Significance of human chorionic gonadotropin, alpha-fetoprotein, and pregnancy-specific beta-1-glycoprotein in the detection of tumor relapse and partial remission in 126 patients with nonseminomatous testicular germ cell tumors

Serum Tumour Markers in Testicular Germ Cell Tumours: Frequencies of Elevated Levels and Extents of Marker Elevation Are Significantly Associated with Clinical Parameters and with Response to Treatment

Introduction

Although serum tumor markers beta human chorionic gonadotropin (bHCG), alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH) are well-established tools for the management of testicular germ cell tumours (GCTs), there are only few data from contemporary cohorts of primary GCT patients regarding these biomarkers. Our aim was to evaluate marker elevations in testicular GCTs and to document their associations with various clinical characteristics.

Patients and Methods

A total of 422 consecutive patients with GCTs were retrospectively analysed regarding serum levels of bHCG, AFP, and LDH during the course of treatment. Additionally, the following characteristics were recorded: histology, age, laterality, clinical stage (CS), pT-stage, and tumour size. Marker elevations were first tabulated in dichotomized way (elevated: yes/no) in various subgroups and second as continuous measured serum values. Descriptive statistical methods were employed to look for differences among subgroups and for associations of elevations with clinical parameters.

Results

In all GCT patients, the frequencies of elevated levels of bHCG, AFP, LDH, and bHCG or AFP were 37.9%, 25.6%, 32.9%, and 47.6%; in pure seminomas 28%, 2.8%, 29.1%, and 30.3%; and in nonseminoma 53.0%, 60.1%, 38.7%, and 73.8%. Significant associations were noted with pT-stages >pT1, clinical stages >CS1, tumour size, and younger age. Frequencies of marker elevations dropped significantly after treatment, but LDH levels remained elevated in 30.5%-34.1%. Relapsing patients (n=27) had elevated levels of bHCG, AFP, and LDH in 25.9%, 22.2%, and 29.6%, respectively, thirteen of whom with a changed marker pattern.

Conclusions

The classical GCT-biomarkers correlate with treatment success. Clinical utility is limited due to proportions of < 50% of patients with elevated levels and the low specificity of LDH. The elevation rates are significantly associated with histology, clinical and pT-stages, tumour size, and younger age. Individual marker patterns may change upon relapse. Clinically, ideal biomarkers are yet to be found.

The diagnostic performance of current tumour markers in surveillance for recurrent testicular cancer: A diagnostic test accuracy systematic review

In this diagnostic test accuracy systematic review we summarise the evidence on the diagnostic accuracy of blood α-fetoprotein (AFP), human chorionic gonadotropin (HCG) and lactate dehydrogenase (LDH) in surveillance for testicular cancer recurrence in adults. We searched four electronic databases for studies that reported the diagnostic accuracy of HCG, AFP, and/or LDH in sufficient detail for sensitivity and specificity to be calculated by extracting a 2 × 2 table comparing biomarker positivity with testicular cancer recurrence. Screening, data extraction and QUADAS-2 quality assessment were completed by two independent reviewers. From 2406 studies, nine met our inclusion criteria. Eight reported data at the per-patient level. Sample sizes were small (range 5 to 449 patients) and clinical heterogeneity precluded meta-analysis. In most studies the specificity for recurrence with AFP and HCG was high (90-100%) but sensitivity was often relatively low, suggesting that many recurrences would not be detected by tumour markers alone. The diagnostic performance of LDH appears poorer. Studies were methodologically weak, with probable selection, incorporation and partial verification bias, and many studies were excluded for not reporting on recurrence-free patients. Limitations including small sample sizes, high heterogeneity, and inconsistent and incomplete reporting mean these results must be interpreted with caution. Despite inclusion of biomarkers in international surveillance guidance, there remains a lack of high quality evidence about their accuracy, optimal thresholds, and the most effective surveillance strategy in relation to contemporary investigative modalities. Higher quality research using data from modern-day follow-up cohorts is necessary to identify opportunities to reduce unnecessary testing.

National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines for Use of Tumor Markers in Testicular, Prostate, Colorectal, Breast, and Ovarian Cancers

Background: Updated National Academy of Clinical Biochemistry (NACB) Laboratory Medicine Practice Guidelines for the use of tumor markers in the clinic have been developed.

Methods: Published reports relevant to use of tumor markers for 5 cancer sites—testicular, prostate, colorectal, breast, and ovarian—were critically reviewed.

