Incidence of metachronous testicular cancer in patients with extragonadal germ cell tumors

MRI Findings and Differential Diagnosis of Anterior Mediastinal Solid Tumors

The anterior mediastinum is the most common location of mediastinal tumors, and thymic epithelial tumors are the most common mediastinal tumors. It is important to differentiate thymic epithelial tumors from malignant lymphomas and malignant germ cell tumors because of the different treatment strategies. Dynamic contrast-enhanced MRI and diffusion-weighted imaging can provide additional information on the differential diagnosis. Chemical shift imaging can detect tiny fat tissues in the lesion and is useful in differentiating thymic hyperplasia from other solid tumors such as thymomas. MRI findings reflect histopathological features of mediastinal tumors, and a comprehensive evaluation of MRI sequences is important for estimation of the histopathological features of the tumor. In this manuscript, we describe the MRI findings of anterior mediastinal solid tumors and the role of MRI in the differential diagnosis.

Extragonadal Germ Cell Tumors of the Mediastinum and Retroperitoneum: A Surveillance, Epidemiology, and End Results-based Study

OBJECTIVES

Extragonadal germ cell tumors (EGCT) are a rare entity, most of them being located in the mediastinum and retroperitoneum. Information on these tumors is scarce, requiring carrying out large population-based studies to better understand these diseases. We aimed to determine the clinical features and prognosis of patients with EGCT of the mediastinum and retroperitoneum.

MATERIALS AND METHODS

Demographic and clinicopathological features of patients diagnosed with EGCT of the mediastinum and retroperitoneum from 1975 to 2016 were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database.

RESULTS

A total of 1674 patients were included, 1297 (77.5%) of mediastinal origin and 377 (22.5%) of retroperitoneum. Nonseminomatous tumors (56.3%) were slightly more frequent than seminomas (43.7%) with similar distribution between mediastinum and retroperitoneum. After a median follow-up of 137 months, the median overall survival was 263 months (95% CI, 220-296) whereas the median cause-specific survival (CSS) has still not been reached. The 10-year overall survival and CSS were 57.4% (95% CI, 55-59.7) and 63% (95% CI, 60.6-65.2) respectively. Multivariate analysis showed that older age, mediastinal location, nonseminomatous histology, and distant disease at diagnosis were independent prognostic factors correlated with a worse prognosis. Patients with mediastinal choriocarcinoma and embryonal carcinoma have the worst prognosis, both with a median CSS of only 12 months.

CONCLUSIONS

Despite a decreasing incidence observed in recent decades, EGCT continues to represent a challenge for oncologists. The prognosis of choriocarcinoma and embryonal carcinoma of the mediastinum remains poor and treatment strategies need to be improved urgently.

Chemoradiotherapy is an alternative choice for patients with primary mediastinal seminoma

Background

The low incidence of primary mediastinal seminomas has precluded the development of clinical trials on mediastinal seminomas. We investigated the clinicopathologic characteristics, prognosis of patients with primary mediastinal seminomas as well as the efficiency of nonsurgical treatments compared with treatments containing surgery.

Methods

We retrospectively collected data on the clinicopathologic characteristics, treatments, toxicities, and survival of 27 patients from a single center between 2000 and 2018. Patients were divided into two groups according to whether they received operation. Survivals were assessed using the Kaplan–Meier method. Univariate analysis was performed using the log-rank test.

Results

The median age was 28 (13–63) years. The most common symptoms were chest pain (29.6%), cough (25.9%), and dyspnea (22.2%). There were 13 and 14 patients in surgery and non-surgery group. Patients in the non-surgical group were more likely to be with poor performance scores (100% vs. 76.9%) and disease invaded to adjacent structures (100% vs. 76.9%) especially great vessels (100% vs. 46.2%).The median follow-up period was 32.23 (2.7–198.2) months. There was no significant difference of overall survival (5-year 100% vs. 100%), cancer-specific survival (5-year 100% vs. 100%), local regional survival (5-year 91.7% vs. 90.0%, p = 0.948), distant metastasis survival (5-year 90.9% vs. 100.0%, p = 0.340) and progression-free survival (82.5% vs. 90.0%, p = 0.245) between patients with and without surgery.

