Germ-cell testicular cancer in adults (first of two parts)

Testicular Neoplasms: Primary Tumour Size Is Closely Interrelated with Histology, Clinical Staging, and Tumour Marker Expression Rates-A Comprehensive Statistical Analysis

The role of primary tumour size (TS) in the clinical course of testicular tumours is incompletely understood. We retrospectively evaluated 641 consecutive patients with testicular neoplasms with regard to TS, histology, clinical stage (CS), serum tumour marker (STM) expression and patient age using descriptive statistical methods. TS ≤ 10 mm was encountered in 13.6% of cases. Median TS of 10 mm, 30 mm, 35 mm, and 53 mm were found in benign tumours, seminomas, nonseminomas, and other malignant tumours, respectively. In cases with TS ≤ 10 mm, 50.6% had benign tumours. Upon receiver operating characteristics analysis, TS of > 16 mm revealed 81.5% sensitivity and 81.0% specificity for detecting malignancy. In subcentimeter germ cell tumours (GCTs), 97.7% of cases had CS1, and CS1 frequency dropped with increasing TS. Expression rates of all STMs significantly increased with TS. MicroRNA-371a-3p (M371) serum levels had higher expression rates than classical STMs, with a rate of 44.1% in subcentimeter GCTs. In all, TS is a biologically relevant factor owing to its significant associations with CS, STM expression rates and histology. Importantly, 50% of subcentimeter testicular neoplasms are of benign nature, and M371 outperforms the classical markers even in subcentimeter tumours.

Father-Son Testicular Cancer, Case Report

A case of familial testicular malignancy in a father and his son is reported. This represents the seventh described case of father-son testicular cancer. The father had seminoma and the son had teratocarcinoma. Both patients’ peripheral blood lymphocytes were tested for 52 HLA specificities: the father's antigens were HLA A3, B13, B14, Cw6, Cw8 and the son's were HLA A2, A3, B14, Cw8. (Common haplotype: A3, B14, Cw8). The association between HLA antigens and testicular cancer is discussed.

Detection of serum alpha-fetoprotein in dogs with naturally occurring malignant neoplasia

Serum alpha-fetoprotein (AFP) concentrations were determined, by use of an automated microparticle enzyme-linked immunoassay (MEIA), in 16 control dogs and 48 dogs with previously untreated, histologically confirmed, naturally occurring neoplasia (17 dogs with lymphoma and 31 dogs with nonhematopoietic malignancies, 13 dogs with carcinomas, 18 dogs with sarcomas). Mean serum AFP concentrations for untreated dogs with lymphoma, for dogs with sarcomas, and for dogs with carcinomas were not significantly different from the mean serum AFP concentration for the 16 untreated control dogs. Mean serum AFP concentration for dogs with transitional cell carcinoma (n=7) was not significantly different from the mean serum AFP concentration for the control dogs. It has been shown previously by others that a mean serum AFP concentration > 225 ng/mL is suggestive of a hepatic malignancy (e.g., hepatocellular carcinoma, lymphoma). In our study, all 48 dogs had a normal complete blood count, serum biochemical analysis, and urinalysis. Only one of the 48 dogs was found to have a serum AFP concentration > 225 ng/mL. Later evaluation of this dog confirmed hepatic involvement with lymphoma. AFP can be detected in the serum of dogs with naturally occurring tumors using the MEIA technique. A serum AFP concentration above that observed in normal dogs is not a common finding in dogs with naturally occurring neoplasia; however, we confirmed that a serum AFP concentration > 225 ng/mL, with or without evidence of a serum biochemical abnormality, may suggest primary and/or secondary hepatic involvement with a neoplastic disease and may warrant an adjustment in clinical stage and prognosis. A prospective diagnostic and therapeutic evaluation of dogs, with naturally occurring tumors having an elevated serum AFP concentration would determine the validity of this conclusion.

Factors involved in diagnostic delay of testicular cancer

In testicular cancer, which is one of the highly curable cancers, the beneficial effect of early diagnosis on survival has been well accepted for years. This study was planned to determine the probable factors involved in diagnostic delay of testicular cancer. A total of 140 patients with testicular cancer were included in this study. We attempted to find a relationship between the mode of presentation, stage of the tumour, patients' socioeconomic status and the delay in diagnosis. Majority of patients presented with scrotal pain (49.3%). No significant correlation was found between the mode of presentation and stage of the disease (p>0.05). The median time of delay in diagnosis was 5.4 months. The stage at presentation was not influenced by the delay in diagnosis. Similarly the annual income and the educational level of the patients had no significant impact on the delay in diagnosis. No effect of delay in diagnosis on the stage at presentation could be demonstrated in our study. Our results indicate that in this country people are not thoroughly educated about the importance of routine self-examination of the testes. It must also be emphasized that painful testicular masses need to be evaluated carefully to rule out malignancy.

Comparative evaluation of serum CA 195 and carcinoembryonic antigen in metastatic carcinoma

BACKGROUND

Carcinoembryonic antigen (CEA) is a well-described human tumor-associated antigen most useful clinically in colon cancer. However, the clinical usefulness of CEA is limited by the marker's overall poor specificity and low sensitivity in patients with minimal disease. CA 195 is a recently discovered human tumor-associated glycoprotein that can be measured in serum using an immunoradiometric assay. CA 195 is expressed on the membrane of human colon cancer cells and shares an epitope with the Lewis A blood group antigens. The authors initiated a study to compare the clinical utility of serum CA 195 with CEA in patients with advanced cancer. A control population was studied to assess the effects of age, gender, alcohol, and tobacco on the measured levels of serum CA 195.

