this technique, a single cancer cell could be detected in 10(6) peripheral blood mononuclear cells. This is the first report of an attempt to detect circulating malignant cells in the peripheral blood of patients with testicular cancer by nested RT-PCR.

Testicular germ cell tumors, an update. Results of the German cooperative studies 1982-1997

BACKGROUND

Oncologic treatment of childhood testicular germ cell tumors can be regarded as a model of curable neoplasm. Over 50% of the tumors are stage I A, produce alpha-fetoprotein and thus provide after semicastration a "wait and see" policy.

PATIENTS

The MAHO 82, 88, 94 cooperative studies registered between 1982 and 1997 197 patients, 110 patients had yolk sac tumors (YST), 47 differentiated teratomas (TD), 38 malignant teratomas of either intermediate (MTI), undifferentiated (MTU), or trophoblastic type (MTT) and two seminomas. After semicastration only 65 patients received standard chemotherapy according to stage and histology consisting of four courses of vinblastine, bleomycin and cisplatin. If after two courses viable tumor was indicated, delayed laparotomy was performed (seven patients). Patients with incomplete tumor response after two courses received three courses of etoposide, ifosfamide and cisplatin (nine patients).

RESULTS

105 patients had YST stage I, five higher stages of disease. One of these died by tumor progression. Of 91 patients followed according to "wait and see" only 14 needed standard chemotherapy. The NED of 105 patients is 99%. 47 patients had TD stage I; the NED is 100%. 13 patients had malignant teratomas stage I. 13 patients had stage II and received chemotherapy; the NED for these 26 patients is 100%. 12 patients had stages III or IV, four died.

CONCLUSION

In testicular germ cell tumors of childhood in alpha-fetoprotein producing tumors of stage I A a "wait and see" program is safe. X-irradiation or primary lymphadenectomy can be omitted since chemotherapy alone reveals excellent results.

Semen quality and reproductive hormones before orchiectomy in men with testicular cancer

PURPOSE

To obtain information about preorchiectomy gonadal function in patients with testicular germ cell cancer to improve the clinical management of fertility and other andrologic aspects in these men.

PATIENTS AND METHODS

In group 1, a group of 83 consecutive patients with testicular germ cell cancer (TGCC) investigated before orchiectomy, semen analysis was carried out in 63 patients and hormonal investigations, including measurement of follicle-stimulating hormone, luteinizing hormone (LH), testosterone, estradiol, sex hormone-binding globulin (SHBG), inhibin B, and human chorionic gonadotropin (hCG), in 71 patients. Hormone levels in patients with elevated hCG (n = 41) were analyzed separately. To discriminate between general cancer effects and specific effects associated with TGCC, the same analyses were carried out in a group of 45 consecutive male patients with malignant lymphoma (group 2). Group 3 comprised 141 men employed in a Danish company who served as controls in the comparison of semen parameters. As a control group in hormone investigations, 193 men were selected randomly from the Danish National Personal Register to make up group 4.

RESULTS

We found significantly lower sperm concentration (median, 15 x 10(6)/mL; range, 0 to 128 x 10(6)/mL) and total sperm count (median, 29 x 10(6)/mL; range, 0 to 589 x 10(6)) in patients with testicular cancer than in patients with malignant lymphomas (sperm concentration: median, 48 x 10(6)/mL; range, 0.04 to 250 x 10(6)/mL; sperm count: median, 146 x 10(6); range, 0.05 to 418 x 10(6)) (P < .001 and P < .001) and healthy men (sperm concentration: median, 48 x 10(6)/mL; range, 0 to 402 x 10(6)/mL; sperm count: median, 162 x 10(6); range, 0 to 1253 x 10(6)) (P < .001 and P < .001). FSH levels were increased in men with testicular cancer (median, 5.7 IU/L; range, 2.0 to 27 IU/L) compared with both men with malignant lymphomas (median, 3.3 IU/L; range, 1.01 to 12.0 IU/L) and healthy controls (median, 4.1 IU/L; range, 1.04 to 21 IU/L)(P = .001 and P = .007, respectively). Surprisingly, we found significantly lower LH in the group of men with TGCC (median, 3.6 IU/L; range, 1.12 to 11.9 IU/L) than in healthy men (median, 4.7 IU/L; range, 1.3 to 11.9 IU/L) (P = .01). We could not detect any differences between men with testicular cancer and men with malignant lymphomas and healthy men with regard to serum levels of testosterone, SHBG, and estradiol. Men with testicular cancer who had increased hCG levels had significantly lower LH and significantly higher testosterone and estradiol than those without detectable hCG levels.

