Treatment outcome of metastatic testicular cancer at a single institution in Japan, a country with low incidence of germ cell tumor

Improved survival of poor-risk non-seminomatous germ cell tumor patients: real-world data from a single institute in Japan

OBJECTIVES

The International Germ Cell Cancer Collaborative Group Update Consortium showed the improved survival of patients with a non-seminomatous germ cell tumor. We updated the survival data of the non-seminomatous germ cell tumor patients treated at our hospital.

PATIENTS AND METHODS

We analyzed the outcomes of 138 patients treated in 1981-2018. We compared the survival of the patients treated in the early (1981-99) and later (2000-18) periods and determined the groups' progression-free survival and overall survival using the Kaplan-Meier method. We used a web-based application of the International Germ Cell Cancer Collaborative Group Update model to calculate each patient's predicted 3-year progression-free survival.

RESULTS

The 5-year progression-free survival rates of the good, intermediate and poor prognosis groups were 91, 83 and 64%, and their 5-year overall survival rates were 97, 89 and 82%, respectively. There were no significant differences in the progression-free survival or overall survival of the good and intermediate prognosis groups by treatment year. The 5-year progression-free survival of the poor prognosis group was almost identical in both treatment year (60 and 65%, respectively). By contrast, the 5-year overall survival in the later period (85%) was higher than that in the early period (70%). The median-predicted 3-year progression-free survival rates of the good, intermediate and poor prognosis groups were 92, 83 and 51% (P < 0.01), respectively. The concordance index for the good, intermediate and poor prognosis groups were 0.56, 0.79 and 0.67, respectively.

CONCLUSION

The survival of our poor prognosis non-seminomatous germ cell tumor patients improved over time. The 5-year overall survival of patients treated in 2000-18 reached 85%.

Treatment at an Inexperienced Center Suggests Worse Prognosis of Metastatic Germ Cell Tumors

BACKGROUND/AIM

We evaluated the clinical outcomes of patients with metastatic germ cell tumors (GCT) treated at our hospital, which belongs to a regional cancer center.

PATIENTS AND METHODS

Data pertaining to patients with metastatic GCT were obtained between April 2007-October 2017 and was retrospectively analyzed. Key outcome measures included objective response rates and survival rates.

RESULTS

All 42 patients received chemotherapy [complete response: eight (19.0%); partial response: 21 (50.0%); stable disease (SD): nine (21.4%); progressive disease: four patients (9.5%)]. Post-chemotherapeutic surgery was performed for seven out of 21 cases of partial response and two out of nine of stable disease. The 5-year survival rates of patients with good, intermediate and poor prognosis (International Germ Cell Consensus Classification) were 100%, 100%, and 71.4%, respectively. Patients who received induction chemotherapy at other hospitals had significantly poorer prognosis than those at our hospital (p=0.0043).

CONCLUSION

Patients with metastatic GCT should preferably receive chemotherapy at an experienced institution.

Sentinel Amenable Mortality: A New Way to Assess the Quality of Healthcare by Examining Causes of Premature Death for Which Highly Efficacious Medical Interventions Are Available

BACKGROUND

Amenable mortality, or premature deaths that could be prevented with medical care, is a proven indicator for assessing healthcare quality when adapted to a country or region's specific healthcare context. This concept is currently used to evaluate the performance of national and international healthcare systems. However, the levels of efficacy and effectiveness determined using this indicator can vary greatly depending on the causes of death that are included. We introduce a new approach by identifying a subgroup of causes for which there are available treatments with a high level of efficacy. These causes should be considered sentinel events to help identify limitations in the effectiveness and quality of health provision.

METHODS

We conducted an extensive literature review using a list of amenable causes of death compiled by Spanish researchers. We complemented this approach by assessing the time trends of amenable mortality in two high-income countries that have a similar quality of healthcare but very different systems of provision, namely, Spain and the United States. This enabled us to identify different levels of efficacy of medical interventions (high, medium, and low). We consulted a group of medical experts and combined this information to help make the final classification of sentinel amenable causes of death.

RESULTS

Sentinel amenable mortality includes causes such as surgical conditions, thyroid diseases, and asthma. The remaining amenable causes of death either have a higher complexity in terms of the disease or need more effective medical interventions or preventative measures to guarantee early detection and adherence to treatment. These included cardiovascular diseases, diabetes, hypertension, all amenable cancers, and some infectious diseases such as pneumonia, influenza, and tuberculosis.

CONCLUSIONS

Sentinel amenable mortality could act as a good sentinel indicator to identify major deficiencies in healthcare quality and provision and detect inequalities across populations.

