[Radiotherapy of seminoma: small-volume irradiation at the stage pT1N0M0--prophylactic irradiation of the mediastinum]

122 patients suffering from seminoma were irradiated between 1971 and 1981 at the Radiotherapy Department of the University of Munich. 113 patients were available for retrospective analysis. The ten year actuarial survival for all patients was 93%. The survival rate in stage pT1N0M0 (UICC classification) was 100%, in stage pT2-4-xN0M0 97%, in stage pT1-4-xN1-3M0 93%, and in stage pT1-xN4M0/pT1-xN1-4M1 69%. Using a stage adapted target volume, the exclusive irradiation of the paraaortic nodes in the stage pT1N0M0 led to a cure-rate of 100%. Because of this result, and due to the improved tolerance and lower exposure to the remaining testis we recommend this method. The effectiveness of radiotherapy, also in advanced seminomas, the benefit of prophylactic mediastinal irradiation and the therapeutic modalities for treatment of extragonadal seminomas are discussed.

Gastroparesis after radiation. Successful treatment with carbachol

Following abdominal radiation, a 16-year-old male developed persistent vomiting, metabolic alkalosis, and cachexia secondary to gastric stasis, atony, and dilatation in the absence of mechanical obstruction. Fluoroscopically and manometrically, antral motility was found to be severely impaired. Antral motor activity was not influenced by metoclopramide, but stimulated by carbachol. During oral maintenance carbachol therapy, gastric emptying of food was restored and sufficient oral nutrition could be resumed. The improvement persisted even after termination of therapy four months later. Systematic investigations on the effects of abdominal radiation on gastrointestinal motility appear to be necessary.

Vinblastine-ifosfamide-cisplatin treatment of bulky seminoma

Eighteen patients with pure seminoma in advanced Stages IIC-IV of disease were treated with VIP combination chemotherapy consisting of vinblastine (6 mg/m2, days 1 and 2), ifosfamide (1.5 g/m2, days 1 to 5), and cisplatin (20 mg/m2, days 1 to 5). Eleven patients had Stage IIC, four had Stage III, three had Stage IV, and two had primary extragonadal seminoma. Primary histologic diagnoses were typical seminoma in 15 patients and anaplastic seminoma in three patients. Human chorionic gonadotropin (HCG) levels were elevated to 350 U/1 in eight patients; alpha-fetoprotein (AFP) levels were always normal. No primary lymphadenectomy was carried out. Seven of 18 patients had prior radiotherapy and were treated because of relapse or progression. There was one early death and one patient has not yet completed therapy. Of 16 evaluable patients, 14 reached complete remission (CR) (88%), which was documented surgically in six cases, whereas in the non-pretreated group, all nine patients reached CR and in the pretreated group, CR could be induced in five of seven patients (71%). The remission duration ranged from 6+ to 41+ months (median, 29+ months). No relapse has occurred. The bone marrow toxicity of VIP was remarkable. Because of leukopenia below 1000/mm3 and/or thrombopenia below 50,000/mm3, dose reduction and interval prolongation were necessary in 10 of 16 patients, especially in all those who were pretreated. Even though it is not superior to other platin-based regimens, VIP chemotherapy is highly effective in bulky seminoma with and without prior radiotherapy.

Cisplatin combination chemotherapy in advanced seminoma

Thirty-one patients were treated with cisplatin combination chemotherapy for advanced seminoma (26 Stage III or bulky Stage II testicular, and five disseminated extragonadal). Seventeen (89%) of 19 patients not previously pretreated and four (80%) of five who had received only abdominal irradiation entered continuous complete remission (CR), versus only two (28%) of seven patients who had received extensive infra- and supradiaphragmatic radiotherapy. Results were not significantly influenced by stage, human chorionic gonadotropin (HCG) titers and histologic subgroups, whereas patients with lactic dehydrogenase (LDH) values exceeding 500 mIU/ml did worse (50% continuous CR rate in 12 cases) than those with normal or less elevated titers (89% continuous CR rate in 19 cases). After a median follow-up period of 34 months (range, 12+ to 77+ months), 23 patients (74.5%) remain alive in continuous CR, two (6%) died in CR and another one (3%) entered CR after deferred treatment of residual disease. Five patients (16%) died of cancer. Toxicity was severe in extensively irradiated patients, but it was acceptable in those not pretreated and in those who had received only subdiaphragmatic radiotherapy. Cisplatin combination chemotherapy can be successfully and safely used as the primary treatment of choice in patients with advanced seminoma. It is also an excellent salvage therapy for patients who had received subdiaphragmatic irradiation only. On the contrary, it is very difficult to treat with chemotherapy extensively irradiated patients.

