Serum alpha-fetoprotein surge after the initiation of chemotherapy for non-seminomatous testicular cancer has an adverse prognostic significance

'FLARE' of tumor marker in advanced gastric cancer treated with first-line systemic therapy

BACKGROUND

Transient tumor marker elevations caused by chemotherapy were defined as 'Flare' and have been demonstrated in some solid tumors. In clinical practice, we observed that some patients were accompanied by elevated tumor markers during treatment, but subsequent imaging proved that the treatment they received was effective.

OBJECTIVES

We aimed to study the Flare and the prognosis in advanced gastric cancer.

DESIGN

This is an observational retrospective study. A total of 167 patients were enrolled in this study. Carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19-9 and CA125 values were obtained before the first, second, third, fourth, fifth and sixth cycles of treatment, respectively.

METHODS

Imaging for the first efficacy assessment was reviewed according to the Response Evaluation Criteria in Solid Tumors 1.1 (RECIST 1.1) criteria. Kaplan-Meier analyses and log-rank tests were performed for overall survival (OS) analyses. Univariate and multivariate Cox analyses were used to determine the prognostic factor for OS and progression-free survival (PFS).

RESULTS

37.1% of patients were accompanied with at least one tumor marker Flare during the course of treatment. The median time to tumor marker peak was 24-30 days and the Flare duration lasted 49-53 days. Patients with tumor markers Flare had a worse OS. Flare may be associated with the use of 5-fluorouracil. Baseline CEA and CA125 levels were the independent prognostic factors for OS and baseline CA125 level was the independent prognostic factor for PFS.

CONCLUSION

Initial elevation of tumor markers during treatment is not an indication of tumor progression. Patients with tumor markers 'Flare' may had a worse OS.

The value of serum thyroglobulin alteration after ultrasonography-guided fine-needle biopsy of suspicious cervical lymph nodes in the diagnosis of metastasis in patients with differentiated thyroid cancer

BACKGROUND

It is known that serum thyroglobulin (TG) can increase after fine-needle biopsy of thyroid nodules. We aimed to determine whether TG is increased after ultrasonography (US)-guided fine needle capillary biopsy (FNC) of suspicious cervical lymph nodes (LNs) in thyroidectomised patients and investigate the possible association between change in TG and cytology results.

MATERIAL AND METHODS

Data of 188 patients who underwent FNC of suspicious cervical LNs were retrospectively evaluated. Demographical, laboratory and ultrasonography features of LNs were noted. TG levels before FNC (TG_b-FNC ), after FNC (TG_a-FNC ), TG_a-FNC /TG_b-FNC ratio and the number of patients with increased TG were determined. Patients were grouped as benign, nondiagnostic, suspicious for malignancy and malignant according to the cytological results.

RESULTS

TG_a-FNC , TG_b-FNC /TG_a-FNC and rate of patients with increased TG were significantly higher in malignant cytology group than other groups (P < .001). The optimal cut-off level of TG increase that was predictive for malignancy was 7.6% with a sensitivity of 73.7% and specificity of 85.2%. TG increase was not associated with age, sex, Thyroid-stimulating hormone (TSH) level, anti-TG positivity and US features of LNs while significantly lower in patients who received radioactive iodine (RAI) treatment. Among 31 patients with positive anti-TG, TG_b-FNC /TG_a-FNC , and rate of patients with increased TG were higher in malignant compared to benign and nondiagnostic cytology groups.

CONCLUSIONS

Serum TG increment and rate of patients with increased TG after FNC of suspicious cervical LNs were higher in patients with malignant cytology than with all other cytology results both in all study group and in sub-group of anti-TG positive patients. Increase in TG after FNC might be an additional tool for determining LN metastasis.