METHODS

Using a solid-phase two-site immunoradiometric assay, serum CA 195 and CEA levels were measured in 71 control subjects and 167 patients with a prior diagnosis of cancer. The tumor histologic types included breast cancer, 49 patients; colon cancer, 38; prostate cancer, 24; lung cancer, 22; gastrointestinal noncolon cancer, 7; and miscellaneous, 27. Among patients with a history of cancer, 124 (74%) had active metastatic disease, and 43 (26%) were without evidence of active disease. The control population was composed of subjects without a history of malignancy. Clinical data collected from them included age, gender, smoking history, and alcohol consumption.

RESULTS

In this laboratory, the normal ranges established for CA 195 and CEA in the control group were: 0.0-8.3 U/ml and 0.2-4.2 ng/ml, respectively. In the control subjects, the serum CA 195 level, unlike that of CEA, was not affected by age, gender, alcohol consumption, or tobacco use. In the study population, CA 195 had either equivalent or inferior specificity and sensitivity to CEA in all tumor types. A determination of the additive specificity and sensitivity of CA 195 and CEA did not significantly improve its clinical utility compared with CEA alone. However, CA 195 was significantly elevated in three patients with a prior history of colon cancer thought to be without evidence of active disease. Because all three of these patients had a relapse within the next 1-15 months, CA 195 might identify early relapses of colon cancer in some patients.

CONCLUSIONS

Based on these results, it was concluded that CA 195 is not superior to CEA as an indicator of disease activity in advanced colon cancer or other solid tumors. However, studies utilizing CA 195 in the detection of early relapses of colon cancer may be warranted. A review of the English literature revealed that CA 195 might be a useful marker in pancreatic cancer.

Right atrial extension of an embryonal carcinoma of the testis

A case of embryonal carcinoma of the testis extending into the inferior vena cava and the right atrium is presented. Tumor extension was demonstrated preoperatively by computed axial tomography. Successful resection of the intravascular and right atrial extension was achieved using extracorporeal circulation. It is concluded that intravascular and right atrial extension is not a contraindication to radical surgery. This type of metastasis raises the same therapeutic and prognostic problems as those raised by tumor masses in the lungs or lymph nodes found after chemotherapy for malignant nonseminomatous germ cell tumor of the testis.

Hepatic resection for disseminated germ cell carcinoma

Improvements in operative technique and perioperative management have expanded the application of hepatic resection for metastatic cancer. Although a policy of aggressive surgical resection of residual pulmonary and retroperitoneal disease following chemotherapy and normalization of serum tumor markers has been adopted for disseminated germ cell carcinoma, resection of residual hepatic disease in these cases has not been addressed. This report concerns a series of prospectively randomized patients who received systemic cisplatin-based chemotherapy for testis cancer during the past 13 years. Twenty-eight patients underwent resection of residual hepatic disease after serologic remission. Most (23 of 28 patients) of these procedures were performed concomitantly with other cytoreductive procedures. There were no operative deaths, although 28% of the patients developed complications. The 2-year survival rate was 54%, with an average follow-up of 34 months. Patients were stratified into three groups based on the most aggressive histology noted in the resected specimen. Survival is predicted by this histologic classification system. Hepatic resection can be performed safely and is an important component in the treatment of disseminated testicular carcinoma.

Treatment of malignant germ cell tumors

In an unselected group of 278 patients with germ cell tumors, disease-free status was obtained in 97% by a treatment program including a surveillance-only strategy for stage I testicular cancer, and low-or high-dose cisplatinum-etoposide treatment for patients with more extensive disease. The overall follow-up period was a median of 40 months (range 20-62 months). At present 100% of patients with stage I disease, 91% with stage II disease, 86% with stage III disease, 75% with extragonadal germ cell tumors, and 3 of 3 patients with germ cell tumors in the ovary are alive and without disease. Among 36 patients treated with high-dose cisplatinum and etoposide there were six toxic deaths, four of them in patients with residual malignant disease. Three patients died of progressive disease. There were no toxic deaths among 54 patients with disseminated disease but without poor prognostic features who were treated with low-dose cisplatinum-etoposide; six of these patients died of progressive disease. It is concluded: 1) that surveillance is a feasible and reasonable strategy for patients with stage I disease; 2) that excellent survival results can be achieved with standard-dose cisplatinum-etoposide in patients with disseminated disease and a favorable prognostic profile; and 3) that disease-free status can be obtained in nearly all patients with poor prognostic features at the expense of significant toxicity. Standardized criteria for selection of patients with poor prognoses are needed. Randomized trials should be carried out to define the role of high-intensity treatment and, finally, measures to decrease or prevent serious toxicity should be explored.

Reduced metabolic clearance of acidic variants of human choriogonadotropin from patients with testicular cancer

We investigated the plasma disappearance of purified urinary human choriogonadotropin (hCG) and acidic variants of hCG (AV-hCG) that are excreted in the urine of patients with testicular cancer to determine if there are differences in their disappearance rates. All cancer patients had relatively increased fractions (10% to 46%) of AV-hCG in their serum when compared with hCG from pregnant control subjects (less than 4% present as AV-hCG). After initiation of therapy in 12 patients with nonseminomatous testicular tumors, the proportion of hCG present as acidic variants in serum rose despite lower serum total hCG concentrations. Samples of highly purified AV-hCG (pI, 3.3 to 4.0) obtained from three patients by concentration from urine and isoelectric focusing were evaluated for their disappearance from serum after injection into rats. All AV-hCG samples had decreased clearance rates when compared with that of highly purified hCG (CR123). These data indicate that acidic forms of hCG have a delayed clearance that contributes to the increased proportion of AV-hCG in the serum of patients with hCG-producing neoplasia after therapy.

