Prognostic factors in patients progressing after cisplatin-based chemotherapy for malignant non-seminomatous germ cell tumours

Testicular cancer in 2023: Current status and recent progress

Testicular germ cell tumor (GCT) is the most common solid tumor in adolescent and young adult men. Progress in the management of GCT has been made in the last 50 years, with a substantial improvement in cure rates for advanced disease, from 25% in the 1970s to nearly 80%. However, relapsed or platinum-refractory disease occurs in a proportion, 20% of whom will die from disease progression. This article reviews the current evidence-based treatments for extracranial GCT, the acute and chronic toxic effects that may result, and highlights contemporary advances and progress in the field.

Therapeutic efficacy of high-dose chemotherapy with autologous stem-cell transplantation in 44 relapsed or refractory germ-cell tumor patients: A retrospective cohort study

Despite having a higher mortality risk than conventional chemotherapeutics, high-dose chemotherapy (HDCT) has the potential to be curative in relapsed/refractory germ-cell tumors. Therefore, selecting the best patient group for this treatment is critical. This study aimed to determine the factors that affect survival in our relapsed/refractory GCT cohort who received HDCT and autologous stem-cell transplantation. Between September 2010 and 2020, we included in the study 44 relapsed/refractory male patients with GCT treated with HDCT plus autologous stem-cell transplantation. The patients' demographic features, clinical characteristics, and treatment outcomes were evaluated. Statistical analyses were performed to identify risk factors associated with survival. The median age of all cohorts was 28 years. Thirty-six patients had nonseminomatous tumors, and 8 patients had seminomatous tumors. The most common primary tumor sites were the gonads (75%), followed by the mediastinum (15.9%) and the retroperitoneum (9.1%). After HDCT, 11 patients had a complete response, 12 patients had a partial response, and 17 patients had a progressive disease, respectively. About 23 patients (52.3%) experienced at least 1 treatment-related grade 3 to 4 nonhematological toxicity. About 4 patients (10%) died due to HDCT-related toxicity. The total group's median progression-free survival (PFS) was 7 months, and the median overall survival (OS) was 14.9 months. Primary tumor site (hazard ratio [HR]: 1.84; P = .028), type of HDCT regimen (HR: 0.35; P = .010), and best response to HDCT (HR: 11.0; P < .0001) were independent prognostic risk factors for PFS. The only independent prognostic risk factor associated with OS was the best response to HDCT (HR: 6.62; P = .001). The results of the study promise the best response to HDCT as a primary measure for predicting survival in relapsed/refractory GCT. In contrast, primary mediastinal GCT is not a good candidate for HDCT. Furthermore, a carboplatin-etoposide regimen in combination with cyclophosphamide and paclitaxel may improve PFS.

A decade in focus: mixed germ cell tumors with choriocarcinoma components

Introduction

This 10-year registry review aimed to investigate the clinical behaviour and outcomes of mixed germ cell tumours with choriocarcinoma components, a rare and aggressive subtype of testicular cancer, in Saudi Arabia. The study explores the demographic characteristics of affected patients, tumour profiles, and the mortality rate associated with this malignancy.

Methods

Utilizing data from the Saudi Cancer Registry, the authors identified 33 cases of mixed germ cell tumours with choriocarcinoma components among 1001 testicular cancer cases recorded between 2008 and 2017. Demographic information, including age, marital status, region of residency, year of diagnosis, and 10-year survival status, were collected. Tumour factors, such as the basis of diagnosis, origin site, behaviour, grade, extension, and laterality, were also analyzed.

Results

The majority of cases (78.8%) occurred in the young age group (18-45 years), and most tumours (97%) originated in normally descended testes. Grade IV (undifferentiated anaplastic) tumours and distant metastasis were present in 45.5% of patients. All cases exhibited malignant tumour behaviour. The overall mortality rate was 15%, with a mean time from diagnosis to death of 7.72 months (range: 0.5-21.5 months).

Conclusion

Mixed germ cell tumours with choriocarcinoma components are rare and tend to affect younger populations. These tumours demonstrate aggressive clinical behaviour, with a significant proportion presenting with high-grade lesions and metastasis at diagnosis. The observed mortality rate underscores the poor prognosis associated with this malignancy. Our study provides essential insights into the clinical characteristics of this rare tumour subtype in the Saudi Arabian population, emphasizing the need for further research to identify prognostic factors and optimize management strategies for affected patients.

Multicentric phase II trial of TI-CE high-dose chemotherapy with therapeutic drug monitoring of carboplatin in patients with relapsed advanced germ cell tumors

Background

High‐dose chemotherapy (HDCT) with TI‐CE regimen is a valid option for the treatment of relapsed advanced germ cell tumors (GCT). We report a phase II trial with therapeutic drug monitoring of carboplatin for optimizing area under the curve (AUC) of this drug.

Methods

Patients with unfavorable relapsed GCT were treated according to TI‐CE regimen: two cycles combining paclitaxel and ifosfamide followed by three cycles of HD carboplatin plus etoposide administered on 3 days. Carboplatin dose was adapted on day 3 based on carboplatin clearance (CL) at day 1 in order to reach a target AUC of 24 mg.min/mL per cycle. The primary endpoint was the complete response (CR) rate.

Results

Eighty‐nine patients who received HDCT were included in the modified intent‐to‐treat (mITT) analysis. Measured mean AUC was 24.4 mg.min/mL per cycle (22.4 and 26.8 mg.min/mL for 10th and 90th percentiles). Thirty‐five (44.3%) patients achieved a CR with or without surgery of residual masses and 20 patients achieved a partial response with negative tumor markers. With a median follow‐up of 44 months (m), median PFS was 12.3 m (95% CI: 7.5–25.9) and OS was 46.3 m (95% CI: 18.6–not reached). For high‐ and very high‐risk patients, according to the International Prognostic Score at first relapse or treated after at least one salvage treatment (n = 51), 2‐year PFS rate was 41.1%.