Results of radiotherapy for stage II testicular seminoma

Of 53 patients with Stage II seminoma treated with radiotherapy between 1970 and 1984, 9 (17%) relapsed, 5 (9%) died of testicular cancer and 1 (2%) died of intercurrent disease. Relapse rates for IIA, IIB and IIC were 11, 18 and 28% respectively. Supradiaphragmatic irradiation was not advantageous; of 22 patients receiving infradiaphragmatic irradiation, 3 (14%) relapsed, compared with 6/31 (19%) of those who had supra- and infradiaphragmatic irradiation. Despite the radioresponsiveness of seminoma, 50% of IIC patients had residual masses 4 months after radiotherapy and 20% at one year, however, this finding did not predict eventual outcome. Serum human chorionic gonadotrophin (HCG) levels were raised prior to radiotherapy in 3/26 (11.5%) Stage IIA and IIB patients and 3/10 (30%) IIC patients. However, this did not influence the outcome of radiotherapy since only 0/6 patients with raised HCG levels relapsed compared with 7/30 (23%) of those with normal levels. Analysis of the pattern of relapse together with the fact that 2/6 patients who had the extent of tumour defined at laparotomy and/or who had total abdominal irradiation relapsed, suggests that further refinement of radiotherapy is unlikely to improve the results of treatment for IIC patients and that chemotherapy should be considered the treatment of choice.

[Successful chemotherapy in undescended testicular and extragonadal germ cell tumors: report of 2 cases]

Two patients with advanced germ cell tumor who entered complete remission following intensive combination chemotherapy, radiation therapy and surgical intervention are reported. A 28-year-old businessman presented with abdominal pain and masses associated with an elevated HCG level for which he underwent exploratory laparotomy. Large retroperitoneal masses were found and microscopical examination of the masses were revealed seminoma. Three courses of combination chemotherapy consisting of CDDP, VLB and PEP were given to the patient followed by radiation therapy to the parailiac, paraaortic, mediastinal and supraclavicular lymph nodes with boost irradiation to the paraaortic lymph nodes where the large masses were located. The other patient was a 21-year-old student who developed sharp precordial chest pain which proved to be due to a large mediastinal mass accompanied by an elevated AFP level. He was treated with radiation therapy to the mediastinum, surgical resection and combination chemotherapy. However, he showed recurrence in the lungs associated with rising AFP levels, and was given a salvage chemotherapy consisting of 3 courses of CDDP, ADR, PEP and Etoposide. Both patients were successfully treated with combined modalities of treatment including intensive chemotherapy and have been off therapy without recurrence for over 12 and 4 months, respectively.

An increased frequency of human sperm chromosomal abnormalities after radiotherapy

13 cancer patients were studied before radiotherapy (RT) and at regular intervals after RT to determine the effect of RT on chromosomal abnormalities in sperm. The men were 19-47 years old and received testicular radiation doses of 0.4-5.0 Gray. Human pronuclear sperm chromosomes were analysed after penetration of zona-pellucida-free hamster eggs. Unfortunately the hamster egg penetration rates were exceedingly low, both before and after RT and this limited the number of sperm chromosome complements which could be analysed. Before RT, the frequency of abnormal sperm chromosome complements was 0% (0/9). After RT, the majority of men were azoospermic for 24 months but complements could be analysed from 4 men. In the first 12 months the frequency of abnormalities was 13% (1/8) and at 24 months it was 13% (7/55). By 36 months after RT, most men had recovered sperm production and the frequency of abnormalities in 8 men was 21% (18/86), which is significantly higher than the rate in control donors (8.5%). For individual men the range was 6-67%, and there was a significant correlation between testicular radiation dose and the frequency of sperm chromosomal abnormalities. The frequencies of both numerical and structural abnormalities were significantly increased after RT. This is the first evidence that radiation may increase the frequency of chromosomal abnormalities in human gametes.

Post-treatment fertility in patients with testicular cancer. III. Influence of radiotherapy in seminoma patients

Sperm analysis and serum hormone measurements (LH, FSH, testosterone) were performed in 29 patients after orchiectomy for seminoma before and after irradiation. Before radiotherapy 14 of 20 orchiectomized patients were azoospermic or had impaired spermatogenesis. A minimum sperm count was found 1 year after radiotherapy with gradual improvement up to 2 years. The recovery of sperm cell production was impaired most in patients with pre-treatment sperm counts less than 3 million/ml. Serum testosterone remained at low normal levels throughout the observation period. The mean serum FSH was increased 1 year after radiotherapy but returned to normal in 50% of patients within 3 years after treatment. This post-treatment increase in FSH was significantly correlated with increased pre-treatment FSH but not with the gonadal dose, which was 1 to 3% of the target dose. Severe disturbances in spermatogenesis, observed 2 to 3 years after radiotherapy for early seminoma, are likely to be the expression of a highly impaired pre-treatment sperm cell production and only to a lesser degree dependent on the irradiation of the remaining testicle.