Results of adjuvant chemotherapy for low-stage nonseminomatous germ cell tumors of the testis with vascular invasion

Vascular invasion has been well established as one of the prime prognostic indicators in nonseminomatous germ cell tumors of the testis (NSGCT). In a retrospective series of node negative or minimally involved patients by radiology, only eight of 28 (28.6%) survived when vascular invasion was detected, compared with 50 of 72 (69%) without vascular invasion. In 1977 a policy of adjuvant cytotoxics (vinblastine and bleomycin) was added to the radiotherapy which was standard postorchidectomy treatment at the Peter MacCallum Cancer Institute. When platinum-based combination regimens were found to be effective, the radiotherapy was discontinued. Only two relapses with the original treatment occurred with one death 10 years later. The modified Einhorn protocol used as primary postorchidectomy treatment has prevented relapse in all six cases in whom it was used. The overall survival rate at 2 to 10 years is 94%. There are important implications in these findings for the "watch policy" which is becoming increasingly popular. In our opinion patients should not be merely watched when histologic sectioning of the primary reveals invasion of the vessels, of whatever type, by the tumor. Instead they should be treated.

Controversies in urologic oncology

The persistent controversies that characterize urologic oncology reflect the significant advances that have been made in our understanding of genitourinary malignancy and the objective posture that has been taken both by those active in this area and by those whose interests are more indirect. Ultimately, the beneficiaries of these controversies are the patients and their physicians. As continued problems are recognized and investigations are designed to explore them, controversy and skepticism become a healthy concomitant so that true knowledge and understanding can be achieved and such issues ultimately resolved.

Ultrastructure of four human germ cell tumor-derived cell lines: effect of 12-O-tetradecanoyl phorbol-13-acetate

Cells derived from human germ cell tumors (HGCT) are potential models for the study of human embryonic differentiation. Differentiation in four HGCT-derived lines (1618K, 833KE, 1777Ndif, 2806B) was examined by light and electron microscopy, after exposure of cells to dimethyl sulfoxide (DMSO) and 12-O-tetradecanoyl phorbol-13-acetate (TPA). In line 1618K, the effect of retinoic acid was also examined. After exposure to TPA, the cells of line 1618K had a loss of microvilli, an increased amount of nuclear heterochromatin, and an increase in the number of cytoplasmic vacuoles. The cells of line 833KE exposed to TPA showed only an increase in cytoplasmic vacuoles. No changes were observed in any cell line after exposure to DMSO. Similarly no changes were observed in 1618K after exposure to retinoic acid. These findings indicate that DMSO and retinoic acid are not effective inducers of differentiation in these HGCT-derived cell lines. The phorbol ester, TPA, appears to induce differentiation of some HGCT-derived cell lines.

Histopathology in the prediction of relapse of patients with stage I testicular teratoma treated by orchidectomy alone

259 patients with stage I non-seminomatous germ-cell testicular teratoma who were treated by orchidectomy alone and monitored at one often centres in the United Kingdom were followed for a median of 30 months. 62 of the 70 relapses occurred in the first 18 months after orchidectomy. The 2-year relapse-free rate was 74%, falling to 68% at 4 years. Histological sections from 233 of the orchidectomy specimens were reviewed centrally. Four features independently predicted relapses: invasion of testicular veins, invasion of testicular lymphatics, absence of yolk-sac elements, and presence of undifferentiated tumour. An index, based on the number of these features observed, identified a high-risk subgroup of 55 patients who had a 42% relapse-free rate at 2 years.

Orchidectomy alone versus orchidectomy plus radiotherapy in stage I nonseminomatous testicular cancer: a randomized study by the Danish Testicular Carcinoma Study Group

All Danish patients with stage I nonseminomatous testicular cancer diagnosed between December 1980 and January 1984 entered a randomized study comparing irradiation of retroperitoneal lymph nodes with surveillance only after orchidectomy. Twenty-four of the seventy-nine patients in the observation-only group have relapsed, three patients relapsing more than 2 years after orchidectomy. Ten of the seventy-three patients receiving irradiation have relapsed, all within 10 months after orchidectomy. The median time to relapse in both groups was 4.5 months. Irradiation prevented retroperitoneal relapses. Thirty-three of the relapsed patients were rendered disease free with chemotherapy, and one is still being treated. Four deaths have occurred, all unrelated to testicular cancer or antineoplastic treatment. Absence of embryonal carcinoma and presence of teratocarcinoma correlated with improved relapse-free survival. Patients with increased serum concentrations of tumour markers before orchidectomy had an increased risk of relapse. Surveillance-only is a reasonable treatment strategy in clinical stage I nonseminomatous testicular cancer. Preferably control and treatment of relapses should take place in specialized centres.

The role of delay in stage III testicular tumours

Twenty-nine patients with stage III testicular tumours seen between 1979 and 1984 were analysed for the relation between delay in both diagnosis and chemotherapy, and prognosis. The complete response (CR) rate was 40% for patients who were treated within 6 months from onset of symptoms, and 26.3% for patients who had an interval longer than 6 months. We believe that delay in diagnosis and chemotherapy may affect the response to treatment. Health education of the male population for self-examination of the testes is an important factor to minimize this delay.

Indolent nonseminomatous germ cell tumor of testis. Prolonged survival of patient with persistent metastatic disease

The complete response rate of disseminated nonseminomatous germ cell tumors (NSGCT) of the testes with current aggressive chemotherapy and surgical resection of residual disease is between 70 and 80 per cent. Those patients who do not attain complete response tend to have short survivals. A case is presented of a forty-one-year-old white man who has had nearly continuous evidence of metastatic embryonal carcinoma for more than eleven years. Although NSGCTs are characterized by rapid proliferation, early metastasis, high response rate to chemotherapy, and rapid death if uncontrolled, this case demonstrates an indolent form of disease with poor response to chemotherapy and yet prolonged survival in spite of uncontrolled disease. This is the first reported case of indolent metastatic germ cell neoplasm with survival of more than ten years.