Conclusion

The rates of complete and favorable responses were clinically relevant in this very poor risk population. Individual monitoring of carboplatin plasma concentration permitted to control more accurately the target AUC and avoided both underexposure and overexposure to the drug.

[Intensification by high dose chemotherapy for germ-cell tumors, still an ongoing subject?]

More than 80 % of patient with metastatic germ cell tumor are cured with first line chemotherapy. Twenty to 30 % of patients will experience relapse or refractory disease with a very poor long-term prognosis. Most of them had metastatic germ cell tumors with a poor prognosis according to the international germ cell classification collaborative group (IGCCCG). The role of treatment intensification by high dose chemotherapy (HDCT) followed by stem cell rescue has not been demonstrated yet in the first line setting compared to standard chemotherapy. The role of HDCT in first or second salvage is also not yet demonstrated, many studies have been published in this situation with a lot of different regimen. Outside clinical trial, HDCT remains an option in salvage therapy, depending on many factors including prognostics factors, previous therapy, general condition and reference center consideration to select eligible patient who could benefit the most of this approach. Results from the international randomized trial TIGER will provide evidence-based information for HDCT strategy.

Surgical salvage in patients with advanced testicular cancer: indications, risks and outcomes

The purpose of this review is to present a comprehensive and updated review of the literature and summary of the indications, risks and outcomes related to salvage, desperation and late relapse surgery for advanced testicular cancer. After completing a thorough review of the current literature, this review has attempted to provide an overview of the indications for salvage, desperation and late relapse retroperitoneal lymph node dissection (RPLND) followed by a summary of the histopathologic and clinical outcomes regarding each. Recent literature, combined with a significant contribution from historical studies suggest that while testicular cancer is a relatively uncommon malignancy overall, it represents the most common solid organ malignancy for young men. Although a significant number of men are cured with a combination of first-line treatments, the remaining men are a diverse and often challenging cohort who require the benefit of expertise to improve their outcomes. The role of surgical strategies in the salvage, desperation and late relapse settings is unquestionable, although the most important question remains who will benefit. This often requires a multi-disciplinary approach at centers specializing in this disease process in order to recognize who should get surgery, what surgery to do and how to minimize the potential morbidity associated with the operation.

Genitourinary Pathology Reporting Parameters Most Relevant to the Medical Oncologist

Pathologic variables play an important role in prognostication in urologic malignancies. Histologic subtype, histologic grade, and anatomic extent of disease (pathologic tumor and nodal staging) influence treatment decisions in both the adjuvant and metastatic settings. This article discusses treatment paradigms for the most common urologic malignancies, followed by the evidence base to support the relationship between pathologic assessment and decision making by the medical oncologist.

Conventional-Dose versus High-Dose Chemotherapy for Relapsed Germ Cell Tumors

The majority of metastatic germ cell tumors (GCTs) are cured with cisplatin-based chemotherapy, but 20–30% of patients will relapse after first-line chemotherapy and require additional salvage strategies. The two major salvage approaches in this scenario are high-dose chemotherapy (HDCT) with autologous stem cell transplant (ASCT) or conventional-dose chemotherapy (CDCT). Both CDCT and HDCT have curative potential in the management of relapsed/refractory GCT. However, due to a lack of conclusive randomized trials, it remains unknown whether sequential HDCT or CDCT represents the optimal initial salvage approach, with practice varying between tertiary institutions. This represents the most pressing question remaining for defining GCT treatment standards and optimizing outcomes. The authors review prognostic factors in the initial salvage setting as well as the major studies assessing the efficacy of CDCT, HDCT, or both, describing the strengths and weaknesses that formed the rationale behind the ongoing international phase III “TIGER” trial.

IGG* Practice Guidelines on Germ Cell Tumor in Adult Male Patients

Germ cell tumors are rare neoplasms that affect young males. Nearly 99% of patients with localized stage I disease and nearly 80% of patients with metastatic disease can be cured. Even patients who relapse following chemotherapy can achieve a long-term survival in approximately 30–40% of cases. The main objective in early stages and in good prognosis patients has changed in recent years, and it has become of major importance to reduce treatment-related morbidity without compromising the excellent long-term survival rate. In poor prognosis patients, there is a correlation between the experience of the treating institution and the long-term clinical outcome of the patients, particularly when the most sophisticated therapies are needed. So far, of utmost importance is the information from updated practice guidelines for the diagnosis and treatment of germ cell tumors. The Italian Germ cell cancer Group (IGG) has developed the following clinical recommendations, which identify the current standards in diagnosis and treatment of germ cell tumors in adult males.

Consensus Recommendations from the Spanish Germ Cell Cancer Group on the Use of High-dose Chemotherapy in Germ Cell Cancer

BACKGROUND

High-dose chemotherapy (HDCT) has been studied in several clinical scenarios in advanced germ cell cancer (GCC).

OBJECTIVE

To establish a clinical practice guideline for HDCT use in the treatment of GCC patients.

DESIGN, SETTING, AND PARTICIPANTS

An expert panel reviewed information available from the literature. The panel addressed relevant issues concerning and related to HDCT. The guideline was externally reviewed by two international experts.