Radiotherapy for stage I seminoma testis: results of treatment and complications

The results of treatment by infradiaphragmatic lymph node irradiation and orchiectomy in 232 patients with Stage I testicular seminoma seen between 1963 and 1983 are reported. Of this group, only five (2%) patients relapsed and none died from seminoma. Contralateral testicular tumours occurred in 12 patients and five developed second non-testicular malignancies. The acute and late morbidity of radiotherapy was low although 15 patients developed peptic ulceration. There was a significant association between prior abdominal surgery and a history of dyspepsia with ensuing peptic ulceration. Future management policy is discussed on the basis of these observations.

Germ cell tumor in the basal ganglia: immunohistochemical demonstration of alpha-fetoprotein, human chorionic gonadotropin, and carcinoembryonic antigen

A case of germ cell tumor in the basal ganglia and its vicinity was successfully treated surgically and by radiation. alpha-Fetoprotein, human chorionic gonadotropin, and carcinoembryonic antigen were found in the tumor tissue, using the immunoperoxidase method. The presence of three immunohistochemically demonstrated tumor markers in a single germ cell tumor is extremely unusual. These results strongly suggest a cell differentiation or transformation in germ cell tumors.

Testicular seminoma: analysis of treatment results and failures

Pure testicular seminoma has historically been treated primarily with radiation therapy, and excellent results have been achieved. Recently, several aspects of the treatment of seminoma have been questioned; namely, the value of mediastinal irradiation in Stage II disease, and whether a dose response curve existed for seminoma. Because these questions have remained unanswered, we undertook a retrospective review of all patients with pure testicular seminoma treated in the Department of Radiation Oncology at Indiana University Medical Center. From 1961-1981, 54 patients with pure testicular seminoma were given megavoltage irradiation with curative intent. Thirty three patients were Stage I, with tumor confined to the testicle with no evidence of nodal spread. Fifteen patients were Stage IIA, with metastases less than 5 cm in size in the retroperitoneal nodes. Four patients were Stage IIB, with metastases greater than 5 cm in size in the retroperitoneal nodes. One patient was Stage III, with supradiaphragmatic metastases confined to the mediastinum and supraclavicular area. One patient was Stage IV, with evidence of extralymphatic metastases. The crude survival rate (corrected for intercurrent death, except for treatment toxicity) for the entire group was 87%. For Stage I, it was 91%, Stage IIA-80%, Stage IIB-75%, Stage III-100%, and Stage IV-0%. All patients had a minimum follow-up of 2 years with a range of 2 to 21 years. Evaluation of the Stage I patients reveals that 2500 rad in 3 weeks appears to be adequate in controlling microscopic disease, as there were no in-field recurrences when this dose was given. Those patients with Stage IIA and IIB disease who received greater than or equal to 3500 rad to macroscopic disease had 100% (7/7) survival and local control, while those receiving less than or equal to 3000 rad had a 66.6% (8/12) survival with three of four demonstrating persistent or recurrent abdominal disease. Thus, we feel that macroscopic disease requires 3500 rad to 4000 rad for control. All Stage II and III patients had planned mediastinal irradiation. No patients who received mediastinal irradiation recurred in the mediastinum. Whether this is because of our treatments or the natural disease process remains unanswered. Overall, we were able to salvage 12.5% (1/8) of our recurrences, while 37.5% (3/8) died from toxicity of their salvage therapy.(ABSTRACT TRUNCATED AT 400 WORDS)

[Radiation treatment of malignant testicular tumors--results, side effects, analysis of recurrences]

A retrospective study was conducted in order to investigate the radiotherapeutic results of 123 patients with testicle tumors. The overall five-year survival rate was 85% out of 75 patients suffering from seminoma and 70% out of 48 patients suffering from teratoma. Recurrences as well as complications are analyzed in detail. The authors underline the necessity of an adaption of radiotherapy to the individual stage comprising the complete regional lymph node regions.

Sexual and marital relationships after radiotherapy for seminoma

Questionnaires on sexual function, marital status, and fertility were returned by 84 men who received radiotherapy for seminoma (Stage I, II, or III). The mean length of follow-up was ten years. Although 93 per cent were married, 19 per cent had low rates of sexual activity, 12 per cent reported low sexual desire, 15 per cent had erectile dysfunction, 10 per cent had difficulty reaching orgasm, and 14 per cent had premature ejaculation. The most common problems were reduced intensity of orgasm (33%) and reduced semen volume (49%). Twenty-one men remained childless, and 30 per cent of men worried at least occasionally about infertility. Thirteen children were conceived after cancer therapy. The data suggest that sexual dysfunction and infertility are important concerns for a subgroup of men treated for seminoma.