Serum thyroglobulin elevation after needle aspiration of the lymph nodes: the predictive value for detecting metastasis in papillary thyroid cancer patients - a pilot study

Ultrasonography (USG)-guided fine needle aspiration (FNA) is widely used for diagnosis of lymph node (LN) metastasis in papillary thyroid cancer (PTC). However, FNA cytology sometimes shows inconclusive results. Recently, the measurement of thyroglobulin (Tg) in FNA washout fluid (aspirate-Tg) has been widely adopted, but there are some difficulties in the preparation of the sample and standardization of the procedure. Here, we examined serum Tg after FNA as a new predictive marker for LN metastasis of PTC. We performed USG-guided FNA cytology and examined aspirate-Tg in PTC patients showing suspicious metastatic LNs during follow-up. We measured baseline serum thyroid stimulating hormone (TSH), Tg, and Tg antibody levels before FNA, and serum Tg level within an hour after FNA. We defined aspirate-Tg level above 0.9 ng/mL as positive, and a 30% increase in serum Tg level after FNA compared to the baseline as elevation of serum Tg. Twenty-two patients were included in our study. Nine patients (40.9%) showed elevation of Tg level after FNA, and the mean value of Tg elevation was 24.8 ± 48.0 ng/mL. Among these 9 patients, 8 were diagnosed with PTC and 1 patient showed cellular atypia on cytopathology. All these patients showed positive aspirate-Tg. Thirteen patients (59.1%) did not show elevation of Tg level after FNA. Among these patients, 2 had PTC, 2 had cellular atypia, and 9 yielded negative results for malignancy on cytopathology. Elevation of serum Tg level after FNA might have a diagnostic role for predicting LN metastasis of PTC.

The present and future of serum diagnostic tests for testicular germ cell tumours

Testicular germ cell tumours (GCTs) are the most common malignancy occurring in young adult men and the incidence of these tumours is increasing. Current research priorities in this field include improving overall survival for patients classified as being 'poor-risk' and reducing late effects of treatment for patients classified as 'good-risk'. Testicular GCTs are broadly classified into seminomas and nonseminomatous GCTs (NSGCTs). The conventional serum protein tumour markers α-fetoprotein (AFP), human chorionic gonadotrophin (hCG) and lactate dehydrogenase (LDH) show some utility in the management of testicular malignant GCT. However, AFP and hCG display limited sensitivity and specificity, being indicative of yolk sac tumour (AFP) and choriocarcinoma or syncytiotrophoblast (hCG) subtypes. Furthermore, LDH is a very nonspecific biomarker. Consequently, seminomas and NSGCTs comprising a pure embryonal carcinoma subtype are generally negative for these conventional markers. As a result, novel universal biomarkers for testicular malignant GCTs are required. MicroRNAs are short, non-protein-coding RNAs that show much general promise as biomarkers. MicroRNAs from two 'clusters', miR-371-373 and miR-302-367, are overexpressed in all malignant GCTs, regardless of age (adult or paediatric), site (gonadal or extragonadal) and subtype (seminomas, yolk sac tumours or embryonal carcinomas). A panel of four circulating microRNAs from these two clusters (miR-371a-3p, miR-372-3p, miR-373-3p and miR-367-3p) is highly sensitive and specific for the diagnosis of malignant GCT, including seminoma and embryonal carcinoma. In the future, circulating microRNAs might be useful in diagnosis, disease monitoring and prognostication of malignant testicular GCTs, which might also reduce reliance on serial CT scanning. For translation into clinical practice, important practical considerations now need addressing.

Transient therapy-related surge in serum tumor biomarkers: characterizing behavior and postulating its biologic role

A phenomenon of serum tumor biomarker surge or flare that ensues shortly after initiating cancer therapy and that may precede the actual therapeutic response-related decline is poorly understood and remains under-appreciated. However, it may have a significant clinical implication as it could be misinterpreted in clinical practice as therapeutic failure and lead to a premature discontinuation of potentially effective therapy. Therefore, in the present study, attempts have been made to understand the behavior of this phenomenon with respect to a reported median incidence, duration, and its relationship to clinical response. The results of these analyses suggest a significantly lower incidence of this phenomenon with carcinoembryonic antigen (CEA) as determined in colorectal cancer and prostate specific antigen (PSA) in prostate cancer as compared to the other biomarkers studied (p=0.006). Furthermore, regardless of the type of biomarker or the extent of its incidence, a therapy-related initial surge appears to correlate with eventual response to therapy. Although, the biologic significance of this phenomenon is currently elusive, two distinct hypothesis-generating cases with CEA and alpha-fetoprotein (AFP) are presented that, if supported by further research, would provide insights into the role of a biomarker surge in overall tumor growth control by cancer therapy.