Conclusions

Primary mediastinal seminoma was with favorable prognosis, even though frequently invasion into adjacent structures brings difficulties to surgery administration. Chemoradiotherapy is an alternative treatment with both efficacy and safety.

How to classify, diagnose, treat and follow-up extragonadal germ cell tumors? A systematic review of available evidence

PURPOSE

To present the current evidence and the development of studies in recent years on the management of extragonadal germ cell tumors (EGCT).

METHODS

A systematic literature search was conducted in Medline and the Cochrane Library. Studies within the search period (January 2010 to February 2021) that addressed the classification, diagnosis, prognosis, treatment, and follow-up of extragonadal tumors were included. Risk of bias was assessed and relevant data were extracted in evidence tables.

RESULTS

The systematic search identified nine studies. Germ cell tumors (GCT) arise predominantly from within the testis, but about 5% of the tumors are primarily located extragonadal. EGCT are localized primarily mediastinal or retroperitoneal in the midline of the body. EGCT patients are classified according to the IGCCCG classification. Consecutively, all mediastinal non-seminomatous EGCT patients belong to the "poor prognosis" group. In contrast mediastinal seminoma and both retroperitoneal seminoma and non-seminoma patients seem to have a similar prognosis as patients with gonadal GCTs and metastasis at theses respective sites. The standard chemotherapy regimen for patients with a EGCT consists of 3-4 cycles (good vs intermediate prognosis) of bleomycin, etoposid, cisplatin (BEP); however, due to their very poor prognosis patients with non-seminomatous mediastinal GCT should receive a dose-intensified or high-dose chemotherapy approach upfront on an individual basis and should thus be referred to expert centers Ifosfamide may be exchanged for bleomycin in cases of additional pulmonary metastasis due to subsequently planned resections. In general patients with non-seminomatous EGCT, residual tumor resection (RTR) should be performed after chemotherapy.

CONCLUSION

In general, non-seminomatous EGCT have a poorer prognosis compared to testicular GCT, while seminomatous EGGCT seem to have a similar prognosis to patients with metastatic testicular seminoma. The current insights on EGCT are limited, since all data are mainly based on case series and studies with small patient numbers and non-comparative studies. In general, systemic treatment should be performed like in testicular metastatic GCTs but upfront dose intensification of chemotherapy should be considered for mediastinal non-seminoma patients. Thus, EGCT should be referred to interdisciplinary centers with utmost experience in the treatment of germ cell tumors.

Metachronous testicular tumour recurrence in extra-gonadal germ cell tumour: A case report and review of the literature

A 24-year-old male presented in 2014 with left sided abdominal pain and a palpable abdominal mass. After appropriate investigation a diagnosis of an extra-gonadal germ cell tumour was made and he was treated with platinum based chemotherapy. He then underwent retroperitoneal lymph node dissection due to residual disease identified on imaging with no specific tissue type identified on the histological sample. In early 2019 he presented to his General Practitioner with a left sided testicular lump and was diagnosed with non-seminomatous germ cell tumour of the testis, an uncommon condition; metachronous testicular tumour.

Level of Evidence: 5

Mediastinal Masses in Children: Radiologic-Pathologic Correlation

Most pediatric masses in the chest are located in the mediastinum. These masses are often initially detected incidentally on chest radiographs in asymptomatic children, although some patients may present with respiratory symptoms. At chest radiography, the mediastinum has been anatomically divided into anterior, middle, and posterior compartments. However, with the International Thymic Malignancy Interest Group classification scheme, which is based on cross-sectional imaging findings, the mediastinum is divided into prevascular, visceral, and paravertebral compartments. In the prevascular compartment, tumors of thymic origin, lymphomas, germ cell tumors, and vascular tumors are encountered. In the visceral compartment, lymphadenopathy and masses related to the foregut are seen. In the paravertebral compartment, neurogenic tumors are most common. Using the anatomic location in combination with knowledge of the imaging and pathologic features of pediatric mediastinal masses aids in accurate diagnosis of these masses to guide treatment and management decisions. An invited commentary by Lee and Winant is available online. ^©RSNA, 2021.