CONCLUSION

Spermatogenesis is already impaired in men with testicular cancer before orchiectomy. Neither local suppression of spermatogenesis by tumor pressure nor a general cancer effect seems to fully explain this impairment. The most likely explanation is preexisting impairment of spermatogenesis in the contralateral testis in men with testicular cancer. The question of whether also a pre-existing Leydig cell dysfunction is present in men with testicular cancer could not be answered in this study because the tumor seems to have a direct effect on the Leydig cells. Men with testicular cancer had low LH values as compared with controls. We speculate that increased intratesticular level of hCG also in men without measurable serum hCG may play a role by exerting LH-like effects on the Leydig cells, causing increased testosterone and estrogen levels and low LH values in the blood.

[In which marker-positive patients with germ cell tumors is residual tumor resection of value?]

We analyzed 33 patients with disseminated germ cell tumors (GCT) who underwent residual tumor resection (RTR) during the period from 1991-1997. The patients were marker positive prior to surgery were analyzed. The histopathological examination of the resected masses, the marker dynamics and the relapse-free respectively the progression free survival, were evaluated. The status differed at primary diagnosis: minimal disease n = 1, moderate disease n = 15, advanced disease n = 17. The patients received at average 8.5 cisplatin-containing cycles of polychemotherapy. Only 11 patients underwent surgery after first-line-chemotherapy. The remaining received second- or third-line-chemotherapy prior to surgery. In 12 of 31 evaluable patients, a durable CR was achieved. The median follow-up for this group is 30 months (2-58 months). The histopathologic examination of the resected specimen and the tumor marker level prior to RTR do not permit determination of prognostic outcome. After operation 44% of the AFP-positive and 30% of the beta-HCG-positive patients had a durable remission. If tumor marker levels at time of RTR are within normal range, disease-free survival is 72%; in case of elevated markers 39% will survive. If intensive chemotherapy fails to normalize markers, RTR remains the only option to change the fatal course of the disease.

Nonteratomatous germ cell tumors in children

BACKGROUND/PURPOSE

Totipotential germ cells may give rise to a broad range of tumors. The teratomatous variety of germ cell tumors has been the subject of several large studies. The goal of the current study was to describe the clinical features of nonteratomatous germ cell tumors (NTGCT) by reviewing a large series of patients.

METHODS

Between 1945 and 1997, there were 78 cases of nonteratomatous germ cell tumors (NTGCT's) in children at The Children's Hospital, Columbus. Their records were reviewed retrospectively. There were 35 boys and 43 girls (M:F ratio 0.8). Mean follow-up was 87 months.

RESULTS

Histological subtypes included germinoma (33 cases, 42%), endodermal sinus tumor (24 cases, 31%), embryonal carcinoma (12 cases, 15%), gonadoblastoma (4 cases, 5%), mixed histology (4 cases, 5%), and choriocarcinoma (1 case, 2%). Forty-two tumors were in gonadal sites, but a significant percentage were extragonadal (36 cases, 46%). Forty-six patients (59%) had localized disease, 18 (23%) had regional disease, and 14 (18%) had metastases. Treatment consisted of surgery and selective chemotherapy and radiation. Complete tumor resection was more likely for gonadal (29 of 42, 69%) than extragonadal primaries (15 of 36, 41%; P < or = .05). Forty-nine (63%) of all patients survived, whereas 29 (37%) died of their disease. Survival in patients with gonadal primaries (32 of 42, 76%) exceeded that in patients with extragonadal primaries (17 of 36, 47%; P < or = .01). Survival in patients with localized disease (34 of 46, 74%) exceeded that in patients with regional extension or metastases (15 of 32, 47%; P < .05).

