Markers and management of germ-cell tumours of the testes

Management of Stage II Germ Cell Tumors: Be Sure, Be Patient, Be Safe

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.A healthy 27-year-old man discovered a left testicular mass. Several months later he saw an urologist, who palpated a suspicious mass on the left testicle; an ultrasound confirmed a 2-cm solid mass. Serum tumor marker testing disclosed a slightly elevated alpha-fetoprotein (AFP) of 12.3 µg/L (upper limit of normal, 8.0 µg/L), and a normal β-human chorionic gonadotropin (HCG). Staging imaging with a contrast-enhanced computed tomography (CT) scan of the chest/abdomen/pelvis showed no evidence for retroperitoneal lymphadenopathy or distant metastases. He underwent a left radical orchiectomy, and pathology showed a 1.5-cm mixed germ cell tumor with 85% embryonal, 10% yolk sac tumor, and 5% mature teratoma histologies. Lymphovascular invasion was present. His AFP normalized after surgery. After discussion of management alternatives, he chose active surveillance, but 4 months later a scheduled surveillance CT scan identified a 1.4-cm left para-aortic lymph node just below the left renal hilum (Fig 1). Serum tumor markers remained negative. He returns to discuss his results and potential management options.

Cancer risk in male factor-infertility

Severe forms of male-factor infertility are associated with an increased risk of testicular cancer and scrotal ultrasonography is widely used for diagnosis. In this study, 2172 male members of infertile couples referred to our Reproductive Medicine Unit were submitted to scrotal ultrasonography and 835 selected patients had been followed during a 2-year period. Eight out of nine neoplastic nodules found at the initial examination were unpalpable and discovered by ultrasonography. Ten tumoral lesions were found in 370 testicular biopsies performed for diagnostic purposes or to extract spermatozoa; and eight additional neoplastic lesions were discovered during the 2-year follow-up of 835 patients. The cumulative rate of neoplastic disease was 3.2%. Thirteen cases (1.5%) were malignant (12 germ cell tumours and one non-Hodgkin lymphoma of testicular origin); the remaining 14 were benign forms (Leydig cell tumours and hyperplasias, Sertoli cell nodules, adenomatoid tumours). Testicular volume (cut-off: 12ml) resulted weakly correlated with germ cell cancer (p=n.s., odds ratio 2.01) while low total sperm count (<40x10(6)) (p=0.002, odds ratio 8.4), previous cryptorchidism (p=0.04, odds ratio 7.5) and hypergonadotrophic hypogonadism (p=0.04, odds ratio 7.9) were associated with an increased risk. But a stronger correlation with germ cell cancer was found in the patients with some utrasonographic anomalies, i.e. testicular microlithiasis (p=0.0015, odds ratio 37.1) or larger calcifications not fitting the description of testicular microlithiasis (p<0.0001, odds ratio 69.5). Our findings indicate that scrotum ultrasonography should always be advised in subfertile men with <40x10(6) spermatozoa/ejaculate or hypergonadotrophic hypogonadism or previous cryptorchidism, and that particular care should be taken in the presence of testicular microlithiasis or testicular calcifications. These men should be aware of the existence of higher risk of testicular cancer and trained in testicular self-examination.

Advances in the management of non-seminomatous germ cell tumors during the cisplatin era: A single-institution experience

BACKGROUND

The objectives of the present study were to review chronological changes in the long-term survival of patients with non-seminomatous germ cell tumor (NSGCT) who were treated at a single institution after the introduction of cisplatin-based combination chemotherapy.

METHODS

One hundred and twenty patients with NSGCT who were treated between January 1978 and October 2001 were enrolled in this study. To evaluate chronological changes in treatment outcome between 1978 and 2001, data were analyzed according to the timing of initial treatment in two consecutive 12-year periods. The numbers of patients who were treated during 1978-1989 and 1990-2001 were 59 and 61, respectively. Patients were classified according to criteria of both the Japanese Urological Association (JUA classification) and the International Germ Cell Cancer Collaborative Group (IGCCCG classification).

RESULTS

The mean follow up of surviving patients during the periods 1978-1989 and 1990-2001 was 84 months and 63 months, respectively. The overall 5-year survival rate of patients with NSGCT significantly increased from 72.8% during the period 1978-1989 to 83.6% during the period 1990-2001 (P = 0.02, log-rank test). A significant improvement in survival was found in the patients with stage III disease, according to the JUA classification, and in the patients with poor-risk disease, according to the IGCCCG classification (P = 0.004 and 0.05, respectively).

CONCLUSIONS

The overall 5-year survival rate of patients with NSGCT increased significantly from 72.8% during 1978-1989 to 83.6% during 1990-2001. This improvement resulted mainly from an increased survival of patients with metastatic poor-risk NSGCT.