Impact of luteinizing hormone suppression on hematopoietic recovery after intensive chemotherapy in patients with leukemia

Treatment of acute leukemia with intensive chemotherapy leads to an increased risk of myelosuppression. Luteinizing hormone (LH) blockade improves hematopoietic recovery in mice after radiation or chemotherapy, through protection of the hematopoietic stem cells which express the LH receptor. We hypothesized that LH blockade improves hematopoietic recovery following intensive chemotherapy in patients with leukemia. We conducted a retrospective analysis on pre-menopausal women with acute myeloid leukemia (AML) or acute lymphoblastic leukemia (ALL) who received intensive chemotherapy and leuprolide given for abnormal uterine bleeding prevention or treatment. Given that leuprolide is more commonly administered in younger patients, we performed propensity score matching between the leuprolide (AML n=64; ALL n=49) and control groups (AML n=128; ALL n=98 patients). Patients with AML who received leuprolide had an additional increase of 13.8x10⁹/L/year in their platelet count, and a 0.19x 10⁹/L/year increase in their lymphocyte count after chemotherapy compared to control (P=0.02; P=0.03 respectively). Those with ALL who received leuprolide had an additional increase of 0.37x10⁹/L/year in their absolute neutrophil count (P=0.02). In AML, leuprolide was associated with higher long-term hemoglobin levels (P<0.001) and less blood transfusions (mean, 23.9 vs. 34.7 units; P=0.002) compared to control. In a multivariate analysis, leuprolide was identified as an independent factor predicting improved hemoglobin levels, lymphocyte and platelet counts in AML. In conclusion, leuprolide use in leukemia patients receiving intensive chemotherapy was associated with improved long-term blood count recovery and with decreased transfusion requirements in AML.

Late testicular relapse two decades after primary extragonadal germ cell tumor with uncommon metastases: a case report

BACKGROUND

Extragonadal germ cell tumor (EGCT) is a relatively rare condition, reportedly representing 3-7% of all germ cell tumors. We report a patient who had metachronous testicular tumor with uncommon metastases 20 years after primary retroperitoneal EGCT treatment, along with a corresponding literature review.

CASE PRESENTATION

A 49-year-old Japanese man visited our department in November 2017 with chief complaints of indolent right scrotum enlargement and a right inguinal mass. History showed that the patient visited our department of gastroenterology with chief complaints of blackish feces and ill complexion in February 1997. Computed tomography (CT) showed a right retroperitoneal tumor, which was removed in the same month. Histopathological examination showed a teratoma and yolk sac tumor. He was diagnosed with primary retroperitoneal EGCT and received three courses of chemotherapy (bleomycin/etoposide/cisplatin; BEP). Periodic imaging and the determination of tumor markers (alpha-fetoprotein [AFP], human chorionic gonadotropin [HCG], and lactate dehydrogenase [LDH]) showed no recurrence or metastasis during the 5 years postoperatively. Subsequently, he did not visit the outpatient ward. In August 1999, he underwent surgery of right hydrocele. Contrast-enhanced CT showed a 35-mm contrast effect with uneven content in the right testicle and enlarged nodes that raised suspicion for metastases in the right inguinal and right external iliac lymph nodes. All tumor markers were within normal ranges. He underwent right high orchiectomy and resection of the right inguinal lymph nodes in the same month. Histopathological findings revealed seminoma (pT1, pN2, M0, S0, and TNM stage IIB). He received postoperative chemotherapy, one course of BEP therapy, and three courses of etoposide and cisplatin therapy. Post-chemotherapy CT confirmed a complete clinical response at the right external iliac lymph nodes, and this response continued 12 months later. No recurrence or metastasis has been found so far.