Results: For testicular cancer, α-fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase are recommended for diagnosis/case finding, staging, prognosis determination, recurrence detection, and therapy monitoring. α-Fetoprotein is also recommended for differential diagnosis of nonseminomatous and seminomatous germ cell tumors. Prostate-specific antigen (PSA) is not recommended for prostate cancer screening, but may be used for detecting disease recurrence and monitoring therapy. Free PSA measurement data are useful for distinguishing malignant from benign prostatic disease when total PSA is &lt;10 μg/L. In colorectal cancer, carcinoembryonic antigen is recommended (with some caveats) for prognosis determination, postoperative surveillance, and therapy monitoring in advanced disease. Fecal occult blood testing may be used for screening asymptomatic adults 50 years or older. For breast cancer, estrogen and progesterone receptors are mandatory for predicting response to hormone therapy, human epidermal growth factor receptor-2 measurement is mandatory for predicting response to trastuzumab, and urokinase plasminogen activator/plasminogen activator inhibitor 1 may be used for determining prognosis in lymph node–negative patients. CA15-3/BR27–29 or carcinoembryonic antigen may be used for therapy monitoring in advanced disease. CA125 is recommended (with transvaginal ultrasound) for early detection of ovarian cancer in women at high risk for this disease. CA125 is also recommended for differential diagnosis of suspicious pelvic masses in postmenopausal women, as well as for detection of recurrence, monitoring of therapy, and determination of prognosis in women with ovarian cancer.

Conclusions: Implementation of these recommendations should encourage optimal use of tumor markers.

An attempt to treat pediatric intracranial alphaFP and betaHCG secreting germ cell tumors with chemotherapy alone. SFOP experience with 18 cases. Société Française d'Oncologie Pédiatrique

PURPOSE

Intracranial alphaFP and betaHCG secreting germ cell tumors have a very poor prognosis with local treatment alone. Because of efficacy of chemotherapy in extracranial forms, we tried in the SFOP (Société Française d'Oncologie Pédiatrique) to treat them with chemotherapeutic treatment exclusively.

PATIENTS AND METHODS

Eighteen patients (10 alphaFP, 2 betaHCG, 6 alphaFP and betaHCG secretion) were enrolled from January 1988 to December 1992. After biological diagnosis patients were to receive 6 cycles of chemotherapy (vinblastine bleomycin - carboplatin or etoposide - carboplatin/ifosfamide - etoposide). After completion of chemotherapy, surgery was to be performed in case of residual tumor. Focal radiation was only to be delivered in case of viable residual tumor.

RESULTS

All patients had biological remission and tumor reduction. Fifteen patients were treated according to the protocol by chemotherapy alone (13) or chemotherapy and radiation of residue (2). Twelve of the 13 non irradiated patients relapsed, 8 in local and/or regional area, 3 in cerebrospinal area and 1 in undeterminated area with mild elevation of markers except in one case. Six patients are alive in second complete remission after chemotherapy and/or surgery and then a consolidation treatment with radiation and/or high dose chemotherapy (5) or craniospinal radiation (1). Three patients received radiation after 2 or 3 cycles of chemotherapy as protocol violations and didn't relapse. Thus, 12 patients out of the 18 patients are alive with a median follow up of 68 months. All but 1 had focal radiation as part of treatment. No toxic death was observed.

CONCLUSION

Although survival rate is noteworthy (66%), these tumors were not curable with this conventional chemotherapy alone and focal radiotherapy should be part of the treatment.

Alpha-fetoprotein half-life as a predictor of residual testicular tumor. Effect of the analytic strategy on test sensitivity and specificity

BACKGROUND

Alpha-fetoprotein (AFP) serum values after orchiectomy for testicular cancer can be used to predict the residual disease status. However, the optimal strategy for postorchiectomy marker analysis has not been studied. This article evaluated different analytic methods in an effort to identify the approach that provided the greatest sensitivity and specificity for occult residual disease.

METHODS

Statistical information on the AFP half-life (t1/2) derived from a clinical data set of 24 patients with AFP-secreting clinical Stage A testicular cancer and pathologically defined nodal status was incorporated into a mathematic model of postorchiectomy marker values as a function of residual tumor volume and time. The model was used to test the effect of various analytic strategies on detecting the residual tumor. The clinical data set then was analyzed to measure the effect of different analytic methods on the predictive value of the AFP t1/2.

RESULTS

In the model, the AFP t1/2 calculated from a single set of serum measurements obtained from the initial serum t1/2 was a poor predictor of disease status in patients with up to 40% residual tumor volume. Determined by the sequential addition of serum values obtained at normal t1/2 intervals, the AFP t1/2 improved in sensitivity but required up to seven serial values (35 days) to detect an abnormal t1/2 in patients with 10% residual tumor. By contrast, changes in the most recent interval t1/2 relative to the initial calculated t1/2 predicted the disease status in patients with 10% residual tumor after four t1/2 (20 days) and in patients with 1% residual volume after 35 days.