Gynecomastia in testicular cancer patients. Prognostic and therapeutic implications

Eighty-one patients with advanced testicular cancer were evaluated for gynecomastia or severe breast tenderness at diagnosis and after platinum-based chemotherapy. The prognostic significance of gynecomastia in these two settings was explored. At presentation, 10% (8 patients) had gynecomastia or breast tenderness and elevated HCG levels. The likelihood of gynecomastia was greater with increasing HCG level (P = 0.002). However, gynecomastia at presentation was a more powerful independent discriminant of poor survival than the initial HCG level by multivariate analysis (P = 0.004). Fifteen percent (12 patients) developed transient gynecomastia after chemotherapy not attributable to other known causes. HCG levels were normal. Endocrine evaluation typically revealed elevated FSH, LH, and estradiol/testosterone ratios. This may have reflected damage to testicular germinal epithelium. All 12 patients are alive without disease in contrast to the 8 patients who had gynecomastia at diagnosis. Therapy decisions should therefore be based on the time of onset of gynecomastia and in the context of appropriate clinical markers and evaluation.

Intracranial germ-cell tumors: natural history and pathogenesis

The natural history of primary intracranial germ-cell tumors (GCT's) is defined from 389 previously published cases, of which 65% were germinomas, 18% teratomas, 5% embryonal carcinomas, 7% endodermal sinus tumors, and 5% choriocarcinomas. Intracranial GCT's display specificity in site of origin. Ninety-five percent arise along the midline from the suprasellar cistern (37%) to the pineal gland (48%), and an additional 6% involve both sites. The majority of germinomas (57%) arise in the suprasellar cistern, while most nongerminomatous GCT's (68%) preferentially involve the pineal gland (p less than 0.0001). The age distribution of afflicted patients is unimodal, centering with an abrupt surge in frequency in the early pubertal years; 68% of patients are diagnosed between 10 and 21 years of age. Nongerminomatous GCT's demonstrate an earlier age of onset than do germinomas (p less than 0.0001). Prolonged symptomatic intervals prior to diagnosis are common in germinomas (p = 0.0007), in suprasellar GCT's (p = 0.001), and among females (p = 0.02). Parasellar germinomas commonly present with diabetes insipidus, visual field defects, and hypothalamic-pituitary failure. Nongerminomatous GCT's present as posterior third ventricular masses with hydrocephalus and midbrain compression. Germ-cell tumors may infiltrate the hypothalamus (11%), or disseminate to involve the third ventricle (22%) and spinal cord (10%). Among a subpopulation of 263 conventionally treated patients, two factors were of prognostic significance: 1) histological diagnosis; germinomas were associated with significantly longer survival than nongerminomatous GCT's (p less than 0.0001); and 2) staging of the extent of disease; this emphasizes the ominous character of involvement of the hypothalamus (p = 0.0002), third ventricle (p = 0.02), or spinal cord (p = 0.01). Specific recommendations regarding the necessity of histological diagnosis and staging of the extent of disease are made in light of modern chemotherapeutic advances. The pathogenesis of GCT's may be revealed by their specificity of origin within the positive (suprasellar cistern-suprachiasmatic nucleus) and negative (pineal) regulatory centers for gonadotropin secretion within the diencephalon. The abrupt rise in age distribution at 10 to 12 years suggests that the neuroendocrine events of puberty are an "activating" influence in the malignant expression of these embryonal tumors.

A human embryonal-yolk sac carcinoma model system in athymic mice

Two new human cell lines (1411H and 1411HRQmet) have been established from a patient with metastatic testicular cancer whose primary and metastatic histology included seminoma, teratoma, embryonal carcinoma (EC), and yolk sac tumor (YST). In vitro, the cells have been maintained for more than 70 passages, produce alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG), and have a human karyotype. When 2 X 10(7) cells of either line are inoculated into athymic mice, 87.5% of the animals (21/24) develop tumors. Initially 80% to 90% of the mass is EC, whereas the central portion is YST. After 90 to 390 days in vivo, the tumors achieve a large volume (2.13 +/- 0.97 cm3), become cystic, and undergo histologic change. The peripheral rim of the mass remains EC, but the central 80% to 90% becomes YST. The sera of tumor-bearing mice were positive for hCG and AFP in 11% and 38% of animals, respectively. Tumor cyst fluid was positive for hCG and AFP in 87% and 59% of animals, with mean values of 108 mIU/ml and 2,478 ng/ml, respectively. Tumor cyst fluid also contained placental alkaline phosphatase and human fibronectin. These two cell lines are useful for studies on the interrelationship of EC and YST and the differentiation of human germ cell cancer.

Chemotherapy trials in recurrent primary intracranial germ cell tumors

Gonadal germ cell tumors respond favorably to chemotherapy either at diagnosis or when they recur. Histologically similar tumors may arise in the CNS usually in the pineal or suprasellar regions. Although radiation therapy may produce a 5 year disease-free survival in excess of 60% in localized pure germinoma, germ cell tumors of other histology tend to recur. We have conducted 14 chemotherapy trials in 8 patients with recurrent CNS germ cell tumors using 3 different single agent and 2 multi-agent chemotherapy regimens. The histologic diagnoses of the patients were germinoma (4), endodermal sinus tumor (2), embryonal carcinoma (1), and mixed tumor - germinoma plus choriocarcinoma (1). There were 7 males and 1 female with a median age of 13 years. The primary tumor arose in the pineal region in 6 and was multicentric in 2. Seven patients had local recurrences and one developed an initial recurrence in the spinal canal. Three patients had CNS metastases at relapse and 2 had systemic metastases. Objective responses were documented in 7 of 14 trials (50%). Responses were observed with cyclophosphamide (80 mg/kg) in 3 of 4 patients for 2+, 3, and 5 mos, cisplatin (120 mg/m2) in 1 of 2 patients for 2+ mos, and the VAB 6 protocol (vinblastine, bleomycin, cyclophosphamide, actinomycin-d, cisplatin) in 3 of 5 patients for 5, 8, and 18 mos. The median duration of response was 5 mos. (2+-18). High doses of single chemotherapy agents such as cyclophosphamide and cisplatin as well as VAB 6 regimen have definite activity in recurrent CNS germ cell tumors, especially germinoma. Good palliation may be achieved with chemotherapy alone with acceptable morbidity.(ABSTRACT TRUNCATED AT 250 WORDS)