CONCLUSIONS

We report a patient in whom a testicular tumor with uncommon metastases occurred 20 years after primary retroperitoneal EGCT treatment. After EGCT treatment, testicular relapses tend to occur after relatively long-term follow-up. After EGCT treatment, such patients must be closely monitored for testicular recurrences and onset of testicular tumor.

Educational Case: Testicular Germ Cell Tumor: Clinical Presentation, Pathogenesis, and Diagnostic and Therapeutic Modalities

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, seehttp://journals.sagepub.com/doi/10.1177/2374289517715040.¹

Clinical Characteristics and Outcomes of Patients With Primary Mediastinal Germ Cell Tumors: A Single-Center Experience

Purpose: Primary mediastinal germ cell tumors (PMGCTs) are rare. The natural history and optimal treatment strategies still need to be defined. The aim of the study was to summarize the clinical characteristics, treatment outcomes, and prognostic factors of PMGCTs.

Methods: Twenty-four patients with PMGCTs who were treated from December 2008 to January 2019 were evaluated retrospectively. The Kaplan–Meier method and Cox regression analysis were used to evaluate factors associated with prognosis.

Results: The study population consisted of 23 male patients and 1 female patient. Five patients were diagnosed with seminoma and 19 patients were diagnosed with nonseminoma. The median follow-up time for all patients was 15.8 (3.9–114.5) months. The 5-year overall survival (OS) and progression free survival (PFS) rates for all patients were 65.2 and 44.3%. For nonseminoma and seminoma, the 5-year OS rates were 54.1 and 100% (P = 0.093), respectively, and the 5-year PFS rates were 28.7 and 100%, respectively (P = 0.044). In patients with nonseminoma, first-line radiotherapy indicated superior OS and PFS (P = 0.037 and 0.027, respectively). The median survival time after recurrence was 4.3 months and the 1-year survival rate after recurrence was 23.4%.

Conclusion: These results indicated that in PMGCTs, the prognosis of seminoma is superior to that of nonseminoma. Radiotherapy may be an essential treatment in patients with nonseminoma. Patients with relapse have unfavorable prognosis.

Playing the long surveillance ball game: Metachronous testicular tumor developing after treatment and remission of extragonadal germ cell tumor

A 32-year-old man with vague abdominal pain was found to have enlarged para-aortic and mediastinal lymph nodes on computed tomography. He was diagnosed with retroperitoneal mixed germ cell tumor as confirmed on percutaneous biopsy. At the time of diagnosis, lactic dehydrogenase, human beta-chorionic gonadotropin, and alpha-fetoprotein were elevated. He completed four cycles of platinum-based chemotherapy with excellent response and no clinical disease progression. Three years later, he presented to the Urology clinic with a right testicular mass. His tumor markers remained negative. He was taken for a right radical orchiectomy with the pathology resulting in pure seminoma (pT1Nx).

Management of Primary Testicular Tumor

In any man with a solid testicular mass, cancer should be considered until proven otherwise. Radical inguinal orchiectomy is the treatment of choice in patients with testis mass. Placement of a testicular prosthesis is safe with a very low complication rate and should be offered to all patients undergoing radical orchiectomy. In patients with widespread or life-threatening advanced disease, delayed orchiectomy following chemotherapy is recommended. Testis-sparing surgery can be performed in highly selected patients with solitary testicle mass, bilateral testicular tumors, or strong suspicion of a benign lesion.

Mixed extragonadal germ cell tumour of the prostate

Extragonadal germ cell tumours (EGGCTs) originated in prostate are extremely rare, with <20 cases described in the literature. We report a case of a patient with a primary prostatic mixed EGGCT. A 47-year-old man presenting severe low urinary tract symptoms and signs of prostatic enlargement, with no malignancy suspicion, underwent transurethral resection of the prostate. The histopathological evaluation suggested the diagnosis of a retroperitoneal sarcoma. The patient underwent neoadjuvant chemotherapy and then was submitted to radical cystoprostatectomy. Histology revealed a mixed EGGCT of the prostate with yolk sac tumour and seminoma components. No testicular abnormalities were identified on the postoperative scrotal ultrasound. The patient went through four cycles of chemotherapy with bleomycin, etoposide and cisplatin. After 12 months of follow-up, the patient is alive and free of recurrence.