CONCLUSIONS

The use of this last strategy in the clinical data set improved both the sensitivity and specificity of the AFP t1/2 in predicting residual tumor relative to the other methods.

Elevated serum tumor markers in patients with testicular cancer after induction chemotherapy due to a reservoir of markers in cystic differentiated mature teratoma

Elevated serum tumor markers in patients with testicular cancer after induction chemotherapy indicate in most instances the presence of residual malignant disease. We describe 2 patients with elevated tumor markers after chemotherapy and before retroperitoneal lymph node dissection who did not prove to have residual malignant disease but cystic differentiated mature teratoma with a high content of alpha-fetoprotein and beta-human chorionic gonadotropin, respectively, in the cysts. It is postulated that leakage of the contents of these cysts to the plasma compartment was responsible for maintaining elevated serum tumor marker levels. Recognition of such entities is of consequence since unnecessary salvage chemotherapy in these patients may be avoided.

Clinical biochemistry of neuron specific enolase

The soluble brain protein 14-3-2 first described by Moore and McGregor in 1965 is now known to be a cell specific isoenzyme of the glycolytic enzyme enolase (EC 4.2.1.11), designated neuron specific enolase (NSE). It is not only a marker for all types of neurons, but also for all neuroendocrine or paraneuronal cells. The appearance of NSE is a late event in neural differentiation, thus making NSE a useful index of neural maturation. The demonstration that tumors of the nervous system and of neuroendocrine origin contain NSE has promoted the study of NSE as a possible tumor marker. Immunocytochemistry has been used to identify NSE in cytologic preparations from several types of tumors, offering useful indications for differential diagnosis. NSE levels in serum from tumor patients are not useful in the diagnosis of early stage disease. However, serum NSE levels have been shown to be helpful in the identification of advanced small cell lung cancer, neuroblastoma and several other neoplasms. The main use of serum NSE is the monitoring of chemotherapy and the detection of a relapse in these cases.

Prolonged survival in a patient with disseminated malignant teratoma in the presence of a persistently elevated serum alpha-fetoprotein level

The authors report a patient with disseminated malignant teratoma who has survived for 3.5 years after discontinuation of treatment despite a persistent and nonprogressive elevation of his serum alpha-fetoprotein level. Potential sources of the marker in his case are discussed and the possibility of a chemotherapeutically induced evolution of his tumor considered.

Clinical evaluation of basic fetoprotein in testicular cancer

We attempted to determine the efficacy of basic fetoprotein as a marker in testicular cancer. The levels of serum basic fetoprotein were studied in 58 patients (31 with seminoma and 27 with nonseminoma). Elevated levels were observed in 22 seminoma (71 per cent) and 15 nonseminoma (56 per cent) patients, while the levels of other markers (beta-subunit of human chorionic gonadotropin, alpha-fetoprotein and lactic dehydrogenase) remained normal in 6 seminoma (19 per cent) and 2 nonseminoma (7 per cent) patients. The levels of basic fetoprotein changed in relation to the clinical courses and they elevated again in 3 of 4 patients with recurrence. The concentration of basic fetoprotein in testicular cancer tissue was significantly higher than in the normal testis. Histological localization of basic fetoprotein in testicular cancer tissue was demonstrated immunohistochemically. Thus, basic fetoprotein was considered to be a useful serum marker for testicular cancer.

Serum neuron-specific enolase. A marker for responses to therapy in seminoma

Neuron-specific enolase (NSE) was evaluated as a serum marker in 105 patients with testicular cancer and compared with the established tumor markers alphafetoprotein (AFP) and human chorionic gonadotropin (HCG). Increased serum NSE activity was measured in eight of 11 (73%) patients with metastatic seminoma. Serum NSE concentrations fell to within the normal range following chemotherapy. Localization of NSE in seminoma cells was demonstrated immunohistochemically. Only six of 40 (15%) patients with metastatic nonseminomatous germ cell tumors showed elevated serum NSE levels. AFP and HCG were both positive in 70% of patients in this group, and NSE determination gave no additional information. Serum NSE concentrations were normal in 53 of 54 testicular cancer patients after orchiectomy and there was no evidence of metastatic disease; only one had borderline NSE levels, indicating the specificity of serum NSE determination. NSE is a new marker of seminoma and its measurement may be of clinical value in monitoring chemotherapy in patients with metastatic seminoma.