Testicular carcinoma. A curable malignancy

The progress in the management of testicular germ cell tumours is reviewed. A marked improvement of the treatment results has been obtained in non-seminomas, especially by the use of cis-platinum based chemotherapy. At present long term survival can be expected in 85 per cent of all non-seminomas and in 95 per cent of all seminomas after adequate treatment. The natural history of the disease, symptomatology, diagnostic procedures, staging and different treatment modalities, as surgery, radiation therapy, chemotherapy and their combination, are discussed.

Metastatic carcinoma involving the testis. Clinical and pathologic distinction from primary testicular neoplasms

Metastatic carcinoma to the testis is unusual. There are only seven previously reported cases in which a testicular mass was the first clinical manifestation of an underlying malignancy. The authors review 127 cases in which the testis was involved by metastatic carcinoma, and describe an additional two patients in whom a malignant testicular mass was the presenting sign of an underlying nontesticular carcinoma. The tumors most commonly reported to metastasize to the testis are: prostate (45 cases), lung (25 cases), melanoma (12 cases), colon (11 cases), kidney (10 cases), stomach (6 cases), and pancreas (5 cases). Neuroblastoma, retinoblastoma, carcinoid tumor, and cancers of the bile duct, ureter, bladder, salivary gland, and thyroid have also involved the testis secondarily. Nineteen patients (15%) had bilateral testicular metastases. Patients with secondary testicular neoplasms were older in general than those with germ cell tumors (mean, 55 years; median, 57 years). Histologically, the presence of extensive lymphatic and vascular invasion and an interstitial pattern, in which the seminiferous tubules are spared, is suggestive of a metastasis. In four of the nine cases (44%) in which testicular enlargement was the first manifestation of an underlying carcinoma the correct pathologic diagnosis was initially missed. Serum alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG) are occasionally elevated in patients with nontesticular primary tumors, but markedly elevated levels in young patients suggest a nonseminomatous germ cell tumor, as does positive immunoperoxidase staining for AFP and HCG.

Correlation of serum tumor markers in advanced germ cell tumors with responses to chemotherapy and surgery

Remission rates induced by chemotherapy alone or by combined chemotherapy and surgery were analyzed in relation to specific serum tumor marker abnormalities immediately before treatment in 103 patients with Stage III or bulky Stage II nonseminomatous germ cell tumors. Complete remission occurred in 92% (12 of 13) of patients with normal levels of alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG), in 26% (6/23) with elevated AFP only, in 46% (13/28) with elevated HCG only, and in 39% (13/36) with abnormalities of both AFP and HCG. Patients with elevated AFP less frequently had a complete remission (CR) to chemotherapy (CR, 34% versus 61% with normal AFP), but benefitted from adjunct surgery (CR, up to 59%). Patients with very high (greater than 1000 ng/ml) serum AFP or HCG responded poorly to chemotherapy (CR, 17%) but especially large tumor burdens may have contributed to these unfavorable responses. Patients with both minimal and advanced metastatic disease had higher CR rates if they had serum tumor marker levels below rather than above 1000 ng/ml. Adjunct surgery eliminated the correlation between the "poor prognostic factors" associated with specific marker abnormality and an incomplete response to chemotherapy by rendering a significant number of such patients free of disease through resection of residual metastatic deposits.

The pattern of gamma-glutamyl transpeptidase, alkaline phosphatase, serum glutamyl oxalate transaminase and serum glutamyl pyruvate transaminase in patients with disseminated non-seminomatous testicular tumors

The serum enzyme activities of gamma-glutamyl transpeptidase (GGT), alkaline phosphatase (AP), serum glutamyl oxalate transaminase (sGOT) and serum glutamyl pyruvate transaminase (sGPT) were determined longitudinally in 51 patients with a disseminated non-seminomatous testicular tumor. Elevated levels of one or more enzymes before chemotherapy were observed in 13 patients, all with stage III disease. If, after two cycles of chemotherapy, the established tumor markers alpha-fetoprotein (AFP), human chorionic-gonadotropin (HCG) and/or lactate dehydrogenase (LDH) were normalized, the initially increased enzyme activities were declined to normal values as well. Peaking concentrations of one or more of the tumor markers during induction chemotherapy, probably due to tumor cell lysis, were found in 34 of 45 marker-positive patients (76%). In addition, increases of one or more of the investigated enzyme activities were also noticed in 20 patients. In 76% of these patients the highest point of the tumor marker concentration coincided well with that of the enzyme activities. Indications are given that the peak activities were probably not caused by liver damage. Enzyme elevations were also found in 3 out of 7 patients with progressive disease. The behaviour of the enzyme activities of GGT, AP, sGOT and sGPT in patients with a disseminated non-seminomatous testicular tumor coincided with the known tumor markers. It favors the hypothesis that these enzymes are synthesized in the tumor. The mortality amongst stage III patients with or without initially raised GGT levels differed significantly (P less than 0.02). Finally, it is concluded that in patients with a non-seminomatous testicular tumor, sGOT, sGPT, GGT and AP cannot be used to diagnose liver function.

