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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. BIOMED RESEARCH INTERNATIONAL 2019; 2019:5030349. [PMID: 31275973 PMCID: PMC6558624 DOI: 10.1155/2019/5030349] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/07/2019] [Indexed: 12/12/2022]
Abstract
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.
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Gilligan TD, Seidenfeld J, Basch EM, Einhorn LH, Fancher T, Smith DC, Stephenson AJ, Vaughn DJ, Cosby R, Hayes DF. American Society of Clinical Oncology Clinical Practice Guideline on Uses of Serum Tumor Markers in Adult Males With Germ Cell Tumors. J Clin Oncol 2010; 28:3388-404. [DOI: 10.1200/jco.2009.26.4481] [Citation(s) in RCA: 192] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
PurposeTo provide recommendations on appropriate uses for serum markers of germ cell tumors (GCTs).MethodsSearches of MEDLINE and EMBASE identified relevant studies published in English. Primary outcomes included marker accuracy to predict the impact of decisions on outcomes. Secondary outcomes included proportions of patients with elevated markers and statistical tests of elevations as prognostic factors. An expert panel developed consensus guidelines based on data from 82 reports.ResultsNo studies directly compared outcomes of decisions with versus without marker assays. The search identified few prospective studies and no randomized controlled trials; most were retrospective series. Lacking data on primary outcomes, most Panel recommendations are based on secondary outcomes (relapse rates and time to relapse).RecommendationsThe Panel recommended against using markers to screen for GCTs, to decide whether orchiectomy is indicated, or to select treatment for patients with cancer of unknown primary. To stage patients with testicular nonseminomas, the Panel recommended measuring three markers (α-fetoprotein [AFP], human chorionic gonadotropin [hCG], and lactate dehydrogenase [LDH]) before and after orchiectomy and before chemotherapy for those with extragonadal nonseminomas. They also recommended measuring AFP and hCG shortly before retroperitoneal lymph node dissection and at the start of each chemotherapy cycle for nonseminoma, and periodically to monitor for relapse. The Panel recommended measuring postorchiectomy hCG and LDH for patients with seminoma and preorchiectomy elevations. They recommended against using markers to guide or monitor treatment for seminoma or to detect relapse in those treated for stage I. However, they recommended measuring hCG and AFP to monitor for relapse in patients treated for advanced seminoma.
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Affiliation(s)
- Timothy D. Gilligan
- From the Taussig Cancer Institute and the Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; American Society of Clinical Oncology, Alexandria, VA; Memorial Sloan-Kettering Cancer Center, New York, NY; Indiana Cancer Pavilion, Indiana University, Indianapolis, IN; Patient Representative; University of Michigan Medical Center, Ann Arbor, MI; Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA; and Cancer Care Ontario, McMaster University, Hamilton, Ontario,
| | - Jerome Seidenfeld
- From the Taussig Cancer Institute and the Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; American Society of Clinical Oncology, Alexandria, VA; Memorial Sloan-Kettering Cancer Center, New York, NY; Indiana Cancer Pavilion, Indiana University, Indianapolis, IN; Patient Representative; University of Michigan Medical Center, Ann Arbor, MI; Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA; and Cancer Care Ontario, McMaster University, Hamilton, Ontario,
| | - Ethan M. Basch
- From the Taussig Cancer Institute and the Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; American Society of Clinical Oncology, Alexandria, VA; Memorial Sloan-Kettering Cancer Center, New York, NY; Indiana Cancer Pavilion, Indiana University, Indianapolis, IN; Patient Representative; University of Michigan Medical Center, Ann Arbor, MI; Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA; and Cancer Care Ontario, McMaster University, Hamilton, Ontario,
| | - Lawrence H. Einhorn
- From the Taussig Cancer Institute and the Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; American Society of Clinical Oncology, Alexandria, VA; Memorial Sloan-Kettering Cancer Center, New York, NY; Indiana Cancer Pavilion, Indiana University, Indianapolis, IN; Patient Representative; University of Michigan Medical Center, Ann Arbor, MI; Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA; and Cancer Care Ontario, McMaster University, Hamilton, Ontario,
| | - Timothy Fancher
- From the Taussig Cancer Institute and the Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; American Society of Clinical Oncology, Alexandria, VA; Memorial Sloan-Kettering Cancer Center, New York, NY; Indiana Cancer Pavilion, Indiana University, Indianapolis, IN; Patient Representative; University of Michigan Medical Center, Ann Arbor, MI; Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA; and Cancer Care Ontario, McMaster University, Hamilton, Ontario,