RESULTS AND LIMITATIONS

The efficacy of HDCT has been demonstrated in selected GCC patients. The most conclusive evidence comes from retrospective analyses that need to be interpreted with caution. HDCT can cure a significant proportion of heavily treated GCC patients. When indicated, sequential HDCT with regimens containing carboplatin and etoposide, as well as peripheral stem-cell support, is recommended. There is no conclusive evidence to recommend HDCT as first-line therapy. According to a multinational retrospective pooled analysis, HDCT might be superior to conventional CT as first salvage treatment in selected patients. There is an urgent need for prospective clinical trials addressing the value of HDCT in GCC patients who experience failure on first-line cisplatin-based CT. In patients who progress on conventional-dose salvage CT, HDCT should be considered. Treatment of these patients at experienced centers is strongly recommended.

CONCLUSIONS

It has been demonstrated that HDCT cures selected GCC patients who experience disease progression on conventional rescue regimens. The panel recommends the inclusion of GCC patients in randomized clinical trials including HDCT.

PATIENT SUMMARY

This consensus establishes clinical practice guidelines for the use and study of high-dose chemotherapy in patients with germ cell cancer.

High-dose chemotherapy with autologous stem cell transplantation in relapsed or refractory germ cell tumours: outcomes and prognostic variables in a case series of 17 patients

BACKGROUND

Optimal therapy for men relapsing after initial chemotherapy for germ cell tumours (GCT) is poorly defined. Both conventional dose salvage regimens and high-dose chemotherapy with autologous stem cell transplantation (HDCT-ASCT) have been utilised.

AIMS

To examine patients who received HDCT-ASCT for relapsed GCT within a single Australian centre.

METHODS

Records between 2000 and 2012 were analysed for baseline characteristics, treatment-related toxicity and survival. Prognosis at the time of HDCT-ASCT was classified according to the International Prognostic Factors Study Group (IPFSG).

RESULTS

Seventeen patients received HDCT-ASCT, median age 34 (21-46), with 41% having primary refractory disease and 53% with high/very high risk disease by IPFSG. The most common regimen utilised was paclitaxel/ifosfamide followed by high-dose carboplatin/etoposide (TI-CE; n = 12). The median duration of grade 4 (G4) neutropenia was 11 days (range 9-17) with febrile neutropenia in 90% resulting in four intensive care unit admissions (8%). Median duration of G4 thrombocytopenia was 10 days (range 8-19) requiring a median of two pooled platelets bags (range 0-33) per episode. Transplant-related mortality occurred in one patient (veno-occlusive disease). Twenty-seven per cent of HDCT-ASCT cycles were associated with grade 3 mucositis (median total parenteral nutrition days = 5 (0-23)). Two-year progression-free survival (PFS) and overall survival (OS) rates were 59% and 71%. Patients who received HDCT-ASCT as second or subsequent relapse fared worse than those treated with HDCT-ASCT at first relapse (hazard ratio 0.23 (95% confidence interval: 0.04, 1.37; P-value 0.09). Three-year OS for those who received TI-CE at first relapse was 90%.

CONCLUSIONS

HDCT-ASCT for relapsed GCT is effective with acceptable toxicity. There was encouraging PFS/OS, particularly in a poor-prognosis cohort.

Current chemotherapeutic approaches for recurrent or refractory germ cell tumors

INTRODUCTION

Up to 25% of patients with metastatic testicular germ cell tumour (GCT) are not cured by first line therapy and require treatment for refractory or relapsed disease.

METHODS

A literature search was conducted through PubMed, Medline, Cochrane and EMBASE from January 1950 to April 2014 for articles relating to trials of chemotherapy for patients with relapsed or refractory germ cell tumours. Relevant review papers and conference proceedings were hand searched for additional references.

RESULTS

A range of conventional dose chemotherapy (CDCT) regimens can provide durable remissions in 20-30% of patients at first or subsequent salvage.

CONCLUSIONS

This article reviews the evidence underlying commonly used salvage CDCT based on ifosfamide and cisplatin such as TIP, VIP and VeIP; other active combinations; and single agent salvage regimens. The treatment of growing teratoma syndrome and malignant transformation of teratoma will also be discussed. Companion articles will explore the role of high dose chemotherapy (HDCT) and novel targeted agents.

High-dose chemotherapy for germ cell tumors: do we have a model?

INTRODUCTION

Since the late nineties, the intensification of chemotherapy doses with hematopoietic stem cell rescue held promise for patients with advanced and poor prognosis germ cell tumors (GCTs). High-dose chemotherapy (HDCT) has, nowadays, a recognized indication in the salvage setting of advanced GCTs and is steadily utilized worldwide.

AREAS COVERED

We evaluated the available data with the use of HDCT in these patients. In addition, we provided an original perspective on several issues as experts on behalf of the European Society for Blood and Marrow Transplantation and IGG, including peripheral blood stem cells mobilization and the use of HDCT in special subpopulations of GCT, with the aim to help clarify critical issues in the absence of available clear-cut information.

EXPERT OPINION

Despite HDCT being currently considered a therapeutic option in the salvage setting, critical questions regarding patient selection are still unanswered. Eligibility of patients with a chemoresistant disease, the use of available prognostic factors as well as tumor marker decline in clinical practice are pending issues. Moving forward, these are critical arguments in favor of further clinical research in the field of advanced GCTs.

First salvage treatment in patients with advanced germ cell cancer after cisplatin-based chemotherapy: analysis of a registry of the German Testicular Cancer Study Group (GTCSG)

PURPOSE

We analyzed prognostic categories at first relapse according to the International Prognostic Factors Study Group (IPFSG) criteria as well as the efficacy of salvage treatment.

METHODS

143 patients with relapsed or refractory germ cell cancer undergoing first salvage treatment with conventional-dose (CD-CX, n = 48) or high-dose chemotherapy with autologous stem cell support (HD-CX, n = 95) contributed by nine centers were retrospectively analyzed.