Quality of life of survivors of testicular germ cell cancer: a review of the literature

GOALS OF WORK

Testicular cancer (TC) affects young men in the prime of life. The excellent prognosis and an increasing incidence have led to a growing number of testicular cancer survivors (TCSs). The aim of this review was to summarize and discuss research findings on the quality of life (QOL) of TCSs in terms of physical, psychological, and social well-being.

PATIENTS AND METHODS

Literature databases were used to identify studies published between 1980 and 2003. A quality assessment using methodological and treatment-related criteria was performed to distinguish stronger- from poorer-quality studies.

MAIN RESULTS

Twenty-three studies met the inclusion criteria. Quality assessment showed that seven studies were qualitatively stronger. The majority of TCSs in both stronger and poorer quality studies reported a good QOL. Prospective and retrospective studies showed that QOL after completion of treatment increased and negative consequences of TC on life decreased compared to the situation directly after diagnosis. The stronger-quality studies reported mainly on physical and psychological well-being but did not examine social well-being and the impact of treatment-related characteristics comprehensively.

CONCLUSIONS

Both stronger- and poorer-quality studies indicate that the majority of TCSs experience a good QOL, but the shortcomings on both the methodological and content level prevent us from drawing such a conclusion. Additional research with strong designs is needed to gain clearer insight into the QOL of TCSs as a group and of individuals at risk for physical, psychological, and social problems.

[Cardiac changes in mediastinal seminoma]

Primary pure cell seminoma of the mediastinum is a rare and potentially fatal lesion. Encroachment or invasion of adjacent structures is common, as are distant metastases. We present an unusual case of mediastinal seminoma with directly intracavitary invasion into the right atrium and extension to the left atrium. A 22-year-old male with right side chest pain, progressive cough, dyspnea, fever and right arm swelling lasting about a month is presented. Chest radiography on admission revealed a large mass in the anterior mediastinum. A cardiac ultrasonographic examination showed right atrial compression by the mass, with invasion of the right atrium wall. We also found polyp-like (about 2.5 cm in diameter) masses in left atrium near the area of the right pulmonary veins and a circumferential pericardial effusion. Percutaneous needle biopsy revealed mediastinal seminoma. To our knowledge, no similar case has been previously reported.

Cardiovascular disease as a long-term complication of treatment for testicular cancer

PURPOSE

To assess the risk of cardiovascular morbidity and cardiac risk factors in long-term survivors of testicular cancer according to treatment received.

PATIENTS AND METHODS

All resident male patients registered in the United Kingdom between 1982 and 1992 attending for follow-up were eligible for recruitment. Patients completed a current health questionnaire and underwent clinical review, along with hematologic, biochemical, and hormonal profiles. For patients not under routine review, follow-up information was sought from their general practitioner and mortality data were sought from the Office of National Statistics. Descriptive analysis was performed on all variables and comparisons were made among patients treated by orchidectomy and follow-up only, chemotherapy alone (C), radiotherapy alone (RT), and radiotherapy and chemotherapy (C/RT).

RESULTS

Data on cardiovascular events were available on 992 patients. After a median follow-up of 10.2 years, 68 events had been reported, including 18 deaths. After adjusting for age, increased risk for cardiac events was seen after C (relative risk [RR] = 2.59; 95% confidence interval [CI], 1.15 to 5.84; P =.022), RT (RR = 2.40; 95% CI, 1.04 to 5.45; P =.036), and C/RT (RR = 2.78; 95% CI, 1.09 to 7.07; P =.032). There were no significant differences in cardiac risk factors. On multivariate analysis, age, treatment group, free thyroxine, protein, and magnesium levels were associated with cardiovascular disease.

CONCLUSION

In long-term survivors of testicular cancer, we observed a two-fold or greater risk of developing cardiovascular disease. This was not due to increases in cardiac risk factors, which suggests a direct or indirect treatment effect. These data support the continued research into the minimization of treatment in good-prognosis testicular cancer.