Testicular seminoma: results of treatment at the Northern Israel Oncology Center

The survival, and the patterns and mechanisms of failure of 41 patients with pure testicular seminoma treated at the Northern Israel Oncology Center from 1968 to 1983 were analyzed. The actuarial 5-year survival of all patients was 85.4% and of stage I patients, 92.2%. Treatment failures were analyzed. The following conclusions were reached: in order to increase the cure rate, the use of combination chemotherapy as the initial treatment modality in advanced seminoma is recommended. In cases of transscrotal approach, the scrotum should be irradiated. Adjuvant mediastinal irradiation is not needed.

Pure seminoma of the testis: the results of radiation therapy in patients with elevated human chorionic gonadotropin titers

The management and prognosis of human chorionic gonadotropin-producing seminoma still are controversial issues. In a review of 210 patients irradiated between 1950 and 1982, 10 had elevated human chorionic gonadotropin values: 3 with stage I, 6 with stage II and 1 with stage IV disease. All human chorionic gonadotropin values became negative: 4 postoperatively and 6 following radiotherapy. All patients are well with a mean followup of 6 years. One patient who suffered liver metastases only was salvaged by chemotherapy. Based on these patients human chorionic gonadotropin production is not an unfavorable prognostic sign in cases of pure seminoma.

Children fathered by men treated for testicular cancer

Children fathered by 27 testicular cancer patients treated with radiotherapy, 25 treated with chemotherapy, and 57 control men (46 community controls and 11 Stage I testicular cancer patients) were examined for evidence of congenital malformations. The proportion of malformations in children in the treatment group did not differ from that in children in the control group or from incidence rates for malformations in the general population. Our results suggest that treatment for testicular cancer should not constitute a reason for advising termination of pregnancy, although numbers were too few to detect a relative risk smaller than 3 X 2. More observations are needed to provide a definite answer.

Therapeutic guidelines and results in advanced seminoma

Twenty patients with advanced seminoma were treated with chemotherapy. Fourteen patients were previously untreated (group 1) and received vinblastine, bleomycin, and cisplatin (VPB) at presentation. Six patients had received prior radiation therapy (group 2), and at relapse received either VPB or VP-16-213 (etoposide)-cisplatin. Within group 1, five patients received no further therapy after VPB (group 1A), six patients received radiation to residual radiographic abnormalities (group 1B), and three patients underwent surgery to remove residual radiographic areas following VPB (group 1C). The complete response rate in group 1 was 14/14 (100%). At present within group 1A, 5/5 patients (100%) are alive and disease-free (NED) for a median follow-up of 32 + months. In group 1B, 6/6 patients (100%) are alive and NED for a median follow-up of 17+ months. In group 1C, 3/3 patients (100%) had residual fibrosis at the time of surgical resection. Two of these patients died of postoperative complications with no evidence of disease and the third is alive and NED at 19+ months. In group 2, 4/6 patients (67%) achieved a complete remission, including two patients who are NED at 22+ and 85+ months, respectively. Two have died and two are alive with progressive disease. Doses of chemotherapy to group 2 patients were substantially lower than the doses given to group 1 patients. We conclude that chemotherapy is acceptable initial therapy for advanced seminoma, and prior extensive radiation therapy may impair the ability to give adequate doses of chemotherapy in patients who relapse. Residual masses after chemotherapy are often fibrotic and the role of postchemotherapy radiation therapy in these patients is uncertain.

Seminoma of the testis: a 22-year experience with radiation therapy

An analysis is presented of 188 patients with a histological diagnosis of seminoma testis, treated by radical orchiectomy and radiation therapy between 1960 and 1981 at the Cross Cancer Institute. Using the Walter Reed Hospital staging classification, 149 (79%) patients were Stage I, 34 (18%) were Stage II, and 5 (3%) were Stage III. The 5-year survival for all stages was 90%, and for Stage I was 98%, Stage II, 71%, and Stage III, 0%. All were treated primarily with radiation therapy. Prophylactic mediastinal radiation was not employed for Stage I, and was employed in half of Stage II patients. Eleven patients with Stage I relapsed, five in the mediastinum and/or neck nodes. Eight of 11 were cured with further treatment. Stage II patients were subdivided according to the presence or absence of a palpable abdominal mass. Palpable disease (Stage IIB) carried a poorer prognosis. Three of 20 patients without a palpable mass (Stage IIA) died of disease; there was an 82% five-year survival rate. Eight of 14 with a palpable mass (Stage IIB) were cured by radiotherapy; there was a 54% five-year survival rate. All five Stage III patients died within 1 year of diagnosis. Stage I and IIA seminoma is curable by radiation alone. Prophylactic mediastinal radiation is not indicated in either Stage I or IIA disease. Long term toxicity from radiation is not seen. Optimal treatment for Stage IIB disease is undetermined and new treatment regimens should be explored. Stage III disease requires primary chemotherapy.