RESULTS

Prognostic subgroups according to IPFSG criteria were: very low risk 13/143, low risk 36/143, intermediate risk 66/143, high risk 22/143, and very high risk 6/143 patients. The IPFSG categories significantly correlated with overall survival (OS) (p = 0.025) after 1st salvage treatment. After a median follow-up of 19 months, 55 % of all patients had relapsed and 33 % had died. For the entire cohort, progression-free survival (PFS) rate after 2 years was 43 %, and OS rate after 5 years was 52 %. Compared to the HD-CX group, vital carcinoma was found more often in secondarily resected lesions following CD-CX (22/29 vs. 22/45; p = 0.021). Second relapse rate was higher with 75 versus 44 %, resulting in a shorter median PFS with 8 versus 42 months (p < 0.001), but this did not translate into different OS (p = 0.931). At subsequent relapses, 26/36 patients received HD-CX as ≥2nd-salvage treatment.

CONCLUSION

This analysis confirms the prognostic value of the IPFSG prognostic score. HD-CX seemed superior to CD-CX as first salvage treatment with respect to PFS in this retrospective analysis.

Longitudinal Serum Testosterone, Luteinizing Hormone, and Follicle-Stimulating Hormone Levels in a Population-Based Sample of Long-Term Testicular Cancer Survivors

Purpose

To assess longitudinal long-term alterations of testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) in testicular cancer survivors (TCSs).

Patients and Methods

In all, 307 TCSs treated from 1980 to 1994 provided blood samples after orchiectomy but before further treatment, at Survey I (SI; 1998-2002), and Survey II (SII; 2007-2008). Levels of sex hormones were categorized according to quartiles and reference range (2.5 and 97.5 percentiles) of 599 controls for each decadal age group. TCSs were categorized according to treatment: surgery, radiotherapy (RT), or chemotherapy (CT). The risk of higher (LH) or lower (testosterone) levels was assessed with χ2 test (FSH) or ordinal logistic regression analysis and expressed as odds ratios (ORs) with 95% CIs.

Results

Risk of lower testosterone and higher LH and FSH levels was significantly increased for TCSs at all time points after RT or CT. At SII, ORs were 3.3 (95% CI, 2.3 to 4.7) for lower testosterone categories and 5.2 (95% CI, 3.5 to 7.9) for RT and CT. ORs for increased LH and FSH were 4.4 (95% CI, 3.1 to 6.5) and 18.9 (95% CI, 11.0 to 32.6) for RT, respectively, and 3.6 (95% CI, 2.4 to 5.3) and 14.2 (95% CI, 8.3 to 24.4) for CT, respectively. The cumulative platinum dose was significantly associated with risk of higher LH levels at both surveys and higher FSH at SI. In total, half the TCSs had at least one of three sex hormone levels outside the reference range at SII.

Conclusion

Long-term TCSs are at risk of premature hormonal aging. Our findings may pertain to cancer survivors in general, underlining the importance of extended follow-up.

Salvage therapy for refractory or recurrent pediatric germ cell tumors: the French SFCE experience

PURPOSE

Some children with extracranial germ cell tumors (GCT) relapse after or do not respond to first-line treatment combining chemotherapy and surgery, of whom very few experience long-term survival despite multimodal salvage treatment.

METHODS

This prospective study, part of the French TGM95 Protocol for non-seminomatous GCT (NSGCT), included 19 (7%) children with malignant refractory or recurrent extracranial NSGCT who were studied to identify prognostic factors and determine the best salvage treatment.

RESULTS

At the end of the first-line treatment, 10 and 9 children were in complete and incomplete remission, respectively. Events occurred within 2 years (5-23 months) after initial diagnosis. A progression was observed in 13 patients at least in one site initially involved. Two patients had a purely biological relapse (increase in isolated markers), and four patients had a purely metastatic relapse (brain location in three cases). After salvage treatment combining surgery and various types of chemotherapy (including high-dose chemotherapy (HDCT) in 10 cases), the 5-year event-free survival and overall survival rates were of 26% (95%CI: 9.6-46.8%) and 32% (95%CI: 12.9-52.2%), respectively. Patients who underwent complete surgery (or without any detectable tumor) had higher survival rate than patients who underwent partial surgery or for whom surgery was not feasible (P = 0.0003) at first relapse while this rate was similar between patients treated or not with HDCT.

CONCLUSION

In pediatric recurrent or refractory NSGCT, complete excision of the tumor appears essential. The role of HDCT remains debated.

[EAU guidelines on testicular cancer: 2011 update. European Association of Urology]

CONTEXT

On behalf of the European Association of Urology (EAU), guidelines for the diagnosis, therapy, and follow-up of testicular cancer were established.

OBJECTIVE

This article is a short version of the EAU testicular cancer guidelines and summarises the main conclusions from the guidelines on the management of testicular cancer.

EVIDENCE ACQUISITION

Guidelines were compiled by a multidisciplinary guidelines working group. A systematic review was carried out using Medline and Embase, also taking Cochrane evidence and data from the European Germ Cell Cancer Consensus Group into consideration. A panel of experts weighted the references, and a level of evidence and grade of recommendation were assigned.

RESULTS

There is a paucity of literature especially regarding longer term follow-up, and results from a number of ongoing trials are awaited. The choice of treatment centre is of the utmost importance, and treatment in reference centres within clinical trials, especially for poor-prognosis nonseminomatous germ cell tumours, provides better outcomes. For patients with clinical stage I seminoma, based on recently published data on long-term toxicity, adjuvant radiotherapy is no longer recommended as first-line adjuvant treatment. The TNM classification 2009 is recommended.

CONCLUSIONS

These guidelines contain information for the standardised management of patients with testicular cancer based on the latest scientific insights. Cure rates are generally excellent, but because testicular cancer mainly affects men in their third or fourth decade of life, treatment effects on fertility require careful counselling of patients, and treatment must be tailored taking individual circumstances and patient preferences into account.