Testicular tumors: oncologic imaging and diagnosis

The extreme radiosensitivity of testicular seminomas plus recent advances in chemotherapy for nonseminomatous tumors and for advanced seminomas have made long term survival possible in the large majority of patients with testis cancer. Since choice of therapy is determined by tumor histology and extent of disease, accurate clinical staging is critical. Computed tomography (CT) of the abdomen and chest is the imaging procedure of choice for staging testis cancer. Clinical staging accuracy of 80 to 90% can be achieved using CT in combination with radioimmunoassays for beta-HCG and AFP. Ultrasonography (US), while less sensitive and specific than CT for determining nodal status, may be useful in thin patients with sparse retroperitoneal fat; in addition US may play an important role in detecting occult testicular neoplasms and in assessing primary tumor extent within the scrotum. Lymphangiography should be reserved for Stage I patients in whom elective treatment of the retroperitoneum is not planned. Follow-up should include serial radioimmunoassays for serum AFP and beta-HCG and periodic CT examinations of the abdomen and chest. Technical improvements in CT scanners and further experience with the use of tumor markers should help refine our ability to stage and manage patients with testicular tumors. In addition, nuclear magnetic resonance (NMR) imaging and radionuclide imaging following injection of radioactively labelled antibodies to AFP and beta-HCG are new techniques which offer great promise for the future.

Non-seminomatous testicular germ cell tumours. Preliminary analysis of ongoing trials in the DATECA Study

This report deals with the preliminary results of trials in the DATECA project with stage I, II and III patients with non-seminomatous germ cell tumours. Stage I patients were randomized between infradiaphragmatic irradiation and observation. No significant difference in recurrence rates has been observed as yet. Eighteen of 95 patients had recurrence with a median time to relapse of 3 months. Fifteen patients achieved complete remission after treatment by combination chemotherapy while 3 patients are still undergoing treatment. Stage II patients received 6 series of cis-platinum, bleomycin, and vinblastine. The patients were initially randomized to receive chemotherapy alone versus chemotherapy plus irradiation. Irradiation led to increased toxicity and decreased doses of the antineoplastic drugs. Fifty-one patients were studied. The overall complete remission rate was 89 per cent including 7 patients who achieved complete remission after secondary surgery. Three patients died from testicular tumours and two toxic deaths occurred in this group. Stage III patients were treated with 6 series of cis-platinum, bleomycin, and vinblastine. Fifty patients were studied. The complete remission rate was 72 per cent including 2 patients who achieved complete remission after secondary surgery. Sixteen patients relapsed after achieving complete remission with a median time to relapse of 4 months. Eight of these died, 4 achieved a new complete remission, while 4 patients are still under treatment. Sixty per cent of the patients are at present alive without evidence of disease, while 12 patients died from testicular tumours and 2 from toxic side effects.

Lymphography and computed tomography in staging nonseminomatous testicular cancer: limited detection of early stage metastatic disease

The efficacy of lymphography and computed tomography (CT) in staging nonseminomatous testicular cancer was analyzed in 41 patients. Retroperitoneal lymphadenectomy in 30 patients with early tumor stage revealed 56% sensitivity, 90% specificity, and 80% overall accuracy for lymphography; CT was less accurate (44% sensitivity, 81% specificity, 70% overall accuracy). The presence of advanced disease in 11 patients was depicted equally by lymphography and CT, but CT better demonstrated the anatomic extent of the metastases. CT is valuable for discriminating between advanced and early tumor stages; the similar inaccuracy of lymphography in early disease militates against its routine and complementary use; retroperitoneal lymphadenectomy then remains the only accurate staging modality.

Suprasellar germinoma. Unresolved problems in diagnosis, pathogenesis, and management

A suprasellar germinoma, initially thought to be granulomatous diencephalitis of uncertain cause, responded following chloramphenicol and methicillin treatment both by clinical and radiographic criteria and was not diagnosed until a third biopsy was performed. Analysis of this case and review of the literature lead to the conclusion that adequate diagnostic workup of such lesions requires that biopsy be extensive enough to include the central core as well as the granulomatous reaction that surrounds such tumors. Furthermore, since the degree of inflammation may fluctuate, regression does not mean that the lesion is not neoplastic in origin. In the present instance, the correct diagnosis could have been made earlier if the beta-chain of human chorionic gonadotropin had been measured in spinal fluid.

Molecular heterogeneity of human chorionic gonadotropin and its subunits in testicular cancer

The secretion of human chorionic gonadotropin and its subunits was examined by a heterologous hCG/hCG-beta radioimmunoassay and homologous radioimmunoassays of the alpha- and beta-subunit in patients with nonseminomatous testicular germ cell tumors. Of 53 patients, 32 (60%) had elevated levels of hCG (9 IU/l-4.5 million IU/l), 12 (23%) elevated serum concentrations of hCG-beta (20-286 micrograms/l) and 8 (15%) of hCG-alpha (14-498 micrograms/l). A selective elevation of hCG-subunits without the hormone was never observed. Serum concentrations of hCG-beta were to low to interfere in the heterologous radioimmunoassay using 125I-hCG and anti-hCG-beta antiserum. Gelfiltration of patient's sera (n = 5) on Ultrogel AcA 44 column confirmed the secretion of free subunits and additionally a high molecular form of hCG-beta (70,000) in three of five serum specimens. Furthermore, the molecular heterogeneity of hCG and hCG-subunits was examined by affinity chromatography on Concanavalin A (Con A)-sepharose. There was a significant difference of Con A nonreactive hCG and hCG-alpha between patients with testicular cancer (hCG:2-82%; mean, 22%; n = 7; hCG-alpha: 11-61%; mean, 31%; n = 7) and pregnant women (hCG: 0%; n = 3; hCG-alpha: 0-13%; mean, 6%; n = 5). Con A nonreactive and reactive hCG of patients with cancer revealed similar binding in a radioreceptor gonadotropin assay. The Con A nonreactive fraction of the beta-subunit was determined to be 20-73% (mean, 50%; n = 6) in serum samples of patients with testicular cancer and did not differ from the percentage in pregnant women (29-67%; mean, 46%; n = 4). The lectin binding heterogeneity of hCG and hCG-alpha indicate structural variations in the carbohydrate chains. It is assumed that Con A nonreactive hCG and hCG-alpha are directly liberated by nonsecretory mechanism from tumor cells into the circulation. Determination of hCG released by cell damage may have clinical significance in patients with testicular cancer under chemotherapy.

