Controversies concerning adjuvant regional isolated perfusion for stage I melanoma of the extremities

The use of isolated perfusion with melphalan in an adjuvant setting for stage I extremity melanoma continues to be controversial. In this article, 2 retrospective studies compare patients undergoing perfusion from Groningen, the Netherlands, with matched controls from the Sydney Melanoma Unit in Australia and from 5 hospitals in the Netherlands and Westphalia (a region of Germany bordering the Netherlands). All patients underwent wide local excision for a primary extremity melanoma of 1.5 mm or more in thickness. In the first study, women with a melanoma of the leg (excluding the foot) and treated with perfusion had a significantly higher survival than women treated with local excision alone. In the second study, a proportional hazards regression analysis for recurrent disease and survival identified no statistically significant difference in favor of adjuvant perfusion. Two other studies from the literature evaluating the efficacy of perfusion are examined. Patients treated at the M.D. Anderson Cancer Center, Houston, with wide local excision and perfusion are compared retrospectively with a group of patients individually matched for prognostic factors from the University of Alabama in Birmingham, U.S.A. and the Sydney Melanoma Unit. A small subset of patients with tumors greater than 2 mm thick benefited from perfusion. A prospective randomized study from the University Hospital, Cologne, West Germany found benefits for all perfused patients with tumors greater than 1.5 mm but their patients did not appear to be individually matched for tumor thickness. It is concluded after critical appraisal of all these studies that there is insufficient convincing evidence to date of an advantage of perfusion over wide local excision alone.

Groin dissection in the treatment of lower-extremity melanoma. Short-term and long-term morbidity

Groin dissection was performed in 151 consecutive patients from 1970 to 1984. Groin dissections were therapeutic in 138 cases (91%) and elective in 13 (9%). One hundred forty-three patients (95%) underwent an ilioinguinal node dissection, while eight (5%) were treated with an inguinal node dissection. In 88 patients, the groin dissection was combined with isolated regional perfusion. Primary wound closure was performed in 140 patients (93%). There was no 30-day postoperative mortality. Complications included temporary seroma (26 [17%] of 151 patients), wound infection (14 patients [9%]), wound necrosis (five patients [3%]), and edema (30 patients [20%]). Residual inguinal node metastases after groin dissection did not occur. Morbidity of groin dissection did not increase when the groin dissection was combined with isolated regional perfusion. Quantification of the degree of edema in 66 patients revealed functional limitation due to edema in three patients (4.5%). This technique of groin dissection gives good results with minimal functional morbidity of the affected leg.

Ploidy of testicular carcinoma in situ

The ploidy of carcinoma in situ and invasive germ cell tumors of the adult testis was compared by DNA flow cytometry. Irrespective of the tumor type with which it was associated, the median DNA index of carcinoma in situ was about the same as that of seminomas and higher than the DNA index of invasive nonseminomatous germ cell tumors. These data indicate that seminoma and carcinoma in situ cells are not only phenotypically similar but also have the same ploidy.

Intestinal hemorrhages in patients with a nonseminomatous testicular tumor

This article reports on three patients with intestinal bleeding due to metastases from a nonseminomatous testicular tumor (NSTT) to the gastrointestinal tract. Involvement of the gastrointestinal tract is rare. The mode of spread is either by hematogenous dissemination or by direct extension from involved paraaortic lymph nodes. The symptoms of these patients are briefly described. Early recognition and efficient supportive care are essential in the management of such patients.

Cytogenetic analysis of the mature and immature teratoma components of a metastatic testicular nonseminomatous germ cell tumor

A case is described in which the mature and immature teratoma components of metastases of the same testicular nonseminomatous germ cell tumor were karyotyped. The highly similar karyotypes of both components suggest that the phenotypic difference is predominantly epigenetically determined.

TRA-1-60: a new serum marker in patients with germ-cell tumors

TRA-1-60 is a monoclonal antibody (MAb) that recognizes a mucin-like antigenic determinant expressed on the surface of embryonal carcinoma (EC) progenitor cells. In order to determine whether this antigen is released into the serum of patients with a non-seminomatous germ-cell tumor (NSGCT), we developed a sensitive 2-step immunoenzymometric assay. Of 42 EC-positive NSGCT patients tested, 32 (76%) were found to release TRA-1-60-reactive antigen into their serum, in contrast to 1 positive finding in 10 EC-negative NSGCT patients. The marker was found in 67% (10/15) of the EC-positive patients who were negative for both AFP and HCG. Sera from seminoma patients did not contain elevated levels of the TRA-1-60 antigen. Therefore, we propose that the TRA-1-60 antigen is a useful additional serum marker for following the progress of NSGCT(EC+) patients.

Haematogenous tumour growth in the inferior vena cava in a patient with a nonseminomatous testicular tumour

The case history is reported of a patient with an invasion of the inferior vena cava by metastases of a non-seminomatous testicular tumour. He was treated with combination chemotherapy, followed by laparotomy and resection of residual tumour tissue. Fourteen months after this operation he is in good health. For every retroperitoneal lymph node dissection it is necessary to be on the look-out for invasion of the vena cava, because of the risk of a sudden pulmonary embolism.