Primary mediastinal seminoma

Background

The objective of this study was to evaluate the long term treatment results of patients with primary mediastinal seminoma.

Methods

Sixteen patients aged 21-46 diagnosed with primary mediastinal seminoma between 1983 and 2014. Mean size of the tumor was 65 cm². In all patients gonadal involvement was excluded. In 6 patients, metastases to regional lymph nodes were found and none of them presented with distant metastases. HCG was elevated in 6 patients (38%). Eight patients underwent surgery as first-line of the treatment: 7 partial and 1 complete resection of the tumor. Chemotherapy (CTH) and radiotherapy (RTH) were methods of treatment in 14 cases. Tumor was irradiated to total dose of 36.0-50.4 (median 42.5) Gy. In statistical analysis overall survival (OS) was calculated using Kaplan-Meier method.

Results

During median time of 11 years of the follow-up, complete or partial regression (PR) of the tumor was seen in all patients after primary treatment. Recurrence of the tumor was seen in 3 patients. The 5-, 10- and 15-year local control rates were 75%. One was treated with CTH, other two with RTH. All of them responded with complete regression (CR) of the tumor. Three patients died during the follow-up. All others are alive without disease. The 5-, 10- and 15-year OS was 100%, 91% and 91% respectively.

Conclusions

Chemoradiotherapy of primary mediastinal seminoma gives satisfactory treatment results with good local control rate. The treatment outcome is comparable to primary testicular seminoma.

Oncology health professionals' attitudes toward treatment-focused genetic testing for women newly diagnosed with breast cancer

AIM

This study explored the attitudes of oncology health professionals towards treatment-focused genetic testing (TFGT) for women newly diagnosed with breast cancer.

MATERIALS & METHODS

Members of several relevant medical organizations in Australia and New Zealand were invited via email to participate in an online survey.

RESULTS

A total of 149 respondents, including 40 surgeons, 46 oncologists and 63 breast care nurses, completed the online questionnaire. The majority of respondents believed that TFGT was useful for patient care (87.3%) and valuable for the treatment and management of breast cancer (90.6%). In multivariable analyses, breast care nurses were significantly more likely to agree that TFGT was useful for patient care and the treatment and management of breast cancer compared with oncologists and surgeons (β = 0.30; 95% CI: 0.01-0.60; p = 0.045). Participants also agreed that TFGT has an impact on treatment decision-making (96.0%), uptake of bilateral mastectomy (98.7%) and uptake of risk-reducing salpingo-oophorectomy (98.0%) in women newly diagnosed with breast cancer. A slight preference towards surgeons (49.7%) as the best health professional to make the initial offer of TFGT was observed and the majority of respondents suggested the best time to offer TFGT was shortly after diagnosis, when the treatment plan is discussed.

CONCLUSION

The findings suggest health professionals have positive attitudes towards TFGT. Future training programs focusing on teamwork models and guidelines specifying health professionals' roles in regards to TFGT and follow-up management may be of benefit.

Probability of metachronous testicular cancer in patients with biopsy-proven intratubular germ cell neoplasia depends on first-time treatment of germ cell cancer

PURPOSE

To evaluate the probability of subsequent testicular cancer (STC) in patients with intratubular germ cell neoplasia unclassified (IGCNU) treated for first-time invasive germ cell cancer.

PATIENTS AND METHODS

Sixty-one patients with germ cell testicular cancer or extragonadal germ cell cancer received follow-up from diagnosis of IGCNU to development of STC, initiation of IGCNU-definitive treatment (orchiectomy/radiotherapy), emigration, death, or end of follow-up. The probability of STC was assessed in subgroups according to chemotherapy burden.