Immunosuppressive acidic protein in patients with testicular cancer

Serum immunosuppressive acidic protein was compared to lactic dehydrogenase as a marker for testicular cancer in 54 patients with testicular cancer, 62 with benign urological diseases and 203 healthy controls. The mean value of serum immunosuppressive acidic protein in patients with testicular cancer (598 +/- 293 micrograms. per ml.) was statistically higher than that in patients with benign disease (429 +/- 163 micrograms. per ml.) and healthy controls (368 +/- 73 micrograms. per ml.). There were statistically significant differences in serum immunosuppressive acidic protein levels between controls and patients with stage 2 (p less than 0.0001) or stage 3 (p less than 0.001) testicular cancer, and between those with stage 1 and stage 2 (p less than 0.0001) or stage 3 (p less than 0.001) disease, respectively. The usefulness of immunosuppressive acidic protein as a marker for testicular cancer also was compared to that of lactic dehydrogenase. Immunosuppressive acidic protein and lactic dehydrogenase levels were elevated almost equally in patients with stage 2 or 3 disease (range 71 to 92 per cent). However, immunosuppressive acidic protein levels were elevated in only 3 of 25 patients with stage 1 cancer (12 per cent), compared to 11 of 25 (44 per cent) with elevated lactic dehydrogenase levels. Immunosuppressive acidic protein was correlated better with tumor stage. In conclusion, serum immunosuppressive acidic protein determinations may be useful in patients with testicular cancer for staging, monitoring treatment results and predicting recurrence.

Trophoblastic proteins as tumor markers in nonseminomatous germ cell tumors

In order to examine the relative usefulness of measurements of oncoplacental proteins as tumor markers in patients with nonseminomatous germ cell tumors, the authors measured alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), pregnancy-specific beta 1-glycoprotein (SP1), human placental lactogen (hPL), and placental cystine aminopeptidase (oxytocinase, CAP) in serial blood samples obtained from 26 men with these neoplasms. HCG and AFP were each elevated in 62% of the patients and both were elevated in 38%. SP1 and hPL were increased in 31% and 12%, respectively. None of the patients had elevated CAP activity. Serum hCG and SP1 concentrations were strongly correlated (r = 0.78, P less than 0.001). No patient had an elevated SP1 without a concomitant elevation in serum hCG. Serial measurements of hCG and SP1 indicated that they were concordant in five of the eight patients in whom both were elevated, and AFP and hCG were concordant in only one half of the ten patients in whom both markers were elevated. The number of patients with hPL elevations were too few for meaningful comparison of this marker with the others. These results indicate that measurements of SP1, hPL, and CAP do not provide additional useful information over that obtained from measurements of hCG and AFP in patients with nonseminomatous germ cell tumors.

Pregnancy-associated plasma protein-A concentrations in men with testicular and prostatic tumors

Pregnancy-associated plasma protein-A (PAPP-A) is a macromolecular glycoprotein produced during pregnancy by the trophoblast and the decidua. It is not specific to pregnancy, since immunoreactive PAPP-A is in the circulation of normal women and men and in seminal fluid. Immunohistochemically, PAPP-A is localized in some Leydig cells, in the epididymis, in the rete testis, and in seminal vesicles. This study was conducted to learn whether circulating levels of PAPP-A can be used as a marker for the monitoring of human testicular cancer. PAPP-A was increased only in certain nonseminomatous germ cell tumor [malignant teratoma undifferentiated (MTU) + seminoma, malignant teratoma intermediate (MTI)], but the overlap with the normal values was too big for PAPP-A to have any clinical significance. After orchidectomy or prostatectomy, PAPP-A decreased but the levels were were similar to those of normal men. In men, PAPP-A can be produced by certain nonseminomatous germ cell tumors, but its origin in disease-free males is probably not the testis or the prostate.

Protein composition of cyst fluids from mature teratoma in patients with nonseminomatous germ cell tumors of the testis

Protein analyses were performed in 15 cyst fluids (CF) from mature teratoma (TD) and in 15 corresponding sera from 9 nonseminomatous germ cell tumor patients. Qualitatively, many similarities between the protein compositions of CF and corresponding sera were seen. Quantitative comparisons suggested free diffusion of plasma proteins into the cyst lumen in nine cases, whereas in five CF a decreased size selectivity of the blood-TD barrier was observed. From the quantitative data it was concluded that the significantly increased CCF/Cserum concentration ratios for the tumor markers alpha-fetoprotein (8/14), human chorionic gonadotropin (3/14), and carcinoembryonic antigen (13/13) as well as for lysozyme (12/13), ferritin (12/13), and fibronectin (3/6) were either due to local synthesis or to concentrating properties of the TD cells. The results of the current study encourage further research for new tumor-associated proteins in cyst fluids.