American Society of Clinical Oncology Clinical Practice Guideline on Uses of Serum Tumor Markers in Adult Males With Germ Cell Tumors

Purpose

To provide recommendations on appropriate uses for serum markers of germ cell tumors (GCTs).

Methods

Searches 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.

Results

No 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).

Recommendations

The 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.

Evidence-based treatment for advanced germ cell tumor of the testis with a case illustration

Testicular germ cell tumor is rare in the Asian population. Nevertheless, it is a prototypic cancer of young adults because it can be highly malignant but is also highly curable, even at an advanced stage. We present a case with far-advanced embryonal carcinoma, treated with bleomycin, etoposide and platinum (BEP) x 4 cycles. This case has shown very good results from the treatment. This is the standard therapy for poor- and intermediate-risk patients with germ cell tumors in the advanced stage, supported by current evidence-based literature. BEP x 3 cycles or EP x 4 cycles is the standard therapy for good-risk patients with advanced germ cell tumors. Using these treatments, we can achieve durable remissions of approximately 90%, 75%, and 45% in good-, intermediate-, and poor-risk patients, respectively. However, the physical and psychological long-term outcomes should be carefully monitored.

Predictive value of modeled AUC(AFP-hCG), a dynamic kinetic parameter characterizing serum tumor marker decline in patients with nonseminomatous germ cell tumor

OBJECTIVE

The early decline profile of alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) in patients with nonseminomatous germ cell tumors (NSGCT) treated with chemotherapy may be related to the risk of relapse. We assessed the predictive values of areas under the curve of hCG (AUC(hCG)) and AFP (AUC(AFP)) of modeled concentration-time equations on progression-free survival (PFS).

METHODS

Single-center retrospective analysis of hCG and AFP time-points from 65 patients with IGCCCG intermediate-poor risk NSGCT treated with 4 cycles of bleomycin-etoposide-cisplatin (BEP). To determine AUC(hCG) and AUC(AFP) for D0-D42, AUCs for D0-D7 were calculated using the trapezoid rule and AUCs for D7-D42 were calculated using the mathematic integrals of equations modeled with NONMEM. Combining AUC(AFP) and AUC(hCG) enabled us to define 2 predictive groups: namely, patients with favorable and unfavorable AUC(AFP-hCG). Survival analyses and ROC curves assessed the predictive values of AUC(AFP-hCG) groups regarding progression-free survival (PFS) and compared them with those of half-life (HL) and time-to-normalization (TTN).

RESULTS

Mono-exponential models best fit the patterns of marker decreases. Patients with a favorable AUC(AFP-hCG) had a significantly better PFS (100% vs 71.5%, P = .014). ROC curves confirmed the encouraging predictive accuracy of AUC(AFP-hCG) against HL or TTN regarding progression risk (ROC AUCs = 79.6 vs 71.9 and 70.2 respectively). Because of the large number of patients with missing data, multivariate analysis could not be performed.

CONCLUSION

AUC(AFP-hCG) is a dynamic parameter characterizing tumor marker decline in patients with NSGCT during BEP treatment. Its value as a promising predictive factor should be validated.

PSA surge/flare-up in patients with castration-refractory prostate cancer during the initial phase of chemotherapy

BACKGROUND

Docetaxel-based chemotherapy has shown great promise for the treatment of CRPC and is considered the current standard of care. PSA is mainly used as marker to monitor the treatment response. Several articles were published reporting an initial PSA surge/flare-up after starting chemotherapy. The cause and the impact of this phenomenon are discussed controversially. The intention of this review is to define the significance of initial PSA surge/flare-up and to increase awareness to this phenomenon in the urological community.

MATERIALS AND METHODS

A comprehensive literature search was performed in different data bases using various key words. Relevant articles and references between 1999 and 2009 were reviewed and analyzed for data on the association between chemotherapy and initial PSA surge/flare.