RESULTS

The probability of STC in the nonexposed patients was significantly increased compared with those exposed to chemotherapy (P = .05; 5-year probability of 54% [95% CI, 33% to 78%] and 23% [95% CI, 11% to 45%], respectively). In the group of patients treated with one to three cycles or no chemotherapy, the probability of STC was significantly increased compared with those exposed to four or more cycles (P = .03; 5-year probability of 42% [95% CI, 27% to 62%] and 22% [95% CI, 8% to 54%], respectively). Twenty-two of 22 patients were tumor-free and alive at a median of 56 months (range, 2 to 184 months) after diagnosis of STC.

CONCLUSION

Platinum-based chemotherapy may reduce the probability of STC in patients with IGCNU, particularly in those treated with four or more cycles of chemotherapy. A watch-and-wait strategy for patients with IGCNU may be justified in selected patients with future plans for paternity.

Genomic characterization of testis cancer: association of alterations with outcome of clinical stage 1 mixed germ cell nonseminomatous germ cell tumor of the testis

OBJECTIVE

To identify genomic markers that are reliable in predicting lymph node metastases in clinical stage 1 non-seminomatous germ cell tumors (NSGCTs).

METHODS

Comparative genomic array technology was used to identify regions of genomic amplification or deletion in clinical stage 1 NSGCTs. Twelve stage 1 mixed germ cell testicular tumors were analyzed, which were obtained from 8 patients who had no evidence of nodal metastasis when retroperitoneal lymph node dissection (RPLND) had been performed (ie, were RPLND negative) and 4 patients who had nodal metastases (ie, were RPLND positive).

RESULTS

Differences between the genomic alterations associated with the two classes of tumors were identified. Genomic alterations previously reported in other subtypes of testicular tumors were observed in both metastatic and nonmetastatic cases. Statistically suggestive differences in mean copy number of the Y chromosome were found between metastatic and nonmetastatic cases (P = .0142).

CONCLUSION

This finding suggests the presence of chromosome Y deletions to be a potential genetic marker for prediction of mixed germ cell tumor progression. This is a first step toward identifying chromosomal markers of progression in testicular cancer in clinical stage 1 mixed germ cell NSGCT.

Papillary renal cell-like carcinoma in a retroperitoneal teratoma

We report a case of somatic type malignancy with papillary renal cell carcinoma differentiation arising in a retroperitoneal mixed germ cell tumor. The patient was a 36-year-old man with a synchronous mediastinal teratoma. The somatic type malignancy in the retroperitoneal tumor was composed of papillary structures covered by atypical epithelial cells with eosinophilic cytoplasm, prominent nucleoli and pseudostratified nuclei. Papillary cores contained numerous aggregates of foamy macrophages, typical of type I papillary renal cell carcinomas. The immunohistochemical profile was consistent with papillary renal cell carcinoma, including positive reactions for cytokeratin 7 and alpha-methyl acyl CoA racemase. There was no somatic type malignancy component in the synchronous mediastinal teratoma. Both the retroperitoneal and the mediastinal tumor showed gains of 12p and chromosome 17 material. There was no c-MET mutation in the somatic type malignancy. To our knowledge, this is the first report of a somatic type malignancy with features of papillary renal cell carcinoma arising in a germ cell tumor. It is important not to confuse such a retroperitoneal tumor with a conventional papillary renal cell carcinoma, because presence of other malignant histologies within the germ cell tumor may warrant different treatment. In such cases, the presence of isochromosome 12p can be helpful to the diagnosis.

The incidence and management of metachronous testicular germ cell tumors in patients with extragonadal germ cell tumors

OBJECTIVES

The optimal management of extragonadal germ cell tumor (EGGCT) and metachronous testicular germ cell tumor (MTGCT) has not been determined.

PATIENTS AND METHODS

Fifty-one consecutive patients with EGGCT were identified. Testicular palpation or ultrasonography to rule out a primary testicular tumor was performed. Pretreatment testicular biopsies were not performed. The incidence and outcome of MTGCT, and the prognosis of EGGCT were evaluated.