| | - David C. Smith
- From the Taussig Cancer Institute and the Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; American Society of Clinical Oncology, Alexandria, VA; Memorial Sloan-Kettering Cancer Center, New York, NY; Indiana Cancer Pavilion, Indiana University, Indianapolis, IN; Patient Representative; University of Michigan Medical Center, Ann Arbor, MI; Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA; and Cancer Care Ontario, McMaster University, Hamilton, Ontario,
| | - Andrew J. Stephenson
- From the Taussig Cancer Institute and the Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; American Society of Clinical Oncology, Alexandria, VA; Memorial Sloan-Kettering Cancer Center, New York, NY; Indiana Cancer Pavilion, Indiana University, Indianapolis, IN; Patient Representative; University of Michigan Medical Center, Ann Arbor, MI; Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA; and Cancer Care Ontario, McMaster University, Hamilton, Ontario,
| | - David J. Vaughn
- From the Taussig Cancer Institute and the Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; American Society of Clinical Oncology, Alexandria, VA; Memorial Sloan-Kettering Cancer Center, New York, NY; Indiana Cancer Pavilion, Indiana University, Indianapolis, IN; Patient Representative; University of Michigan Medical Center, Ann Arbor, MI; Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA; and Cancer Care Ontario, McMaster University, Hamilton, Ontario,
| | - Roxanne Cosby
- From the Taussig Cancer Institute and the Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; American Society of Clinical Oncology, Alexandria, VA; Memorial Sloan-Kettering Cancer Center, New York, NY; Indiana Cancer Pavilion, Indiana University, Indianapolis, IN; Patient Representative; University of Michigan Medical Center, Ann Arbor, MI; Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA; and Cancer Care Ontario, McMaster University, Hamilton, Ontario,
| | - Daniel F. Hayes
- From the Taussig Cancer Institute and the Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; American Society of Clinical Oncology, Alexandria, VA; Memorial Sloan-Kettering Cancer Center, New York, NY; Indiana Cancer Pavilion, Indiana University, Indianapolis, IN; Patient Representative; University of Michigan Medical Center, Ann Arbor, MI; Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA; and Cancer Care Ontario, McMaster University, Hamilton, Ontario,
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Application of stem cell markers in search for neoplastic germ cells in dysgenetic gonads, extragonadal tumours, and in semen of infertile men. Cancer Treat Rev 2008; 34:348-67. [PMID: 18289797 DOI: 10.1016/j.ctrv.2007.12.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2007] [Revised: 12/17/2007] [Accepted: 12/18/2007] [Indexed: 01/08/2023]
Abstract
Germ cell tumours (GCTs) are a complex entity. Current areas of attention include early detection and avoidance of unnecessary over-treatment. Novel findings regarding diagnosis of GCTs located in various anatomical sites are described, particularly testicular GCTs and their common progenitor, carcinoma in situ (CIS). Recognition of CIS enables intervention before tumour development, but nevertheless, testicular GCTs are sporadically diagnosed at the pre-invasive stage where minimal treatment is necessary. As presence of CIS is asymptomatic, a simple screening method is needed when CIS is suspected (i.e. in males investigated for infertility). To develop approaches for early detection CIS gene expression studies have been performed showing many similarities with embryonic stem cells with confirmation of established markers (i.e. PLAP, OCT-3/4, KIT) and identification of novel markers (i.e. AP-2 gamma, NANOG). We have reported a very promising new approach of AP-2 gamma (or OCT3/4) based immunocytological semen analysis (specificity 93.6%, sensitivity 54.5%). Comparative studies of gonadal/extragonadal GCTs have revealed resemblance pointing towards similar, but not identical, origins. Moreover, infertility and testicular cancer are connected in the 'Testicular Dysgenesis Syndrome' and 25% of contralateral testes from testicular GCT patients harbour dysgenetic features, including impaired spermatogenesis. Thus, recent data have provided potential diagnostic tools including CIS detection in semen, microarray-based tumour classification, additional serological GCT markers, and novel stem cell markers for immunohistochemical diagnosis of gonadal and extragonadal GCTs. Many CIS candidate genes are yet uninvestigated, and information from these could increase knowledge about CIS tumour initiation/progression and be used for optimisation of a non-invasive detection method.
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