The impact of treatment errors on post-operative radiotherapy for testicular tumours

Twenty-four patients receiving post-operative radiotherapy for testicular tumours have been studied to assess the impact of treatment errors. Regular treatment verification radiographs were performed and compared with simulator planning radiographs. It was demonstrated that lymph nodes in the area most at risk, i.e., para-aortic nodes at L1 to L3 on the ipsilateral side, were inadequately irradiated on 10% of treatments, and that at least one lymph node miss was recorded in 12 of the 24 patients. These results are considered to be a minimum estimate. Mostly para-aortic fields 8.0 cm wide were used, but it was shown that the number of lymph-node misses could have been substantially reduced by using fields 9.0 cm wide, whilst the consequent increase in irradiated kidney volume was considered acceptable.

The management of early stage non-seminomatous germ cell tumours of the testis: Edinburgh 1970-1981

This study describes the management of early stage non-seminomatous germ cell tumours of the testis in Edinburgh between 1970 and 1981. There were 69 patients in clinical Stage I and 22 patients in clinical Stage IIA. All were treated by orchiectomy and radiotherapy to the para-aortic nodes. Some of the patients with Stage IIA disease received additional therapy. The overall 5-year actuarial survival rate was 83%. In a group of 52 patients with Stage I disease who had had lymphography as part of their initial staging the 5-year actuarial survival rate was 94.2%. The overall relapse rate was 27/91 (29.7%). The relapse rate in State IIA disease was 11/22 (50%) and the 5-year actuarial survival rate was 64%. Patients with primary tumours beyond T1 had a significantly higher relapse rate than patients with T1 primary tumours: 10/20 (50%) and 13/52 (25%) respectively. The histology of the primary tumour did not have a statistically significant influence upon relapse rate.

Occlusion of the internal carotid artery after radiation therapy for the chiasmal lesion

Occlusion of the intracranial portion of the internal carotid artery were encountered in two cases with suprasellar tumours, who had received irradiation therapy previously and shown excellent clinical improvement postoperatively. Clinical features and the angiographic characteristics were analysed in these two cases and the results were compared with reports in the literature. The occlusive effect of radiation on the arterial wall was conceived as the cause of carotid obstruction. In order to avoid this side effect of radiation therapy, especially for brain tumours of low malignancy in childhood, careful estimation of the radiation dose should be required and cerebral angiographic follow-up during and after the treatment with radiation is indicated, particularly when the patient develops cerebral transient ischaemic symptoms.

Seminoma of the testis with bone involvement: a report of three cases

Three cases of seminoma metastasising to bone and treated with radiotherapy are reported. All three patients are alive and disease-free between 6 and 16 years after diagnosis. The value of radiotherapy in this situation should be borne in mind.

Advanced seminoma: treatment with cis-platinum-based combination chemotherapy or carboplatin (JM8)

Between 1978 and 1983, 44 patients with advanced seminoma were treated with cis-platinum-based combination chemotherapy (39 patients) or with carboplatin (JM8), as a single agent (5 patients). Of the total group, 40 (90%) are alive and disease free. Two of the 4 patients who died relapsed as non-seminomatous germ-cell tumours. Results in previously untreated patients indicate that tumour volume is less important as a prognostic factor than in non-seminomas. Residual masses were present in almost 80% of patients 1 month after chemotherapy; such masses regress slowly and surgery is not indicated. Elective radiotherapy after chemotherapy appears to be inessential since relapse rates are comparable in irradiated (1/15) and unirradiated patients (1/16). Pretreatment serum HCG concentrations did not influence the outcome of chemotherapy. Preliminary results with JM8 suggest that it is an active single agent in the treatment of seminoma.

Primary mediastinal germinomas in females: a case report and review of the literature

Primary mediastinal germinomas in females are rare. Long-term survival ranges from 50 to 81%, depending on the initial extent of disease. Initial spread occurs intrathoracically and to regional nodes with late hematogenous dissemination. The roles of surgery, radiation therapy, and chemotherapy are discussed.

[Lumbar radiation myelopathy. Case report on localization of lumbar radiation sequelae]

The case of a patient with a radiation lesion of the lumbosacral cord following prophylactic radiation therapy of the paraortic lymph nodes for seminoma is reported. Seven months after radiotherapy he suffered from a pure anterior cell syndrome, followed by a loss of pain and temperature sensation. Ten years later he developed a complete transversal syndrome at the level of L 1. This case indicates the existence of a lumbar radiation myelopathy caused by a lesion at the level of the conus medullaris.