Lung resistance-related protein as a predictor of clinical outcome in advanced testicular germ-cell tumours

This study was undertaken to investigate the expression and predictive value for outcome of multidrug resistance-associated (MDR) proteins P-glycoprotein (Pgp), MRP1, BCRP, and LRP, in advanced testicular germ-cell tumours (TGCT). Paraffin-embedded sections from 56 previously untreated patients with metastatic TGCT were immunostained for Pgp, MRP1, BCRP, and LRP. All patients received platinum-based chemotherapy after orchidectomy. Immunostaining was related to clinicopathological parameters, response to chemotherapy, and outcome. Strong and intermediate expressions of the different MDR-related proteins were: 27 and 41% (Pgp), 54 and 37% (MRP1), 86 and 7% (BCRP), and 14 and 29% (LRP). P-glycoprotein and MRP1 associated, respectively, to low AFP (P=0.026) and high LDH levels (P=0.014), whereas LRP expression associated with high beta-hCG levels (P=0.003) and stage IV tumours (P=0.029). No correlation was found between Pgp, MRP1, and BCRP expression and response to chemotherapy and survival. In contrast, patients with LRP-positive tumours (strong or intermediate expression) had shorter progression-free (P=0.0006) and overall survival (P=0.0116) than LRP-negative patients, even after individual log-rank adjustments by statistically associated variables. Our data suggest that a positive LRP immunostaining at the time of diagnosis in metastatic TGCT is associated with an adverse clinical outcome.

Non-germ cell malignancy in residual or recurrent mass after chemotherapy for nonseminomatous testicular germ cell tumor

BACKGROUND

After chemotherapy for nonseminomatous testicular germ cell tumor (NSTGCT), residual masses or recurrent disease may contain a non-germ cell malignancy (NGCM).

METHODS

Over 20 years, 369 patients with disseminated NSTGCT were treated with cisplatin-based polychemotherapy at the University Medical Center Groningen. Residual tumor masses were resected in 244 patients and recurrent tumor masses in 37 patients. Histology was reviewed, focusing on the presence of NGCM.

RESULTS

Nine patients developed an NGCM. Four patients had an NGCM in the resected residual tumor mass after chemotherapy: three patients had a sarcoma, and one patient had both a sarcoma and an adenocarcinoma. Five patients developed a late recurrence with an NGCM after 39, 40, 72, 72, and 84 months. One patient had a primitive neuroectodermal tumor, one had a sarcoma, and three had an adenocarcinoma in the resected recurrent tumor mass. A complete surgical resection was achieved in five (56%) of the nine patients. After a median follow-up of 48 months (range, 3-271 months), five patients had no evidence of disease (56%), three patients were dead of disease (33%), and one patient was alive with disease (11%).

CONCLUSIONS

Sarcoma, adenocarcinoma, or both in residual or recurrent tumor masses after combined-modality NSTGCT treatment are rare. Complete surgical resection of the tumor mass is the only curative treatment option.

Predicting the risk of bleomycin lung toxicity in patients with germ-cell tumours

BACKGROUND

Bleomycin pulmonary toxicity (BPT) has been known since the early clinical trials of bleomycin in the 1960s. Postulated risk factors include cumulative bleomycin dose, reduced glomerular filtration rate (GFR), raised creatinine, older age and supplemental oxygen exposure.

PATIENTS AND METHODS

From our prospectively collected testicular cancer research database, we reviewed 835 patients treated at the Royal Marsden NHS Trust (Sutton, UK) with bleomycin-containing regimens for germ-cell tumours between January 1982 and December 1999, to identify those with BPT.

RESULTS

Fifty-seven (6.8%) patients had BPT, ranging from X-ray/CT (computed tomography) changes to dyspnoea. There were eight deaths (1% of patients treated) directly attributed to BPT. The median time from the start of bleomycin administration to documented lung toxicity was 4.2 months (range 1.2-8.2). On multivariate analysis, the factors independently predicting for increased risk of BPT were GFR <80 ml/min [hazard ratio (HR) 3.3], age >40 years (HR 2.3), stage IV disease at presentation (HR 2.6) and cumulative dose of bleomycin >300,000 IU (HR 3.5).

CONCLUSIONS

Patients with poor renal function are at high risk of BPT, especially if they are aged >40 years, have stage IV disease at presentation or receive >300,000 IU of bleomycin. In such cases alternative drug regimens or dose restriction should be considered.

Surgery in testis cancer: laparoscopic and open techniques

PURPOSE OF REVIEW

The review focuses on the current developments of the management of patients with testis cancer regarding surgery. For clinical stage I and stage II disease, the pros and cons of surgery as a diagnostic and therapeutic tool are updated. Additionally, the emerging role of laparoscopic techniques in the staging of the disease is critically discussed. The review presents the currently changing indications for surgery in addition to chemotherapy in metastatic disease.

RECENT FINDINGS

The complication rates of primary retroperitoneal lymph node dissection have recently been assessed by the German Testicular Cancer Study Group. These data confirm the excellent results of the Indiana series published some years ago. Laparoscopic surgery has been performed in a larger cohort of patients in specialized centers, and, concomitantly, operative times and complication rates have dropped. Indications for surgery in the post-chemotherapy setting have been more clearly defined recently. Seminoma patients usually do not need surgical removal of the residual tumor after chemotherapy, whereas patients with non-seminoma disease probably need surgery even in cases of complete radiological remission after chemotherapy. In view of the recent data on late relapse, complete surgical removal of residual disease for non-seminoma seems of the utmost importance.