APAF-1 is related to an undifferentiated state in the testicular germ cell tumor pathway

Apoptotic protease activating factor-1 (APAF-1) is a key regulator gene of apoptosis, located downstream from p53. Loss of APAF-1 expression is associated with chemorefractory malignant melanoma and neuronal cell differentiation. In order to make clear the function of APAF-1 in the carcinogenesis of germ cell tumors, we evaluated the expression levels of APAF-1 and several apoptosis and differentiation markers by immunohistochemistry in formalin-fixed paraffin-embedded samples from 43 cases of testicular germ cell tumor (TGCT) and six specimens of normal testis tissue. Expression of cleaved caspase-3, Oct-3/4, and Ki-67 were also examined by immunohistochemistry to evaluate apoptotic reactivity, tumor differentiation, and proliferation activity, respectively. APAF-1 was downregulated in two TGCT cell lines by siRNA transfection, and subsequent expression of the Ki-67 and Oct-3/4 genes and differentiation markers of three embryonic germ layers including keratin16 (KRT16) for ectoderm, vimentin (VIM) for mesoderm and GATA4 for endoderm were then tested. No significant relationship was found between APAF-1 expression and apoptotic activity in TGCTs. Expression of APAF-1, Oct-3/4, and Ki-67 was significantly higher in seminomas than in non-seminomas. In TGCTs, higher APAF-1 expression was correlated with higher proliferation (high Ki-67) and a lower degree of differentiation (high Oct-3/4). Interestingly, the expression of APAF-1 gradually decreased in accordance with tumor differentiation (seminoma and embryonal carcinoma > teratoma). Downregulation of APAF-1 in TGCT cell lines resulted in a decrease of Ki-67 and Oct-3/4 and an increase of VIM and KRT16 gene expression. These data show that higher expression of APAF-1 is related to an undifferentiated state in the TGCT pathway.

[Result of treatment for advanced germ cell tumor in the last decade]

PURPOSE

We retrospectively analyzed our therapeutic results of advanced male germ cell tumors in terms of efficacy and feasibility of our treatment strategy.

PATIENTS AND METHODS

Fifty-one new cases were treated in Saitama Cancer Center between April 1997 and August 2007. Patients age ranged from 16 to 58 (median 33). Primary site of the tumor was testis in 41 (80%) patients, retroperitoneum in 6 (12%), and mediastinum in 4 (8%). Histology of the primary germ cell tumor was pure seminoma in 14 (27%), and non-seminoma in 30 (59%). Twenty (39%), 14 (27%) and 17 (33%) were classified as good-, intermediate-, and poor-risk, retrospectively, based on The International Germ Cell Consensus Classification (IGCCC) criteria. The initial treatment for good-risk patients was BEP x 3. Intermediate- or poor-risk patients were treated by VIP from 1997 to 2000, VIPVB from 2001 to 2004, and BEP from 2005 to 2007. Second line salvage treatments were high-dose VIP or ICE from 1997 to 2000. TIP x 4 has been employed since. Marker-negative cases with residual tumors underwent surgical resection of the mass lesion.

RESULTS

Five-year survival rate was 100%, 74%, and 76% in patients with good-, intermediate- and poor-risk characteristics, respectively. After two courses of initial chemotherapy, tumor marker decline was satisfactory in 37 patients (73%) and unsatisfactory in 14 (27%). Of these 14 patients, 12 (86%) had unsatisfactory hCG decline, 4 (29%) had unsatisfactory AFP decline, and 2 (14%) had unsatisfactory decline in both markers. Five-year overall survival was 94% in cases with satisfactory maker decline and 71% in those with unsatisfactory marker decline (p = 0.03).

CONCLUSIONS

In this IGCCCG era, 5 year survival rates of the advanced germ cell tumors have improved by the earlier administration of second line chemotherapies based on both the prognostic factor-based staging system and the tumor marker decline in initial chemotherapy. Development of effective treatment for cases with unfavorable tumor maker decline is the most challenging issue to be addressed.

Current status of chemotherapy in risk-adapted management for metastatic testicular germ cell cancer

Today, approximately 80% of men with metastatic testicular cancer can be cured with chemotherapy combined with the appropriate surgery. The improved treatment outcome has led to the stratification of patients with metastatic disease by the consensus prognostic index; the International Germ Cell Cancer Consensus Group classification. Currently, the first-line chemotherapy with bleomycin, etoposide, and cisplatin (BEP) remains the standard management of metastatic testicular cancer. Three cycles of BEP for good-prognosis patients and four cycles of BEP for intermediate- and poor-prognosis patients are the standard first-line chemotherapy. To achieve the optimal outcome, BEP should be given with appropriate supportive care and risk assessment for toxicity. Although no universal prognostic criteria have been defined for the recurrent or refractory disease, the risk-adapted approach may clarify the role of ifosfamide- and paclitaxel-containing conventional-dose chemotherapy or high-dose chemotherapy in the second-line setting. Several investigators reported recent improvement of treatment outcome of testicular cancer patients, especially those with poor prognosis. Along with the progress in chemotherapy, the risk-adapted management at experienced hospitals seems to be responsible for the recent progress in treatment outcome.