TAKE HOME MESSAGE

Although testicular cancer has excellent cure rates, the choice of treatment centre is of the utmost importance. Expert centres achieve better results for both early stage testicular cancer (lower relapse rates) and overall survival (higher stages within clinical trials). For patients with clinical stage I seminoma, adjuvant radiotherapy is no longer recommended as first-line adjuvant treatment.

Role of biochemical markers in testicular cancer: diagnosis, staging, and surveillance

Testis cancer is one of the few solid organ malignancies for which reliable serum tumor markers are available to help guide disease management. Human chorionic gonadotropin, alpha fetoprotein, and lactate dehydrogenase play crucial roles in diagnosis, staging, prognosis, monitoring treatment response, and surveillance of seminomatous and nonseminomatous germ cell tumors. Herein we discuss the clinical applications of germ cell tumor markers, the limitations of these markers in the management of this disease, and additional serum molecules that have been identified with potential roles as novel germ cell tumor markers.

Treatment of brain metastases from germ cell tumors

Brain metastases occur in approximately 10% of patients with advanced metastatic germ cell tumors. Patients with nonseminomatous histology, lung metastases, and high β-human chorionic gonadotropin levels are at higher risk for synchronous brain metastases at first diagnosis and for relapsing with brain metastases after successful cisplatin-based chemotherapy. Patients with brain metastases should undergo multimodal treatment strategies, including cisplatin-based combination chemotherapy plus radiotherapy or surgery. However, the optimal combination and sequence of these strategies remain unclear and may differ between subgroups. But in all cases, chemotherapy must be part of treatment, even in patients with isolated cerebral relapse without systemic disease.

[Surgical resection of a massive residual retroperineal mass after chemotherapy in non-seminomatous germ cell tumor of the testis: a borderline case]

BACKGROUND

According to the last EAU Guidelines about testicular cancer, surgical resection of residual masses after chemotherapy in NSGCT is indicated in the case of visible residual masses and when serum levels of tumor markers are normal or normalizing. If markers are not normalized and when several chemotherapeutic regimens have failed to cure metastatic disease, resection of residual tumors (so called "desperation surgery") should be offered to these patients.

METHODS

We are going to present the case of a 30-year-old patient, affected by metastatic NSGCT. According to the prognostic-based staging system for metastatic germ cell cancer, our patient was in the poor prognosis group. The retroperitoneal mass involved all major vascular structures and still caused a bilateral obstruction of the upper urinary tract. Histological examination after radical orchiectomy revealed embryonal carcinoma and immature teratoma. The patient underwent a four-cycle VIP chemotherapy and then salvage chemotherapy with four cycles of TIP. After chemotherapy, the patient still presented large multiple metastatic localizations. Tumor markers were reduced but not normalized. The patient was then proposed for the resection of residual tumor. The residual mass could not be dissected from the left renal pedicle, so the left nephrectomy was unavoidable. The mass was hardly detached from vena cava and aorta. A bilateral iliac and retroperitoneal lymphadenectomy was performed. At the end of the procedure, the retroperitoneal space was completely free.

RESULTS

Post-operative hospital stay was regular. A CT scan performed 3 months after the procedure did not show any residual lesion in the retroperitoneum. Three and six months later, the patient underwent the residual tumor resection of the right mediastinum and then of the left mediastinum and supraclavear metastases. Afterwards the patient underwent an EP consolidation chemotherapy. The patient is alive, 12 months after the retroperitoneal surgery.

CONCLUSIONS

Our experience confirms that resection of residual tumors is safe and feasible also in cases of very large abdominal disease.

[The role of tumour markers in diagnosis and management of testicular germ cell tumours]

Alpha-fetoprotein (AFP), human choriogonadotropin (hCG) and lactate dehydrogenase (LDH) are established tumour markers of testicular germ cell tumours (TGCT) which are used according to the guidelines for primary diagnosis, staging, monitoring of therapeutic response and follow-up. Placental alkaline phosphatase and neurone-specific enolase play no role at all in the diagnosis and management of TGCT.Metastasized TGCT are classified according to the IGCCCG classification system into tumours with good, intermediate and poor prognosis depending on their serum concentration. The risk classification has a direct impact on therapy and determines the intensity of chemotherapy. In rare cases AFP and hCG might be elevated due to non-testicular reasons which have to be taken into consideration for the differential diagnosis especially if marker concentration and clinical presentation do not match. Response to chemotherapy is monitored with AFP and hCG which are determined the day before initiation of the next treatment cycle. Marker increases during or shortly after discontinuation of chemotherapy indicate a poor prognosis and make the immediate initiation of salvage treatment regimes necessary. Only 40-50% and 30% of relapses in patients under active surveillance for clinical stage I disease and after systemic chemotherapy are associated with marker increases. The remainder will be diagnosed by imaging studies or clinical symptoms. Marker increases have to be validated by imaging studies. However, about 10% of all relapsing patients have marker increases only without any imaging evidence of metastatic disease. Residual masses of any size and location have to be treated by postchemotherapy resection once the marker concentration is normalized or once it has reached a stable plateau. So-called desperation surgery in the presence of rising tumour markers is only indicated if no curative chemotherapy is available, all residual masses are completely resectable and no hCG elevation are observed. For follow-up, AFP, hCG and LDH should be evaluated for advanced TGCT and clinical stage I nonseminomas, whereas clinical stage I seminomas should be monitored without any markers.

A Review in Management of Testicular Cancer: Single Center Review

BACKGROUND

Testicular cancer is one of the few solid cancers that can be cured even when it is metastasized with overall survival rate of more than 90%. The aim of this study was to establish the age adjusted incidence of testicular cancer and to critically assess the management of testicular tumor.