Chemotherapy of metastatic seminoma

Response to chemotherapy and survival was retrospectively analyzed in 28 patients with bulky retroperitoneal and disseminated seminoma treated between 1977 and 1983. The median age was 41 years (range: 23-52). All patients had histological evidence of pure testicular seminoma, however, 14 patients revealed moderate increases of human beta-chorionic gonadotropin levels. Prior radiotherapy had been given to 9/28 (32%) patients. Treatment consisted of at least four courses of simultaneous or sequentially alternating therapy with cisplatin, vinblastine, bleomycin plus/minus adriamycin (PVB +/- A), administration of ifosfamide or combination therapy with ifosfamide/cisplatin (IFS/DDP) or ifosfamide/etoposide (IFS/ETP). Twenty-five of 28 patients (89%) achieved a complete (CR), and 3/28 patients a partial remission. Relapse occurred in 1/8 CR patients after adjuvant postchemotherapeutic irradiation, and in 1/11 patients without any further radiotherapy. So far, 23/28 patients (82%) are free of disease after a median follow-up of 28+ (14+----82+) months. Marked myelosuppression was observed in previously irradiated patients, mainly after PVB +/- A therapy. In two patients, transient nephrotoxicity developed after PVB and IFS/DDP, respectively. After PVB +/- A chemotherapy, three patients revealed polyneuropathy, paralytic subileus and bleomycin-induced pneumonitis, respectively. In conclusion, the present series suggests a high probability of continuous CR in even bulky retroperitoneal and widespread metastatic seminoma. So far, no definite conclusions can be made on the therapeutic superiority of one of the different chemotherapeutic regimens used. However, this preliminary experience suggests that the combination of ifosfamide and etoposide or cisplatin may prove less toxic than sequentially alternating or simultaneous PVB +/- A chemotherapy.

Primary seminoma of the mediastinum. Cancer Control Agency of British Columbia experience

Six patients with primary seminoma of the mediastinum were treated at the Cancer Control Agency of British Columbia during the period from 1970 to 1982. Primary treatment used was external beam radiotherapy. Only one patient received both radiotherapy and chemotherapy. Tumor dose ranged from 3000 cGy in 16 daily fractions in 3 weeks to 3500 cGy in 20 daily fractions in 4 weeks using parallel opposed fields on megavoltage machines. Two patients received additional small-volume boost to the superior mediastinum, delivering 500 cGy and 1000 cGy, respectively. All patients had complete resolution of the mediastinal mass after treatment and are alive and free of disease. One patient developed a metastasis to the fifth lumbar vertebra 1 year after treatment. This metastatic lesion was treated with radiotherapy and the patient is alive and free of clinical disease. Mediastinal seminoma is radiosensitive and radiocurable.

Primary intracranial germinoma with massive ventriculoperitoneal shunt metastases

Ventriculoperitoneal shunt metastases from primary intracranial germinomas are extremely rare. To date, only three case reports of this phenomenon have appeared in the literature. We present the case of a 25-year-old black male who developed ventriculoperitoneal shunt metastases 10 months following diagnosis of an intracranial germinoma. Radiotherapy destroyed most of the intracranial tumor, but abdominal metastases became progressive and were not treated with radiotherapy. The role of radiotherapy in the treatment of ventriculoperitoneal shunt metastases is examined and previous cases in the literature are reviewed.

Radiation therapy of seminoma of the testis

This study is a review of 66 patients with a diagnosis of testicular seminoma, treated at the Department of Radiation Oncology, University of Louisville, from 1959 to 1978. Sixty-four of the patients were diagnosed as pure seminomas and two as spermatocytic type. The age of the patients ranged from 16 to 75 years with a median of 39. Fifty-four patients (82%) presented with swelling or mass in the testis, 7 patients with pain, 1 patient with hydrocele, and 4 patients had seminoma diagnosed incidentally. The distribution was equal for both right and left sides. There were 39 (59%) and 27 (41%) patients in stages I and II, respectively. All stage I patients received only infradiaphragmatic irradiation by a "hockey stick" field, and the majority of them received a dose of 3,200-3,600 rads in 3-4 weeks time. Stage II patients received elective irradiation to the mediastinum and neck region, in addition to the infradiaphragmatic irradiation. The 5-year actuarial survival rates for stage I and II seminomas are 96% and 92%, respectively. There were no serious complications during follow-up. The role of elective irradiation in stage I disease is discussed with a brief review of the literature.

Management of testicular tumours. Is radiotherapy defunct?

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[Tumor markers and endocrinologic aspects in intracranial germinoma]

This report outlines the endocrine abnormalities associated with intracranial germinoma in childhood. The presence of special tumoral markers as alpha 1-fetoprotein and beta-HCG could be of diagnostic value and is important in respect to therapy control. However the reported case shows that despite known radiosensitivity and appropriate radiotherapy localized tumor relapse may arise soon after treatment.

Possible New Approaches to the Management of Seminoma of the Testis

A review of 21 newly diagnosed patients with either advanced Stage 2 or Stages 3 and 4 metastatic seminoma treated with platinum based chemotherapy regimes has demonstrated 17 long-term disease-free survivors (81%) compared with 10 of 18 such patients treated by radiotherapy between 1960 and 1977 (56%) and 10 of 34 treated before 1960 (29%). These results somewhat overstate the benefit of chemotherapy over radiotherapy because the incidence of seminoma as a proportion of all germ cell tumours changed, following a change in histological and radiological staging procedures during that period. However, the data presented do suggest that seminoma may be even more sensitive to chemotherapy than malignant teratoma, since 12 of the 21 patients reported received cisplatin as a single agent and 10 of these survived. These observations have lead to a re-investigation of the relapse rate of Stage 1 seminoma in a surveillance study. To date, 10 of 11 patients observed have remained relapse-free for a median of 11 months' follow-up.