SUMMARY

Larger series of surgical procedures, laparoscopic as well as open, have helped to define the role of this approach in the management of testis cancer. Long-term data on patients with complete response to initial treatment and late relapse have shown the danger of limiting the treatment of metastatic disease to chemotherapy alone. These data have also shown the importance of proper surgical techniques for all stages of testis cancer.

Diagnostic delay and risk of relapse in patients with stage I nonseminomatous germ cell tumour followed on active surveillance

OBJECTIVE

To determine whether delayed diagnosis affects the outcome of patients with stage I nonseminomatous germ cell tumour (NSGCT) followed by a policy of 'active surveillance'.

PATIENTS AND METHODS

A series of 185 consecutive patients with either low-risk (no vascular invasion) or unknown risk stage I NSGCT referred to Mount Vernon Hospital between 1983 and 1998 were analysed retrospectively for the type and duration of symptoms before orchidectomy, time to relapse, and for site and stage of relapse.

RESULTS

Twenty-six patients (14%) relapsed within a medium follow-up of 98 months. The median (range) time to relapse was 4 (1-14) months. All patients were effectively salvaged with chemotherapy and in some by surgery. The median duration of symptoms before orchidectomy for those patients relapsing was 2 months, and not significantly different from those who did not relapse.

CONCLUSIONS

In patients with stage I NSGCT the duration of symptoms before diagnosis did not influence the probability of relapse.

Surgery versus surveillance in stage I non-seminoma testicular cancer

Today, the standard treatment for patients with clinical Stage I non-seminomatous testicular germ cell tumors (NSTGCT) following orchidectomy is either primary retroperitoneal lymph node dissection (RPLND) or close surveillance with cisplatin-based polychemotherapy in case of a relapse. Both treatment modalities provide excellent overall survival rates up to 100%. Consequently, selection of the most appropriate management option is not primarily guided by survival considerations. The choice between the available options, each having its merits and its drawbacks, should be made based on a number of factors including treatment-related morbidity, views and expertise of the physician, patient preferences, the expected degree of patient compliance, and prognostic factor analysis. To date, the role of adjuvant chemotherapy as an alternative management option for patients with clinical Stage I NSTGCT at high risk of occult metastases is limited. This systemic treatment modality would be a realistic alternative if the reliability of prognostic factors to identify high-risk Stage I patients could be improved. This review addresses relevant issues in the management of patients with clinical Stage I NSTGCT to provide information that will allow a rational selection of the most appropriate management option.

The changing distribution of stage in nonseminomatous testicular germ cell tumours, from 1977 to 1996

OBJECTIVE

To determine the changes between 1977 and 1996 in the distribution of stages of testicular cancer (TC).

PATIENTS AND METHODS

The stage distribution was assessed, using various classifications, i.e. the Royal Marsden (RM), Indiana, European Organization for Research and Treatment of Cancer (EORTC), International Germ Cell Cancer Collaborative Group (IGCCCG) and the Medical Research Council (MRC), in 517 patients with nonseminomatous testicular germ cell tumours (NSTGCTs) diagnosed at a single institution between 1977 and 1996.

RESULTS

The number of patients in four consecutive 5-year periods (1977-81, 1982-86, 1987-91, 1992-96) was 119, 141, 141, and 116, respectively. Frequency analyses showed a significant increase of RM stage I, in proportion to stage II-IV, in 1982-86 (55%, odds ratio, OR, 2.54), 1987-91 (53%, OR 2.33) and 1992-96 (61%, OR 3.24) compared to the period 1977-81 (33%). A separate analysis of patients with disseminated disease showed a proportionate significant decrease of RM stage II in 1992-96 (29%, OR 0.43) compared with 1977-81 (49%). There was also a relative decrease of good-prognosis patients with disseminated disease in 1992-96 compared with 1977-81, using analyses of the Indiana (from 56% to 33%, OR 0.39) and EORTC classification (from 78% to 56%, OR 0.36). Analyses of the IGCCCG and MRC classification showed a significant decrease of good-prognosis patients in the 1982-86 compared with the first 5-year period (for IGCCCG, from 54% to 35%, OR 0.46, and for MRC, from 43% to 24%, OR 0.42).

CONCLUSION

The stage distribution of NSTGCT over the past two decades has changed. The proportion of stage I patients has increased since the early 1980s, apparently resulting from a shift of low-extent disseminated disease to stage I disease. This finding is relevant in reducing the treatment required in a higher proportion of patients and the subsequent reduction of long-term risk from treatment.