CONCLUSIONS

This study highlights the fact that tumor location, gonadal versus extragonadal, was important in determining prognosis, whereas tumor histology was not. This may be the result of a higher rate of complete tumor resection for gonadal primaries and underscores the important role of surgery in the optimal treatment of these unusual tumors.

CA19-9: a possible serum marker for embryonal carcinoma

We determined whether a carbohydrate antigen in serum, CA19-9, serves as a marker for embryonal carcinoma. Serum CA19-9 was serially measured in 18 male patients with a germ cell tumor. Five of 8 patients with an embryonal carcinoma had an elevated serum CA19-9. The elevated serum CA19-9 returned to normal in parallel to the clinical response to the treatment. Patients with a seminoma had a normal serum CA19-9 irrespective of their tumor size. Paraffin-embedded specimens of germ cell tumors from 9 of the 18 patients and 10 other patients were stained with the monoclonal antibody against CA19-9. These immunohistochemical stainings showed that embryonal carcinomas and mature teratomas were consistently positive and seminomas were often faintly positive for CA19-9, whereas choriocarcinomas, yolk sac tumors and immature teratomas were negative for CA19-9. These results indicate that serum CA19-9 may be a useful serum marker for embryonal carcinomas.

Actual half-life of alpha-fetoprotein as a prognostic tool in pediatric malignant tumors

In a retrospective study, the prognostic value of monitoring the decay of alpha-fetoprotein (AFP) was assessed. Serum AFP was determined serially in 18 children with malignant germ-cell or hepatic tumors: 7 endodermal sinus tumor, 3 embryonal carcinoma, 5 malignant teratoma, 2 hepatoblastomas, and 1 hepatocellular carcinoma. The actual half-life (AHL) of AFP was computed after surgical resection of the tumor. In group 1, which had complete resection and no recurrence during follow-up (n = 13), the AHL of AFP was 4.0 +/- 0.9 days. In group 2, which had incomplete resection or recurrence during follow-up (n = 5), the AHL of AFP was 24.8 +/- 20 days, significantly longer than that of group 1 (P = 0.0026). The increased AHL of AFP indicated residual active tumor after surgical resection. The AHL of AFP may be more sensitive than serial monitoring of AFP in detecting preclinical recurrence after surgical resection of AFP-secreting tumors. Treatment strategies can be based on AFP clearance, and prospective clinical trials are warranted.

Does serum tumor marker half-life complement pretreatment risk stratification in metastatic nonseminomatous germ cell tumors?

The goal of this study was to determine whether the serum tumor marker half-life (MHL) of human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) during initial chemotherapy can complement pretreatment risk stratification in metastatic nonseminomatous germ cell tumors. One hundred forty-seven patients were assessable for MHL during the first two cycles of platinum-based chemotherapy. MHL calculation was based on two consecutive values using Kohn's apparent half-life formula (MHL =ln 1/2/G, where G was the gradient of the marker slope) or on three (or more) values using simple linear regression. MHL was regarded as prolonged if it was more than 3.5 days for HCG or more than 7 days for AFP. The median MHL for HCG was 2.8 days (range, 0.7-16.7) and for AFP was 6.2 days (range, 2. 6-65.4). Thirty-five of 108 patients (32%) had a prolonged MHL for HCG, 41 of 114 (36%) had a prolonged MHL for AFP, and in 59 of 147 patients (40%), either or both MHLs were prolonged. If patients with both MHLs normal were compared against patients with either or both MHLs prolonged, highly significant differences in progression-free survival (P < 0.0001) and overall survival (P = 0.0005) were demonstrated. The test accuracy was 70% for both progression-free and overall survival, and it was slightly greater than the overall predictive value of the Medical Research Council prognostic classification. A combination of Medical Research Council criteria and MHL analysis allowed us to refine prognostic assessment. Because MHL analysis is able to complement pretreatment risk stratification and can support selection of patients for early-dose intensified chemotherapy, it should be included in prospective clinical trials for patients with poor-prognosis disease.