METHODS

This is a quantitative retrospective study utilizing a review of clinical notes for patients who underwent testicular orchidectomy. The number of cancer cases, types of pathology and cancer staging were examined.

RESULTS

There is no substantial difference between the crude and the age-standardized incidence, moreover no difference from the reported crude incidence by the Scottish intercollegiate guidelines. We found 55.1% of seminoma, 14.28% of non-seminoma and 30.61% of combined (seminoma and non-seminoma), and stage I disease in 61.22% of cases, stage II in 36.73% of cases, and stage IV in 2.04% of cases. Most of the cancers were in the age group 20 - 50 with the majority (48.97%) in the age group 31 - 40. About 42.85% of cases were identified with high tumor markers; higher percentage of seminoma at stage II (40.74%).

CONCLUSIONS

There is no substantial difference between the crude and the age-standardized incidence, moreover no difference from the reported crude incidence. Most of the cancers were in the age group 20 - 50 with the majority (48.97%) in the age group 31 - 40. Only 25% of seminomas had elevated tumor markers. Moreover, it is important to re-enforce strict adaptation to the IGCCCG prognostic factor-based classifications.

EAU guidelines on testicular cancer: 2011 update

CONTEXT

On behalf of the European Association of Urology (EAU), guidelines for the diagnosis, therapy, and follow-up of testicular cancer were established.

OBJECTIVE

This article is a short version of the EAU testicular cancer guidelines and summarises the main conclusions from the guidelines on the management of testicular cancer.

EVIDENCE ACQUISITION

Guidelines were compiled by a multidisciplinary guidelines working group. A systematic review was carried out using Medline and Embase, also taking Cochrane evidence and data from the European Germ Cell Cancer Consensus Group into consideration. A panel of experts weighted the references, and a level of evidence and grade of recommendation were assigned.

RESULTS

There is a paucity of literature especially regarding longer term follow-up, and results from a number of ongoing trials are awaited. The choice of treatment centre is of the utmost importance, and treatment in reference centres within clinical trials, especially for poor-prognosis nonseminomatous germ cell tumours, provides better outcomes. For patients with clinical stage I seminoma, based on recently published data on long-term toxicity, adjuvant radiotherapy is no longer recommended as first-line adjuvant treatment. The TNM classification 2009 is recommended.

CONCLUSIONS

These guidelines contain information for the standardised management of patients with testicular cancer based on the latest scientific insights. Cure rates are generally excellent, but because testicular cancer mainly affects men in their third or fourth decade of life, treatment effects on fertility require careful counselling of patients, and treatment must be tailored taking individual circumstances and patient preferences into account.

Management of poor-prognosis testicular germ cell tumors

Currently, the outcome of patients with intermediate-and poor-risk germ cell tumors at diagnosis is optimized by the use of risk-appropriate chemotherapy and post-chemotherapy surgical resection of residual masses. Currently, there is no role for high-dose chemotherapy in the first-line setting. Patients who progress on first-line chemotherapy or who relapse after an initial complete response also have a poor prognosis. In the setting of early relapse, the standard approach at most centers is conventional-dose, ifosfamide-based regimens and post-chemotherapy resection of residual masses. The treatment of patients with late relapse is complete surgical resection whenever feasible. Salvage chemotherapy for late relapse may be used prior to surgery in patients where a complete resection is not feasible. A complete surgical resection of all residual sites of disease after chemotherapy is critical for the prevention of relapse and the long-term survival of patients with advanced germ cell tumors.

A review of second-line chemotherapy and prognostic models for disseminated germ cell tumors

Despite an excellent prognosis even for patients with disseminated disease, about 20% to 30% of men with advanced germ cell tumors are refractory to first-line chemotherapy or experience disease recurrence after an initial remission with such treatment. Many of these are cured with conventional dose cisplatin/ifosfamide-based regimen or high-dose chemotherapy with stem cell rescue. Controversy exists regarding the optimal choice between these 2 second-line approaches, and available data for each is reviewed here. Clinical factors can help prognosticate patients, and recently an international effort developed a prognostic model for the second-line setting that can be universally applied in future studies.

Multidisciplinary management of malignant ovarian germ cell tumours

OBJECTIVES

Malignant ovarian germ cell tumours (MOGCT) are rare cancers of young women. Limited prospective trials exist from which evidence-based management can be developed. This review summarizes the available literature concerning MOGT in order to provide the clinician with information relevant to their multidisciplinary management.

METHODS

MEDLINE was searched between 1966 and 2010 for all publications in English where the studied population included women diagnosed with malignant ovarian germ cell tumours.

RESULTS

The majority of patients can be cured with fertility-preserving surgery with or without combination chemotherapy. Long term survival approaches 100% in early stage disease and is approximately 75% in advanced stage disease. Most studies suggest that the treatment has little, if any, effect on future fertility and limited data suggest that there is no adverse effect on the future quality of life.

CONCLUSION

MOGCTs are rare tumours of young women the majority of which can be successfully treated with fertility-preserving surgery with or without chemotherapy with preservation of reproductive function. Minimisation of chemotherapy in good prognostic groups and improved treatment in resistant and relapsed MOGCT are important goals for the future. Further studies are needed to quantify the late adverse effects of treatment in long term survivors.