RESULTS

The incidence of a PSA surge/flare-up ranges according to the reported studies between 7.6% and 13.6%. A PSA surge/flare-up was reported up to 404% from baseline PSA level followed by PSA response. The median duration of a PSA surge/flare-up is 2-3 weeks and can last up to 6-8 weeks. However, the occurrence of a PSA surge/flare-up did not impact outcome and survival negatively compared to patients with an immediate PSA response.

CONCLUSIONS

A considerable portion of CRPC patients experience an initial PSA surge/flare-up under systemic chemotherapy. The definitions used for PSA surge/flare-up differ slightly in the literature. This issue needs to be solved since it might impact defining treatment response. As a PSA surge/flare-up did not impact outcome and survival negatively, chemotherapy should be continued according to the literature addressing specifically the phenomenon of a PSA surge/flare-up for a minimum of 8 weeks or 3 rounds of a 3-weekly cycle chemotherapy regimen before further decisions are made about efficacy. However, Scher et al. recommended a 12-week period drug exposure based on their results on PSA progression-free survival and overall survival. This dilemma needs to be addressed in further data analysis in order to establish a general rule regarding when to stop chemotherapy. Physicians should be aware of this effect to avoid inadequate early discontinuation of chemotherapy. The underlying mechanisms of a PSA surge/flare-up are still elusive and need further clarification.

Docetaxel in combination with prednisolone for hormone refractory prostate cancer

OBJECTIVE

The objective of this study was to evaluate the efficacy and toxicity of docetaxel in combination with prednisolone in Japanese patients with hormone refractory prostate cancer.

METHODS

Twenty patients with hormone refractory prostate cancer (HRPC) were administered a treatment regimen consisting of docetaxel 75 mg/m(2) once every 3 or 4 weeks and prednisolone 5 mg twice daily at our institution between 2006 and 2008.

RESULTS

The patients received a median of 5.5 cycles of treatment (range, 2-12 cycles). Nine of the 20 patients (45%) had a >or=50% decrease in serum prostate-specific antigen (PSA). The median duration of response was 4 months (range, 1-11 months). The number of cycles performed, the presence of bone metastasis and the extent of disease had statistically significant associations with the response. Three patients had a transient PSA rise among the patients who ultimately had a response. Grade 3/4 leukopenia and neutropenia occurred in 80.0% and 85.0% of the patients, respectively. Interstitial pneumonia occurred in only one patient; however, the patient recovered. Finally, no treatment-related deaths were seen during the observation period.

CONCLUSIONS

The combination of docetaxel 75 mg/m(2) every 3 weeks and prednisolone 10 mg daily was effective and well tolerated in Japanese patients with HRPC. The results of this study suggest that a decision concerning discontinuation of this treatment should be carefully considered because a transient PSA rise was observed. Although interstitial pneumonia was rare, the potential risk of its development should be taken into consideration.

Clinical evaluation of M30 and M65 ELISA cell death assays as circulating biomarkers in a drug-sensitive tumor, testicular cancer

Circulating full-length and caspase-cleaved cytokeratin 18 (CK18) are considered biomarkers of chemotherapy-induced cell death measured using a combination of the M30 and M65 ELISAs. M30 measures caspase-cleaved CK18 produced during apoptosis and M65 measures the levels of both caspase-cleaved and intact CK18, the latter of which is released from cells undergoing necrosis. Previous studies have highlighted their potential as prognostic, predictive, and pharmacological tools in the treatment of cancer. Disseminated testicular germ cell cancer (TC) is a paradigm for a chemosensitive solid malignancy of epithelial origin and has a cure rate of 80% to 90%. We conducted M30/M65 analyses on 34 patients with TC before and during treatment with bleomycin, etoposide, and cisplatin and showed that prechemotherapy serum levels of M65 and M30 antigens are correlated with established TC tumor markers lactate dehydrogenase, alpha-fetoprotein, and beta-human chorionic gonadotropin, probably reflecting tumor load. Cumulative percentage change of M65 and M30 from baseline to end of study was highest in poor prognosis patients (P < .05). Moreover, area under the curve profiles of M65 and M30 during chemotherapy mirrored dynamic profiles for lactate dehydrogenase, alpha-fetoprotein, and beta-human chorionic gonadotropin. Consequently, M65 and M30 levels appear to reflect chemotherapy-induced changes that correlate with changes in markers routinely used in the clinic for management of patients with TC. This is the first clinical study where M65 and M30 antigen levels correlate with established prognostic markers and provides impetus for their exploration in other epithelial cancers where there is a pressing need for informative circulating biomarkers.