Serum tumor markers in patients with metastatic germ cell tumors of the testis. A 10-year experience

The serum values of alphafetoprotein, human chorionic gonadotropin, lactate dehydrogenase, and carcinoembryonic antigen in patients with metastatic testicular cancer were reviewed for the period 1972 to 1982. All values were obtained before chemotherapy was begun. Elevated values of alphafetoprotein were present in 47 percent of patients tested, of human chorionic gonadotropin in 60 percent, of lactate dehydrogenase in 64 percent, and of carcinoembryonic antigen in 11 percent. The frequency of elevated values of alphafetoprotein, human chorionic gonadotropin, and lactate dehydrogenase decreased during the study period. Inverse relations between elevated values of alphafetoprotein, human chorionic gonadotropin, and lactate dehydrogenase and both complete remission rate and survival rate were noted in some of the chemotherapy trials. Carcinoembryonic antigen was believed not to be useful as a marker in this disease. It is concluded that assays of alphafetoprotein, human chorionic gonadotropin, and lactate dehydrogenase are important both clinically and prognostically in patients with testicular cancer.

Gonadal and extragonadal germ cell neoplasia of childhood

Germ cell tumors in children are characterized by diverse clinical, pathologic, and prognostic features. For this reason, it is difficult to generalize about the behavior of these tumors; cases must be evaluated individually, with consideration for the age of the patient at diagnosis, the anatomic site of the tumor, and its histologic appearance. Experimental models and cytogenetic studies of teratomatous development have contributed to our basic understanding of the biology of differentiation and tumorigenesis.

Interrelationships of histopathology and other clinical variables in patients with germ cell tumors of the testis

Possible relationships between histopathologic cell type and several clinical variables were examined in 253 patients with Stage III nonseminomatous germ cell tumors of the testis. No statistically significant associations were found between cell type and either the side of primary tumor or cryptorchidism. The presence of elements of choriocarcinoma was associated with the presence of retroperitoneal tumor (P less than 0.03) but no other association between cell type and site of metastasis was encountered. Elevated serum levels of human chorionic gonadotropin were found in patients with elements of choriocarcinoma but serum levels of alphafetoprotein, lactate dehydrogenase and carcinoembryonic antigen were not correlated with a specific cell type. No statistically significant association was found between cell type and either complete response to combined modality therapy or survival. These results would indicate that cell type is probably not an important prognostic variable in patients with Stage III nonseminomatous tumors of the testis.

Return of fertility after treatment for nonseminomatous testicular cancer: changing concepts

We studied the return of ejaculation in 31 patients who had undergone retroperitoneal lymphadenectomy for stage I or II nonseminomatous germ cell testicular cancer. Ejaculation returned spontaneously in 13 patients and was restored by sympathomimetic drugs in 5 of 8 patients treated. Both patients known to have tried to father a child succeeded. We also studied the effects of chemotherapy (vinblastine and bleomycin with or without cisplatin) in 34 patients, 24 of whom also had undergone retroperitoneal lymphadenectomy. Although chemotherapy profoundly depressed spermatogenesis during treatment 75 per cent of the patients tested 18 months or more after completion of treatment had some return of function, as evidenced by normal follicle-stimulating hormone levels and/or the presence of live sperm in the ejaculate. We concluded that it is possible to perform a therapeutically sound retroperitoneal lymphadenectomy for low stage nonseminomatous testicular cancer that permits return of ejaculation in many patients and that spermatogenesis recovers in a significant number of patients treated for this cancer with modern chemotherapy. Thus, traditional beliefs that operative and drug treatment of nonseminomatous testicular cancer invariably causes infertility must be revised.

Alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG) in testicular germ cell tumours. A comparison of histologic and serologic occurrence of tumour markers

170 patients with testicular germ cell tumours (88 seminomas and 82 non-seminomas) were examined with immunologic techniques for the presence of the tumour markers alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG) in tumour tissue and preoperative serum samples. Patients with pure seminomas had AFP negative tumour tissue and normal levels of serum AFP, whereas 13% had HCG demonstrated in the tumour tissue, mainly in syncytiotrophoblast-like cells (STLC), and 9% had raised serum HCG. 55% of patients with HCG positive seminomas had raised serum HCG. HCG positive seminomas did not occur in higher frequency in metastatic disease than in localized. 65% of patients with non-seminomas had AFP positive tumour tissue and 66% had raised serum AFP. 85% of the former group had raised serum AFP and 83% of the latter had AFP demonstrated in the tumour tissue. 69% of the patients with raised serum AFP had a positively stained yolk sac tumour (YST) component, while 15% had positively stained tumour components other than YST, inclusive teratoma components. Although 71% of patients with metastatic disease had raised serum AFP, AFP positive tumours with or without raised serum AFP did not occur with higher frequency in metastatic than in localized disease at the time of diagnosis. 46% of patients with non-seminomas had HCG positive tumours and 29% had raised serum HCG. 61% of the former group had raised serum HCG and 96% of the latter had HCG demonstrated in the tumour tissue. HCG positive tumours with or without raised serum HCG did not occur more frequently in metastatic than in localized disease at the time of diagnosis. 28% of patients with non-seminomas had raised serum AFP as well as HCG, whereas 23% had neither AFP nor HCG in tumour tissue and serum. A search for new tumour markers in this rather large marker negative group of patients is recommended.