Multiple fusiform intracranial aneurysms following curative radiation therapy for suprasellar germinoma. Case report

A 17-year-old girl died from the rupture of a large fusiform aneurysm of the terminal internal carotid artery. Autopsy revealed three other fusiform aneurysms originating from major cerebral arteries clearly within the ports of previously administered telecobalt radiation therapy. Five years prior to her death, a suprasellar germinoma was partially removed and the area was treated by radiation therapy via three ports. The original arteriograms showed a normal vascular tree. Repeat arteriograms, 3 years and 8 months before her death, demonstrated the aneurysms. The development of aneurysms following radiation damage of the arteries has been reported previously, but not in intracranial vessels.

Suprasellar germinoma occurring two years after total removal of pineal teratoma

A rare case of a suprasellar germinoma occurring 2 years after total removal of a pineal benign teratoma is presented. The suprasellar germinoma was not considered a recurrence or dissemination from the pineal tumor, but to have been transformed from germ cells present in the suprasellar region. Although it is controversial whether radiation treatment should be given to a patient with a totally removed benign teratoma, careful follow-up computed tomography scans are indispensable for detecting a possible occurrence of other germ cell tumors.

Combination chemotherapy in the management of ovarian germ cell malignancies

Twenty-four patients with ovarian germ cell malignancies received combination chemotherapy in the present series. Fifteen patients received intensive vincristine, actinomycin-D, and cyclophosphamide therapy for 12 to 18 courses, and 13 are alive and free of disease 34 to 86 months later. One patient with a stage III pure endodermal sinus tumor and one patient with a stage III mixed germ cell tumor composed predominantly of endodermal sinus tumor elements failed vincristine, actinomycin-D, and cyclophosphamide therapy, but each transiently responded to cis-diamminedichloroplatinum, vinblastine, and bleomycin therapy. Nine patients subsequently were treated on a new protocol that used the intensive vincristine, actinomycin-D, and cyclophosphamide regimen for five to six courses for all stage I ovarian germ cell malignancies and cis-diamminedichloroplatinum, vinblastine, and bleomycin therapy for advanced stage tumors containing endodermal sinus tumor. Each patient on the new protocol is alive and free of disease 14 to 26 months later. Short-term intensive vincristine, actinomycin-D, and cyclophosphamide therapy is recommended for all stage I ovarian germ cell malignancies requiring adjuvant chemotherapy. Preservation of ovarian and reproductive function is appropriate in the present group of patients. Vincristine, actinomycin-D, and cyclophosphamide therapy is also recommended for biomarker negative advanced stage ovarian germ cell malignancies. Cis-diamminedichloroplatinum, vinblastine, and bleomycin therapy is recommended for advanced stage biomarker positive ovarian germ cell malignancies. Serial alpha-fetoprotein (AFP) titers accurately reflect the status of endodermal sinus tumor elements and may be used as a guide to discontinue treatment for patients with pure endodermal sinus tumor malignancies, obviating the need for second-look surgery.

Leukemia following treatment of germ cell tumors in men

We investigated the incidence of leukemia occurring subsequent to the treatment of germ cell tumors in men at our institution over a 30-year interval and found four patients with acute nonlymphocytic leukemia (ANLL) and one patient with chronic myelomonocytic leukemia. The relative risk (observed/expected cases) estimates for the development of leukemia ranged from 13.7 (P = .0005) in the total population to 50.1 (P = .0001) in the group treated with cytotoxic agents alone. All three patients with ANLL treated with contemporary antileukemic therapy had complete responses, with survivals of 7, 29, and 133 + months. In a review of the literature, 14 additional cases of germ cell tumors were found in which the men subsequently developed leukemia. It is concluded that leukemia following germ cell tumors is increased in incidence and is likely to be treatment induced. Complete responses and long-term survival are possible in secondary leukemia and aggressive antileukemic therapy should be given.

[Late arterial complications after radiotherapy]

Late effects of radiotherapy are observed more frequently due to the improved results of the treatment of cancer and the resulting longer survival times. The big arteries, however, are only seldom attacked by late complications. The authors present a single case and stress the importance corresponding therapeutic action.