False tumor marker surge evoked by peripheral blood stem cell transplantation

Peripheral blood stem cell transplantation (PBSCT) allows multiple intensive chemotherapy treatments and hematopoietic progenitor cell rescues for poor-risk patients with a variety of malignancies. We report false surges of a tumor marker, serum human chorionic gonadotropin (hCG), evoked by PBSCT in the course of chemotherapy for a poor-risk testicular cancer patient. We confirmed that this phenomenon resulted from reinfusion of peripheral blood stem cells (PBSCs) containing hCG at a high concentration, collected when the patient's serum hCG levels were remarkably elevated. This is the first report to demonstrate false tumor marker surges caused by PBSCT. Because a rapid rise in tumor markers may demand an immediate change in the therapeutic strategy, physicians should be aware of the possibility of this phenomenon when treating poor-risk cancer patients whose tumor markers are remarkably elevated at the time of PBSC harvest.

The challenge of poor-prognosis germ cell tumors

Patients who have a poor prognosis can be identified at presentation by well-defined prognostic factors. Prognostic groups as defined by the International Germ Cell Consensus Classification should be used in the clinic, in clinical trials, and when reporting results. No systemic treatment has been shown to improve outcome compared with four cycles of chemotherapy composed of bleomycin, etoposide, and cisplatin, which remains the standard of care. Surgery to resect residual masses after chemotherapy and in the salvage setting is a vital component of optimal care. The best outcomes occur with treatment at a center with experience and expertise in their management. Further major improvements are likely to require novel systemic therapies rather than modifications of existing approaches.

Germ cell tumors

PURPOSE OF REVIEW

This review provides an overview of some of the recent pre-clinical and clinical developments in germ cell tumors.

RECENT FINDINGS

Recent epidemiological studies highlight the variations in the geographic and ethnic distribution of germ cell tumors and the changing incidence of seminoma versus nonseminoma in the population. Additional studies are continuing to identify risk factors for germ cell tumors. Expression profiling, both at the gene and protein levels, is beginning to identify, at the molecular level, some of the factors associated not only with germ cell pluripotency but also with the different histologic subtypes of germ cell tumors. Work in the area of identifying potentially new serum tumor markers in germ cell tumor, as well as the role of the traditional tumor markers in predicting outcome to therapy is ongoing. Data is emerging on the role of positron emission tomography in evaluating residual lesions in seminoma. Evolving data on chemotherapy, radiation, and surgery further complements and clarifies information on these treatment modalities, and their potential toxicities, in the management of germ cell tumors.

SUMMARY

Ongoing preclinical and epidemiological studies highlight the complexities underlying germ cell tumor pathogenesis. With enhanced understanding of some of these processes, treatments, particularly for advanced stages, will continue to evolve.

Transient CEA increase at start of oxaliplatin combination therapy for metastatic colorectal cancer

In general a rising carcinoembryonic antigen (CEA) level means tumor progression. We observed a transient increase in CEA level despite objective response among patients receiving chemotherapy for metastatic colorectal cancer. This surge phenomenon has not previously been described for patients with metastatic colorectal disease. CEA was measured every second week in 27 patients receiving oxaliplatin, 5-fluororuracil, and folinic acid as first-line therapy against metastatic colorectal cancer. Four patients (15%, 95% CI 5-31%) met the criteria for therapy-induced CEA surge. The time of reaching maximum CEA level varied from 13 to 56 days. Median rise in CEA from baseline was 263% (range 24-632%). An initial rise of CEA during chemotherapy in colorectal cancer patients may therefore not always indicate progression of disease but may be a transient CEA surge in patients responding to chemotherapy.