Effects of multiple-drug chemotherapy (cis-diammine-dichloroplatinum, bleomycin, and vinblastine) on the maturation of retroperitoneal lymph node metastases of nonseminomatous germ cell tumors of the testis. No evidence for De Novo induction of differentiation

Investigating the mechanisms underlying maturation of metastases of nonseminomatous germ cell tumors on administration of chemotherapy, the histologic characteristics of primary testis tumors was compared to the histologic characteristics of their retroperitoneal metastases in three historical patient groups. The metastases in Group I (20 patients) were not treated; those in Groups II (nine patients) and III (24 patients) were treated, respectively, with three cycles of dactinomycin and with four cycles of cis-diammine-dichloroplatinum, vinblastine, and bleomycin, before retroperitoneal lymph node dissection. In Group III there was a significant increase of metastases consisting of differentiated teratoma only, as compared to the metastases of Group I. However, both with and without chemotherapy, the metastases contained fewer areas of differentiated teratoma than the primary lesions. Metastases containing differentiated teratoma with and without other components, with one exception in Group III, were derived from primary tumors containing mature areas as well. Components other than mature teratoma were almost completely eradicated in Group III. These findings strongly suggest that selective destruction of components other than differentiated teratoma causes the mature histologic characteristics in the metastases upon administration of chemotherapy. The results do not support the hypothesis of induction of differentiation by the chemotherapeutic agents.

A clinical evaluation of serum placental alkaline phosphatase in seminoma patients

Serum levels of placental alkaline phosphatase (PLAP) were measured in 100 patients with seminoma. A specific double antibody radioimmunoassay was used. PLAP was elevated for 9 out of 21 patients with primary tumours, to a mean of 53 micrograms/l. Of the 12 cases with recurrent or metastatic growth, nine had raised PLAP. The sensitivity of PLAP determinations for primary and advanced disease was 55%. After successful treatment of seminoma, the PLAP level decreased. In a group of 68 patients with no evidence of disease, nine had slightly elevated serum PLAP. In many, but not all patients, serum PLAP parallelled the changes in tumour burden. In such patients and for follow-up of treatment, PLAP might be used as a new marker for seminomatous disease.

The management of nonseminomatous testicular cancer: current therapy and future directions

Carcinoma of the testes is the fourth leading cause of death in males between the ages of 15-54, and its incidence may be increasing. Nonseminomatous testicular cancer represents 50% of all testicular tumors. There have been recent advances in diagnosis, staging and therapy of these tumors. Currently, there is a high success rate with platinum containing combination chemotherapy regimens in patients with advanced stages of disease. The article reviews the evolution of successful chemotherapy and the issues of adjuvant therapy for early stage disease, radiation therapy and the role of retroperitoneal lymphadenectomy and surgery following chemotherapy.

A randomized trial of cytoreductive surgery followed by chemotherapy versus chemotherapy alone in bulky stage testicular cancer with poor prognostic features

Thirty-nine patients with Stage III nonseminomatous testicular cancer were treated in a prospective randomized trial comparing cytoreductive surgery followed by a cis-platinum containing combination chemotherapy regimen versus chemotherapy alone. All patients had one or more of the following poor prognostic signs: palpable retroperitoneal disease, liver involvement, invasion or obstruction of the inferior vena cava, or lung metastases larger than 2 cm in diameter. Cytoreductive surgery was technically feasible in this group of patients as assessed radiographically (70-90% reduction in tumor mass) and by the decline in serum levels of alpha-fetoprotein and human chorionic gonadotropin in 75% of the patients following surgery. However, there was no statistically significant improvement in overall response rate (75% versus 84%), complete response rate (50 versus 37%) or in survival between the patients treated with surgery prior to chemotherapy or with chemotherapy as the initial treatment. It is unlikely (P less than 0.028) that any true beneficial effect of surgery was missed due to the relatively small number of patients in each treatment arm. The authors of this study conclude that cytoreductive surgery prior to chemotherapy in patients with poor prognosis Stage III testicular carcinoma is not routinely indicated. Since the overall complete response rate to chemotherapy in these 39 patients with bulky Stage III disease was only 43%, alternate approaches, other than cytoreductive surgery, are necessary to improve the prognosis for this group of patients.

Tumor classification and size in germ-cell testicular cancer: influence on the occurrence of metastases

The influence of local tumor spread (T-classification) and of tumor size on the occurrence of metastases was studied in 241 patients with testicular germ-cell neoplasms. All patients underwent thorough clinical or pathologic staging, or both, and were treated at the University of Minnesota Hospitals. Spread of tumor through the tunica vaginalis (T2) was associated with abdominal lymph node or distant metastases in eight of nine patients. Local tumor extension to the spermatic cord (T4a) was associated with metastatic spread in 29 of 31 men. Tumor size did not appear to correlate with metastatic rate. These findings are an important aid in designing adjuvant therapy trials and in establishing a "no treatment" approach after orchiectomy.

Evaluation of pregnancy-specific beta 1-glycoprotein in patients with non-seminomatous testicular germ cell tumors

Serum SP-1 levels were measured serially in 94 patients with non-seminomatous germ cell tumors to evaluate its clinical significance as a tumor marker. In 12 out of 80 patients (15%) with active tumors serum SP-1 was found to be elevated, whereas serum HCG and AFP in the same sample were raised in 53 and 45% respectively. Elevation of serum SP-1 levels was always associated with raised HCG levels, and with AFP in 7 patients. During chemotherapy, serum SP-1 and HCG disappeared when a complete remission was obtained. In contrast to HCG, serum SP-1 failed to detect tumor progression in two patients. Serum HCG and AFP are superior as tumor markers to serum SP-1.