The role of magnetic resonance imaging and computed tomography in the treatment evaluation of retroperitoneal lymph-node metastases of non-seminomatous testicular tumors

The role of Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) in the treatment evaluation of retroperitoneal lymph-node metastases of non-seminomatous testicular tumors (NSTT) was prospectively studied in 10 consecutive patients before, during and after chemotherapy. The results thus obtained were compared with laparotomy findings before and after chemotherapy, the histology of the primary testicular tumor, and that of retroperitoneal residual lesions after chemotherapy. MRI and CT proved to be equivalent in detection and in determining the anatomical localization and size of the retroperitoneal lymph node metastases. Unlike CT, MRI revealed unmistakable changes in the structure of the retroperitoneal lymph-node metastases during chemotherapy, for which no histological cause was found except in mature teratoma. In mature teratoma a high T2 signal was found within the metastases, corresponding with a high water content. On the basis of tumor consistency and signal intensity in the T1- and T2-weighted images, MRI cannot yet warrant any conclusion about the ultimate effect of chemotherapy.

Complete association of loss of heterozygosity of chromosomes 13 and 17 in osteosarcoma

Mutations of the retinoblastoma (RB1) gene are not confined to retinoblastoma, but are also involved in the development of osteosarcoma. Structural aberrations within the RB1 gene have been studied in fresh samples of eleven cases of osteosarcoma. In five cases a rearrangement was detected, one of which was best explained as a partial duplication. The chromosomal mechanisms by which the nonmutated RB1 allele was lost appeared to be similar in frequency to those that have been reported for retinoblastoma. Loss of heterozygosity was observed for chromosomes 3, 11, 13, 17, and 22. However, when no loss of heterozygosity of chromosome 13 was detected, the other chromosomes retained their heterozygosity as well. A complete association of loss of heterozygosity of chromosomes 13 and 17 was observed. This can be taken as an indication of the involvement of another tumor suppressor gene at chromosome 17 in the initiation of osteosarcoma.

MRI and CT in the preoperative evaluation of soft-tissue tumors

The value of MRI and CT in the diagnosis of soft-tissue tumors was investigated in a prospective study of 25 patients. MRI and CT give a true reflection of the tumor dimensions. It is impossible, however, to make a reliable diagnosis with either technique. If both techniques are available, then MRI is to be preferred in view of the better spatial orientation and sharper contrast it offers between the tumor and adjacent structures. If only CT is available, then an adequate image can generally be obtained with this technique too.

Dual parameter flow cytometry for deoxyribonucleic acid and intermediate filament proteins of residual mature teratoma. All tumor cells are aneuploid

Most testicular germ cell tumors of adults are presumably derived from polyploid carcinoma in situ. Thus, one would expect that even highly differentiated teratoma components are aneuploid and that it is unlikely to find diploid tumor cell (sub)populations. We studied 10 residual mature teratomas (RMTs) using a dual parameter flow cytometry procedure. Nuclear DNA was stained with propidium iodide and cytoplasmic intermediate filament proteins, in particular, cytokeratins, with fluorescein isothiocyanate-labeled specific monoclonal antibodies. Cells in RMTs, immunoreactive with antibodies to cytokeratins were considered to be tumor cells. These were always found to be aneuploid, in agreement with the available cytogenetic data on these tumors. The diploid cells present in RMTs were devoid of cytokeratins; therefore, these cells represent the nonmalignant normal host stromal and inflammatory cells. These results, in accordance with our earlier finding, indicate that diploid testicular germ cell tumors are extremely rare in adults, and that even the histologically benign somatic tissues in RMT after polychemotherapy are aneuploid.

Sarcoid reaction mimicking intrathoracic dissemination of testicular cancer

The close observation of patients treated for testicular cancer led to the suspicion of intrathoracic and/or mediastinal metastases on radiologic examination in a number of patients without other evidence of relapse. This report presents two patients with combined seminomatous and nonseminomatous germ cell tumors with isolated sarcoid reactions of hilar and interlobular lymph nodes, detected concomitant with diagnosis and 12 months after diagnosis, respectively. Histologic examination appears to be imperative in these cases to avoid unnecessary chemotherapy.

[Adjuvant regional isolation perfusion of the extremities of patients with stage I melanoma thicker than 1.5 mm]

The use of isolated regional perfusion with melphalan as an adjuvant treatment for stage I melanoma of the extremity continues to be controversial. The present retrospective study evaluates the past 25 years' experience by comparing 227 perfused patients from Groningen with 238 matched controls from five hospitals in The Netherlands and Westphalia (West Germany). All patients underwent wide local excision for a primary extremity melanoma of 1.5 mm or greater in thickness. A proportional hazards regression analysis for recurrence of disease and survival identified the significant prognostic factors, of which, besides level of infiltration, ulceration, age and sex, tumour thickness was found to be the most important. Corrected for these factors, it was not possible to demonstrate a statistically significant effect for perfusion in terms of time to limb recurrence (p = 0.61), time to regional lymph node metastasis (p = 0.11), time to distant metastasis (p = 0.73), disease-free interval (p = 0.42), and survival (p = 0.90). No statistically significant differences were seen for adjuvant perfusion in any of the subgroups.