Optimizing Liposomal Cisplatin Efficacy through Membrane Composition Manipulations

The first liposomal formulation of cisplatin to be evaluated clinically was SPI-077. Although the formulation demonstrated enhanced cisplatin tumor accumulation in preclinical models it did not enhance clinical efficacy, possibly due to limited cisplatin release from the formulation localized within the tumor. We have examined a series of liposomal formulations to address the in vivo relationship between cisplatin release rate and formulation efficacy in the P388 murine leukemia model. The base formulation of phosphatidylcholine: phosphatidylglycerol: cholesterol was altered in the C18 and C16 phospholipid content to influence membrane fluidity and thereby impacting drug circulation lifetime and drug retention. Phase transition temperatures (T(m)) ranged from 42-55°C. The high T(m) formulations demonstrated enhanced drug retention properties accompanied by low antitumor activity while the lowest T(m) formulations released the drug too rapidly in the plasma, limiting drug delivery to the tumor which also resulted in low antitumor activity. A formulation composed of DSPC : DPPC : DSPG : Chol; (35 : 35 : 20 : 10) with an intermediate drug release rate and a cisplatin plasma half-life of 8.3 hours showed the greatest antitumor activity. This manuscript highlights the critical role that drug release rates play in the design of an optimized drug delivery vehicle.

Prognostic factors in patients with metastatic germ cell tumors who experienced treatment failure with cisplatin-based first-line chemotherapy

PURPOSE

To develop a prognostic model in patients with germ cell tumors (GCT) who experience treatment failure with cisplatin-based first-line chemotherapy.

PATIENTS AND METHODS

Data from 1,984 patients with GCT who progressed after at least three cisplatin-based cycles and were treated with cisplatin-based conventional-dose or carboplatin-based high-dose salvage chemotherapy was retrospectively collected from 38 centers/groups worldwide. One thousand five hundred ninety-four (80%) of 1,984 eligible patients were randomly divided into a training set of 1,067 patients (67%) and a validation set of 527 patients (33%). Seminomas were set aside for posthoc analyses. Primary end point was the 2-year progression-free survival after salvage treatment.

RESULTS

Overall, 990 patients (62%) relapsed and 604 patients (38%) remained relapse free. Histology, primary tumor location, response, and progression-free interval after first-line treatment, as well as levels of alpha fetoprotein, human chorionic gonadotrophin, and the presence of liver, bone, or brain metastases at salvage were identified as independent prognostic variables and used to build a prognostic model in the training set. Survival rates in the training and validation set were very similar. The estimated 2-year progression-free survival rates in patients not included in the training set was 75% in very low risk, 51% in low risk, 40% in intermediate risk, 26% in high risk, and only 6% in very high-risk patients. Due to missing values in individual variables, 69 patients could not reliably be classified into one of these categories.

CONCLUSION

Prognostic variables are important in patients with GCT who experienced treatment failure with cisplatin-based first-line chemotherapy and can be used to construct a prognostic model to guide salvage strategies.

Elevated LDH predicts poor outcome of recurrent germ cell tumours treated with dose dense chemotherapy

AIMS OF THE STUDY

Prognostic factors for recurrent germ cell tumours (GCTs) treated with dose dense salvage chemotherapy have not been identified. This study determines whether lactate dehydrogenase (LDH) or established prognostic models can predict the outcome of recurrent GCTs treated with dose dense cisplatin-based chemotherapy.

PATIENTS AND METHODS

Retrospective analysis of 117 consecutive male patients with a first recurrence of a GCT treated with dose dense chemotherapy at a single cancer centre. Characteristics associated with progression-free survival (PFS) and overall survival (OS) were identified by univariate and multivariate analyses. Prognostic criteria published by the Medical Research Council (MRC) and the Memorial Sloan Kettering Cancer Centre (MSK) were also applied in an attempt to validate them and to compare their performance to that of LDH.

RESULTS

Raised LDH was significantly associated with poor PFS (hazard ratio (HR)=3.7; p<0.001) and OS (HR=3.4; p=0.001). Further factors associated with poor PFS and OS, respectively, were failure to achieve a complete response or marker negative partial response for at least 6 months (HR=2.1; p=0.033) and seminoma histology (HR=3.4; p=0.003). The MRC prognostic model, but not the MSK model, identified groups of patients with statistically significant differences in PFS and OS but raised LDH predicted OS and PFS with a higher HR.

CONCLUSIONS

Raised LDH is associated with a poor prognosis in recurrent GCTs and outperforms established prognostic models in this setting. LDH as a prognostic factor should be validated prospectively and should also be assessed in patients receiving conventional dose chemotherapy regimens.

Optimal management of testicular cancer: from self-examination to treatment of advanced disease

Germ-cell cancer is the most common solid tumor in men aged 15 to 35 years and has become the model for curable neoplasm. Over the last 3 decades, the cure rate has increased from 15% to 85%. This improved cure rate has been largely attributed to the introduction of cisplatin-based chemotherapy. In stage I seminoma and nonseminoma, cure rates approach 100% and treatment is governed by patient choice based on the perceived morbidities of each therapy and personal preferences. For seminoma, treatments include surveillance, radiotherapy, and single course carboplatin. For nonseminoma, treatments include surveillance, retroperitoneal lymph node dissection (RPLND), and adjuvant chemotherapy. Low volume (<3 cm) stage II seminoma is typically managed with radiotherapy while higher volume (>3 cm) stage II and stage III disease treated with chemotherapy. Positron emission tomography (PET) imaging can differentiate active cancer versus necrosis for postchemotherapy residual masses. PET-positive masses are managed with either surgery or second-line chemotherapy. Low volume (<5 cm) stage II nonseminoma with normal serum tumor markers may be managed with either RPLND or chemotherapy. Patients with persistently elevated serum tumor markers and larger volume stage II and stage III disease are managed with systemic chemotherapy. As with seminoma, good risk patients are typically treated with 3 courses of bleomycin, etoposide, and cisplatin (BEP) and intermediate and poor risk patients are treated with 4 courses. Residual postchemotherapy masses should be resected due to the uncertainty of the histology with 50% to 60% harboring residual teratoma or active cancer. The majority of patients completing initial therapy who relapse do so within 2 years. A minority of patients (2%-3%) recur after 2 years and this phenomenon is termed late relapse. Excluding chemonaïve patients, late relapse disease is typically managed surgically with 50% being cured of disease. Current therapeutic challenges in testis cancer include the accurate prediction of postchemotherapy histology to avoid surgery in patients harboring fibrosis only, improved therapy in platinum-resistant and platinum-refractory disease, and the understanding of the biology of late relapse.