RESULTS

Twenty-five and 26 patients, respectively, had mediastinal and retroperitoneal EGGCT. Fourteen and 37 patients, respectively, had seminoma and nonseminoma. Five patients developed MTGCT in patients with retroperitoneal EGGCT. The median interval from the primary treatment for EGGCT to MTGCT diagnosis was 64 months (range 15-120). The cumulative risk of developing MTGCT was 8.3% at 6 y. Five patients underwent an orchiectomy and have survived in the 16-months median follow-up period (range 4-30). Among the patients with seminomatous and nonseminomatous EGGCT, the 5-year survival rate was 84.6% and 78.3%, respectively. Among the patients with retroperitoneal and mediastinal nonseminomatous EGGCT, the 5-year survival rate was 94.7% and 58.8%, respectively.

CONCLUSIONS

The prognosis of EGGCT without testicular biopsies was sufficient. EGGCT patients, especially retroperitoneal EGGCT, need long-term follow-up for MTGCT.

Metachronous testicular tumor developing eight years after retroperitoneal extragonadal germ cell tumor

A 30 year-old man was admitted to our hospital with a chief complaint of left flank pain. Computed tomography revealed a retroperitoneal tumor. Levels of lactic dehydrogenase, human beta-chorionic gonadotropin, alpha-fetoprotein, DUPAN-2 and carbohydrate antigen 19-9 were elevated. No abnormal findings were present according to palpation and ultrasonography of the testes. The patient was diagnosed as having a retroperitoneal extragonadal germ cell tumor (EGCT) considering the elevated markers. Resection of the tumor, two cycles of neoadjuvant and one cycle of adjuvant chemotherapy (cisplatin and etoposide) were performed. The surgical specimen showed total necrotic tissue. Eight years later, the patient noticed an enlargement of his left testicle. The tumor felt elastic and firm on his left testis. Neither distant metastasis nor lymph node metastasis was present according to computed tomography. Left high orchiectomy was performed and histology revealed seminoma. Twenty-three cases have been reported previously about metachronous testicular tumor developing after retroperitoneal EGCT. We report the 24th case.

Genetic testing for familial cancer. The French National Report (year 2003)

BACKGROUND

Since 2002, hereditary cancer gene testing has been funded at the national level in France. Here we report on the impact of this funding on the number of tests carried out and specify the genes/syndromes on which these tests focus.

METHODS

All French laboratory facilities funded had to submit a report on their activities to the French Health Ministry in March 2004.

RESULTS

Funding has led to an increase of >344% in the number of tests carried out between the years 2000 and 2003. For every 100,000 inhabitants, 16.02 cases with a familial cancer syndrome (index cases subjected to 'diagnostic genetic testing') and 4.44 relatives of an index case with a proven mutation were tested. The overall mutation detection rate was 15.2% in the case of breast cancer genes and 17.2% in that of mismatch repair genes.

CONCLUSION

In France, the current mutation detection rate is high in comparison with the 10% benchmark level. A further increase can be expected to occur in the number of tests carried out in the future.

Phase I/II study of sequential dose-intensified ifosfamide, cisplatin, and etoposide plus paclitaxel as induction chemotherapy for poor prognosis germ cell tumors by the German Testicular Cancer Study Group

PURPOSE

To evaluate the feasibility and the toxicity of sequential, dose-intensified chemotherapy combined with paclitaxel plus peripheral blood-derived hematopoietic stem-cell support (PBSC) for patients with untreated metastatic germ cell tumors (GCTs) who have poor International Germ Cell Consensus Cancer Group prognostic features.

PATIENTS AND METHODS

Paclitaxel was added to high-dose (HD) etoposide, ifosfamide, and cisplatin (VIP; etoposide 1,500 mg/m2, ifosfamide 10,000 mg/m2, and cisplatin 100 mg/m2; cumulative dose; days -6 through -2 per cycle) at three dose levels (135, 175, and 225 mg/m2) applied on day -6. Cycles were supported by PBSC and granulocyte colony-stimulating factor. One cycle of standard VIP was administered before start of HD-VIP plus paclitaxel cycles to collect autologous PBSC.