European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG)

Germ cell tumour is the most frequent malignant tumour type in young men with a 100% rise in the incidence every 20 years. Despite this, the high sensitivity of germ cell tumours to platinum-based chemotherapy, together with radiation and surgical measures, leads to the high cure rate of > or = 99% in early stages and 90%, 75-80% and 50% in advanced disease with 'good', 'intermediate' and 'poor' prognostic criteria (IGCCCG classification), respectively. The high cure rate in patients with limited metastatic disease allows the reduction of overall treatment load, and therefore less acute and long-term toxicity, e.g. organ sparing surgery for specific cases, reduced dose and treatment volume of irradiation or substitution of node dissection by surveillance or adjuvant chemotherapy according to the presence or absence of vascular invasion. Thus, different treatment options according to prognostic factors including histology, stage and patient factors and possibilities of the treating centre as well may be used to define the treatment strategy which is definitively chosen for an individual patient. However, this strategy of reduction of treatment load as well as the treatment itself require very high expertise of the treating physician with careful management and follow-up and thorough cooperation by the patient as well to maintain the high rate for cure. Treatment decisions must be based on the available evidence which has been the basis for this consensus guideline delivering a clear proposal for diagnostic and treatment measures in each stage of gonadal and extragonadal germ cell tumour and individual clinical situations. Since this guideline is based on the highest evidence level available today, a deviation from these proposals should be a rare and justified exception.

Early predicted time to normalization of tumor markers predicts outcome in poor-prognosis nonseminomatous germ cell tumors

PURPOSE

The prognostic relevance of the rate of decline of serum alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG) during the first 3 weeks of chemotherapy for nonseminomatous germ cell tumors (NSGCT) was studied in the context of the International Germ Cell Cancer Collaborative Group (IGCCCG) classification.

PATIENTS AND METHODS

Data from 653 patients prospectively recruited in clinical trials were studied. Tumor markers were obtained before chemotherapy and 3 weeks later. Decline rates were calculated using a logarithmic formula and expressed as a predicted time to normalization (TTN). A favorable TTN was defined when both AFP and HCG had a favorable decline rate, including cases with normal values.

RESULTS

The median follow-up was 50 months (range, 2 to 151 months). Tumor decline rate expressed as a predicted TTN was associated with both progression-free survival (PFS; P <.0001) and overall survival (OS; P <.0001). The 4-year PFS rates were 64% and 38% in patients from the poor-prognosis group who had a favorable and an unfavorable TTN, respectively. The 4-year OS rates were 83% and 58%, respectively. This effect was independent from the initial tumor marker values, the primary tumor site, and the presence of nonpulmonary visceral metastases: tumor marker decline rate remained a strong predictor for both PFS (hazard ratio = 2.5; P =.01) and OS (hazard ratio = 4.6; P =.002) in patients from the IGCCCG poor-prognosis group in multivariate analysis.

CONCLUSION

Early predicted time to tumor marker normalization is an independent prognostic factor in patients with poor-prognosis NSGCT and may be a useful tool in the therapeutic management of these patients.

Extragonadal germ cell tumors in Japan

Extragonadal germ cell tumors (EGCT) represent only 2-5% of adult germ cell malignancies. Some publications from Asia have reported inferior treatment outcomes compared to data from an international study group. To ascertain whether this is generally the case, here we analyze treatment outcomes for 30 Japanese patients with EGCT. The medical records of 30 patients (25 nonseminomas and 4 pure seminomas) treated from 1992 to 2002 were reviewed retrospectively. All patients with seminoma achieved long survival except one who died of chemotherapy-related sepsis. Ten and 11 patients with EGCT presented with mediastinal and retroperitoneal primary sites, respectively. The 5-year overall survival (OS) and progression-free survival (PFS) for nonseminoma was 71% and 42%, respectively. The 5-year OS and PFS was 60% and 44%, respectively, for 10 patients with mediastinal nonseminoma, and 91% and 48%, respectively, for patients with retroperitoneal nonseminoma. Tumor marker values on day 7 were available for 19 patients. Among the 19 patients in whom AFP or beta-HCG were measured on day 7, the values had declined in 12 patients and were transiently elevated in 7 patients compared to pretreatment values. The transient elevations of tumor markers were significantly associated with poor OS (P = 0.02) and PFS (P = 0.008). The treatment outcome of Japanese patients with EGCT seemed to be comparable to that reported from international studies, suggesting no difference between ethnic groups. Transient tumor marker elevations on day 7 predict poor survival in EGCT patients and may be a useful parameter for identifying patients requiring more aggressive treatment.