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.

Pituitary hCG production and cerebral tuberculosis mimicking disease progression during chemotherapy for an advanced ovarian germ cell tumour

BACKGROUND

Ovarian germ cell tumours (OGCT) are rare but are usually curable with chemotherapy, even when presenting with advanced disease. The majority of OGCT produce the tumour markers, hCG and/or AFP which can be helpful in the diagnosis and monitoring the response to treatment.

CASE PRESENTATION

In this case of a 36 year old woman, the elevated hCG level at presentation was helpful in making a clinical diagnosis of OGCT in a patient too unwell to permit a tissue diagnosis. Cisplatin based combination chemotherapy produced an initial normalisation of the hCG level, but later in treatment the patient developed new cerebral lesions and a rising serum hCG suggestive of disease progression. Further investigations suggested that the CNS lesions were cerebral TB and that the low levels of hCG elevations was likely to be pituitary in origin. Chemotherapy treatment was continued along with anti-tuberculous therapy and 24 months after successful completion of therapy the patient remains disease free.

CONCLUSIONS

In the treatment of cancer patients it may be helpful to consider the potential non-malignant causes of new CNS lesions and that low hCG elevations may result from physiology rather than pathology in selected cases.

High-dose chemotherapy plus stem cell transplantation in advanced germ cell cancer: a review

CONTEXT

High-dose chemotherapy (HDCT) with stem cell transplantation (SCT) has been investigated as a treatment strategy for advanced germ cell cancer (GCC) for >2 decades. In an effort to improve on the overall cure rates of 80% achievable with conventional chemotherapy, researchers have investigated this therapeutic option as a first-line therapy for those with poor-prognosis disease and as a salvage therapy for those with relapsed or refractory disease.

OBJECTIVE

The primary objective of this review is to define the role of HDCT plus SCT in advanced GCC. Prognostic indicators for this group of patients are also presented.

EVIDENCE ACQUISITION

A Medline search of English-language literature was performed to identify studies published in the last 20 yr relating to the use of HDCT plus SCT in advanced GCC. Phase 1, phase 2, and phase 3 trials were included, as were retrospective reviews and meta-analyses.

EVIDENCE SYNTHESIS

Phase 2 trials investigating HDCT plus SCT as a therapeutic option for advanced germ cell cancer have indicated a survival advantage over conventional chemotherapy. This has not been confirmed in the phase 3 setting. Alternative chemotherapeutic strategies and options following failure of HDCT plus SCT are discussed.

CONCLUSIONS

Studies to date have not indicated a survival advantage for the use of HDCT plus SCT in advanced germ cell cancer. Many questions, however, remain unanswered, and further research is required to identify whether optimising the strategy of HDCT plus SCT will improve outcome in this predominantly young group of patients.

[Salvage treatment in germ cell tumors : high-dose chemotherapy and the impact of prognostic factors]

The majority of patients with germ cell tumors who fail first-line treatment will still be cured. Patients without first-line chemotherapy who fail surveillance, radiotherapy, or surgery will be managed according to the treatment algorithms of their primary metastatic disease. These patients usually receive three to four cycles of cisplatin, etoposide, and bleomycin.Salvage treatment of patients who relapse after first-line chemotherapy is more complex and requires an experienced and highly specialized team. Two distinct treatment strategies can be pursued: four cycles of conventional-dose chemotherapy with cisplatin, ifosfamide, and either etoposide, paclitaxel, or vinblastine; or early intensification of first-salvage treatment using sequential high-dose chemotherapy. Salvage surgery is frequently required after completion of salvage chemotherapy to completely resect all radiologic residual manifestations. Patients with brain metastases should receive upfront whole brain radiation concurrent with salvage chemotherapy. Patients with late relapses more than 2 years after first-line treatment should receive immediate salvage surgery whenever this is technically feasible.

High-dose chemotherapy followed by stem cell rescue for high-risk germ cell tumors: the Stanford experience

Germ cell tumors carry an excellent prognosis with platinum-based therapy upfront. The patients who either relapse or demonstrate refractoriness to platinum pose a challenge. There exist many reports in the literature on the use of high-dose chemotherapy and stem cell rescue improving the outcome in patients with relapsed germ cell tumors. However, the reports have great variability in the patient selection, prior treatments, the choice of the conditioning regimen and variability of the doses within the same regimen. In this report, we present 37 patients who underwent a uniform protocol of high-dose chemotherapy with stem cell rescue. Stem cell mobilization was performed with high-dose CY (4 g per m(2)) and we were able to collect adequate cells for marrow rescue in all patients. Patients received a high-dose regimen with etoposide (800 mg/m(2) per day) days -6, -5 and -4 as a continuous infusion, carboplatin (667 mg/m(2) per day) on days -6, -5 and -4 as a 1 h infusion, and CY (60 mg/kg per day) on days -3 and -2. In this high-risk group of patients, high-dose chemotherapy with autologous stem cell rescue led to a 3-year overall survival of 57% and a 3-year event-free survival of 49%. The results are reflective of a single procedure. No tandem transplants were performed. The treatment-related mortality was low at 3% in this heavily pretreated group.