[Successful chemotherapy for mediastinal seminoma--a case report]

A case with large primary mediastinal seminoma responded very well to chemotherapy. A 13-year-old boy was evaluated for complaints of edematous face and neck. Chest radiography and computerized tomography revealed a large anterior superior mediastinal mass. Needle biopsy demonstrated seminoma. After two-drug combination chemotherapy with vincristine and prednisolone and three-drug combination with vincristine, prednisolone and cyclophosphamide, there was a considerable regression of the mediastinal mass. The lower neck and mediastinum were irradiated at a dose of 3,750 rad after cessation of chemotherapy. The patient has been asymptomatic without evidence of recurrence for a follow-up period of more than four years.

Testis tumors: the clinical significance of the tumor-contaminated scrotum

Between 1977 and 1979 we evaluated 224 patients with testicular cancer. Of these patients 32 had undergone inadequate primary procedures, such as transscrotal orchiectomy, transcrotal exploration, biopsy or aspiration. These 32 patients were compared to a cohort population who had undergone radical inguinal orchiectomy. Differences in management, nodal metastases, local recurrences, intervals free of disease and survival by stage of disease were determined. Patients with seminoma and a contaminated scrotum received radiation therapy to the involved hemiscrotum . Partial scrotectomy without ilioinguinal node dissection was performed on most patients with nonseminomatous disease. An inguinal node metastasis developed before radiation therapy in a patient with seminoma. There were no local recurrences. No statistically significant difference in either intervals free of disease or survival between contaminated and cohort populations was found. We conclude that with prompt adequate management there is no adverse effect on prognosis due solely to scrotal tumor contamination, contrary to what has been implied in the literature.

Dysgerminoma of the ovary

Dysgerminomas of the ovary are rare germ cell tumors. They are more common at puberty. Surgery followed by irradiation has resulted in excellent cure rates in early stages of this disease. This paper is a review of six patients with a diagnosis of dysgerminoma who were treated at the Department of Radiation Oncology, University of Louisville. The controversy on the use of irradiation in Stage Ia tumor is discussed in detail. A review of the literature is also done in this paper.

[Successful treatment of seminoma metastases using partial irradiation]

A patient suffering from pulmonary metastases of a seminoma of the testicle was treated by subtotal-body irradiation with single doses of 15 cGy and a total dose of 1155 cGy. A complete remission lasting more than one year was achieved. This therapy method is recommended for the treatment of the advanced seminoma (hematogenic metastases, extension beyond the diaphragm, or regional lymph node metastases with a size of more than 5 cm) because of its lower acute toxicity.

Changing concepts in the treatment of nonseminomatous germ cell tumors of the testis

The development of effective chemotherapy for advanced nonseminomatous germ cell tumors of the testis has changed dramatically the outlook for this once uniformly fatal disease. We reviewed our experience with changing modalities of therapy during a 7-year period in the treatment of 152 patients with all stages of testis tumor. Survival rates have increased from 84 per cent for patients with stage A, B1 or B2 tumors treated with sandwich irradiation therapy and retroperitoneal lymph node dissection to 100 per cent for patients with node dissection with or without chemotherapy. Survival rates continuously free of disease for patients with advanced (stage B3 or C) disease have increased from 53 per cent in 1975 to 1977 to 82 per cent by the addition of platinum-based polychemotherapy and judicious lymphadenectomy. A unified plan of management for patients with low stage and advanced stage nonseminomatous testicular tumors has evolved.

[Bleomycin, vinca alkaloid and cis-diamminedichloroplatinum combination chemotherapy for advanced testicular tumors]

Thirteen patients with advanced testicular tumors (seminoma 2, non-seminoma 11) were treated with combination chemotherapy involving BLM, vinca alkaloid and CDDP (BVP) as induction therapy and followed with CPM, VCR and CDDP as maintenance therapy. BVP and COP administration was repeated every 3 and 4 to 8 weeks for 1 year, if there were no serious side effects. The overall response rate (CR + PR) was 92% with a 69% CR rate. At a mean follow-up of 30 months (7-52 month range), 54% of the patients were alive with no evidence of disease. Bulky metastases, failure to respond to prior chemotherapy and teratomatous metastases were considered to be poor prognostic factors. The toxicity of BVP was similar to that reported for CDDP, except that allergic reaction occurred in 3 patients after several courses of treatment. Two of the 3 went into anaphylactic shock.

Germ cell tumours of the ovary. A clinical study of 15 cases

Our experience with germ cell tumours of the ovary is reviewed. Over the last 10 years, 15 cases, representing 6,4% of all our referred patients with malignant ovarian tumours, have been analysed. The type of tumour, histological appearances, stage, treatment and results of treatment are presented. The tumour most commonly seen was the dysgerminoma, comprising 60% of all cases (9 patients). Multimodal treatment generally consisted of surgery and radiotherapy for dysgerminoma with the addition of chemotherapy for the non-dysgerminomas. Survival depends on the stage and histological appearances of the tumour. Patients in whom the disease is at advanced stages have a poor prognosis, irrespective of histological features. A general review of this subject is also given.