Current opinion in germ cell cancer 2000

Despite its relative rarity compared with the common adult cancers, scientific and clinical interest in germ cell cancer is increasing. From the point of view of epidemiology, the controversy about the relative importance of intrauterine versus postpubertal risk factors has continued. Evidence to support the importance of intrauterine factors comes from reports from Norway, Canada, and the US, confirming the Danish observation that the rising incidence of germ cell cancer is linked to a birth cohort effect; evidence in support of the importance of postpubertal risk comes from three case/control studies demonstrating increased risk linked to postpubertal exposures such as pesticides, plastics, electromagnetic radiation, trauma, and infections. There has been increasing interest in human endogenous retrovirus K10 as a possible factor explaining genetic susceptibility and providing a linkage between the two groups of risk factors. In cytogenetics, progress was reported in identifying the deletion point of the suspected tumor suppressor gene responsible for the i12p marker chromosome abnormality and development of FISH probes for diagnostic purposes. In molecular biology, the importance of DNA repair deficiency in normal germ cells as a factor in the exquisite chemosensitivity of germ cell cancer has been high-lighted by a report demonstrating a low level of the xeroderma pigmentosa group A (XPA) protein and induction of resistance in vitro by adding XPA. In the clinic, progress in positron emission tomography scanning and laparoscopic lymph node staging are leading to changes in outlook on management of stage 1 cases and patients with small residual masses postchemotherapy. Salvage chemotherapy regimens integrating dose dense and vertical dose intensification strategies reported 60% progression-free survival. New drugs such as gemcitabine demonstrated continued therapeutic potential for chemotherapy in these tumors. A report demonstrating the inadequacies of hormone replacement after bilateral orchidectomy and a report of the first child born after testis-conserving therapy highlight the need for more attention to testis conservation as a quality of life issue. With the cure rates so high, the need for central referral is once again debated both for stage 1 and metastatic disease. With new ways of defining poor risk stage 1 patients and reports on impact of experience highlighting the worse outcome of patients treated in centers treating small numbers, views on this issue remain clearcut.

Treatment of testicular tumours based on risk factors

Germ cell cancer is highly sensitive to cisplatinum-based chemotherapy, resulting in cure rates of over 90% for patients with minimal metastatic disease or low tumour markers, 70% for patients with intermediate prognosis features, and 50% for patients with poor prognosis criteria. Whereas current clinical studies aim to improve the survival of patients with poor prognosis by means of high-dose chemotherapy, or the survival of intermediate prognosis patients by more intensive chemotherapy, for patients with good prognosis the reduction of doses, number of drugs or cycles is investigated to reduce the short-term and, in particular, long-term treatment sequelae. However, apart from these clinical studies, the current treatment standard of three cycles of platinum/etoposide/bleomycin for good prognosis patients and four cycles for intermediate and poor prognosis patients with advanced germ cell cancer has not been changed by recent trial results. The excellent cure rate with cisplatinum-based chemotherapy in the case of early metastatic disease with three cycles of platinum/etoposide/bleomycin as well as the high efficacy of adjuvant chemotherapy with two cycles of platinum/etoposide/bleomycin in the case of microscopic disease did change the treatment standards in stage I and II non-seminomatous germ cell cancer, with defined treatment options depending on prognostic factors. The treatment of testicular cancer based on prognostic factors is mandatory in all stages of seminoma and non-seminoma; however, molecular biological factors might make a major contribution to a more precise determination of prognosis and therefore enable a tailored selection of an individual treatment in the future.