Phase II study of carboplatin and cytosine arabinoside in patients with disseminated malignant melanoma

Twenty-one patients with disseminated malignant melanoma were treated with a combination of carboplatin and cytosine arabinoside. Two complete and three partial remissions occurred. No complete cross-resistance was found with a regimen containing 5-(dimethyltriazeno)imidazole-4-carboxamide (DTIC) in two patients. It is suggested that this regimen might be studied further as a second-line treatment for patients who fail on DTIC-containing treatment.

Cytogenetics of carcinoma in situ of the testis

Carcinoma in situ (CIS) of the testis is the precursor lesion of most testicular germ cell tumors (TGCTs). Karyotyping of CIS is important for a better understanding of the pathogenesis of TGCTs and the progression to invasive cancer. We karyotyped three cases of CIS. All three cases showed a numerical abnormal chromosomal pattern. In one case, two copies of the germ cell tumor marker i(12p) were found.

An extendable modular endoprosthetic system for bone tumour management in the leg

A modular endoprosthetic system has been developed at the Groningen University Hospital and the University of Twente. The system can bridge a defect resulting from the resection of a malignant bone tumour which has developed around the knee joint of a child. Since the other healthy leg continues to grow, the system includes an element whose length can be adjusted non-invasively by using an external magnetic field. In addition to this lengthening element, there are one hip and two knee components, connectors of various lengths, and fixation elements. The paper describes the elements of the modular endoprosthetic system. Tables are created by means of which the elemental composition of such an endoprosthesis can be determined for each individual patient.

Alpha-fetoprotein-lectin binding as a marker of tumour activity or liver damage

To establish whether alpha-fetoprotein (AFP) produced in the early post-treatment phase of a patient with a germ cell tumour of the testis or the ovary originates from the tumour or is due to an underlying disturbance in liver function, the binding of AFP to concanavalin A (Con A) was investigated as a discriminative variable. A two-step assay is described that can distinguish the type of AFP produced at levels as low as 10 ng/ml. A Con A-binding ratio of 12-43% was found in the patients with disseminated germ cell tumours and in patients with AFP-positive gastrointestinal carcinomas. AFP from the liver gives ratios below 10%.

Chromosomal damage in peripheral blood lymphocytes of patients treated for testicular cancer

We describe the presence of a large number of chromosome aberrations in lymphocytes of 50 patients with testicular cancer. These chromosomal aberrations were not only found in patients treated with chemotherapy but also in untreated patients or in patients after surgery alone. Our results suggest a role for genetic instability in the pathogenesis of testicular cancer. This instability might be a risk factor for the development of secondary malignancies.

Children born after their fathers had been treated with chemotherapy for testicular cancer

Twenty children fathered by 15 patients treated with platinum-based combination chemotherapy for disseminated testicular carcinoma were examined and found to have no evidence of congenital malformations. The results indicate no reason for advising against pregnancies in this group of young couples.

Chromosomal changes in human primary testicular nonseminomatous germ cell tumors

A cytogenetic analysis of 14 primary testicular nonseminomatous germ cell tumors has been carried out after short term tissue culture. The modal chromosome numbers ranged from 53 to 113, in agreement with flow cytometric determination of the DNA content of the tumors. At least one copy of an i(12p) was present in 12 tumors. Two tumors, however, lacked that marker. Some chromosomes are apparently overrepresented, whereas others are underrepresented, although some differences between seminomas and nonseminomas were noticed.

Magnetic resonance imaging (MRI) in evaluating in vivo response to neoadjuvant chemotherapy for osteosarcomas of the extremities

Limb-saving procedures for patients with osteosarcomas of the extremities are based on the anatomical localization and extent of the tumor. The effectiveness of neoadjuvant chemotherapy, high-dose methotrexate (HD MTX), was prospectively analyzed in patients using magnetic resonance imaging (MRI) and histologic evaluation of bone biopsies. Evaluation of in vivo response to neoadjuvant chemotherapy for osteosarcomas with MRI is a method which seems promising in predicting the histologic tumor reaction.

A malignant mixed gonadal stromal tumor of the testis with heterologous components and i(12p) in one of its metastases

A malignant mixed gonadal stromal tumor with mesenchymal heterologous elements of the testis is presented. This entity has been described in the ovary, but not hitherto in the testis. Karyotyping and ploidy measurement was done of the primary tumor and of an inguinal and lung metastases. The DNA ploidy and modal chromosome numbers were in agreement with each other in all samples. The most significant cytogenetic finding was the presence of the metacentric germ cell tumor marker i(12p) in an inguinal metastasis. This marker has been demonstrated in testicular and ovarian germ cell tumors and in a mixed Müllerian tumor, which raises the question of a possible relationship between the pluripotency of these tumors and the presence of i(12p).