RESULTS

Fifty-two of 53 patients receiving 152 cycles were assessable. As expected, myelosuppression was the major adverse effect. Median durations of leukocytes less than 1,000/microL and thrombocytes less than 25,000/microL were 6 and 4 days, respectively, independently of the dose of paclitaxel applied. WHO grade 2 neurotoxicity and grade 3 encephalopathy were observed in 5% of patients each. Other main adverse effects observed were stomatitis, diarrhea, and obstipation. Seventy-nine percent of patients achieved a favorable response to chemotherapy plus secondary surgery. After a median follow-up time of 41 months in surviving patients, the calculated 2- and 5-year survival rates were 77.6% (95% CI, 65.4% to 89.9%) and 75.2% (95% CI, 62.5% to 87.8%), respectively.

CONCLUSION

Dose-intensive, sequential HD-VIP plus paclitaxel up to a dose of 225 mg/m2 in patients with poor prognosis GCT is a feasible approach. The regimen warrants investigation for its therapeutic potential in an expanded cohort of poor prognosis GCT patients.

Primary prevention of breast cancer by hormone-induced differentiation

Breast cancer is a fatal disease whose incidence is gradually increasing in most industrialized countries and in all ethnic groups. Primary prevention is the ultimate goal for the control of this disease. The knowledge that breast cancer risk is reduced by early full-term pregnancy and that additional pregnancies increase the rate of protection has provided novel tools for designing cancer prevention strategies. The protective effect of pregnancy has been experimentally reproduced in virgin rats by treatment with the placental hormone human chorionic gonadotropin (hCG). HCG prevents the initiation and inhibits the progression of chemically induced mammary carcinomas by inducing differentiation of the mammary gland, inhibiting cell proliferation, and increasing apoptosis. It also induces the synthesis of inhibin, a tumor suppressor factor, downregulates the level of expression of the estrogen receptor alpha (ER-alpha) by methylation of CpG islands, imprinting a permanent genomic signature that characterizes the refractory condition of the mammary gland to undergo malignant transformation. The genomic signature induced by hCG is identical to that induced by pregnancy and is specific for this hormone. Comparison of the mammary gland's genomic profile of virgin Sprague-Dawley rats treated daily with hCG for 21 days with that of rats receiving 17beta-estradiol (E2) and progesterone (Pg) (E2 + Pg) revealed that in hCG-treated rats 194 genes were significantly up-modulated (> 2.5 log2-folds) (p < 0.01) and commonly expressed, whereas these genes were not expressed in the E2 + Pg group. The genomic signature induced by hCG and pregnancy included activators or repressors of transcription genes, apoptosis, growth factors, cell division control, DNA repair, tumor suppressor, and cell-surface antigen genes. Our data indicate that hCG, like pregnancy, induces permanent genomic changes that are not reproduced by steroid hormones and in addition regulates gene expression through epigenetic mechanisms that are differentiation-dependent processes, leading us to conclude that hormonally induced differentiation offers enormous promise for the primary prevention of breast cancer.

Testicular seminoma occurring 8 years after treatment of a metastatic extragonadal germ cell tumor

A 30-year-old man was admitted with a chief complaint of left-sided scrotal enlargement, and was diagnosed as having testicular seminoma after orchiectomy. Eight years earlier, he had been treated with chemotherapy for an extragonadal germ cell tumor, without orchiectomy, leading to complete remission. His histological diagnosis at that time was a germ cell tumor, composed of choriocarcinoma and embryonal carcinoma. He was followed up without testicular biopsy. Routine pretreatment testicular biopsy in patients with extragonadal germ cell tumor is controversial, but regular long-term follow up and information on the risk of developing a metachronous testicular tumor are needed after treatment of extragonadal germ cell tumors, even when there seems to be a partial or complete clinical response.

Opinions of women with high inherited breast cancer risk about prophylactic mastectomy: an initial evaluation from a screening trial including magnetic resonance imaging and ductal lavage

OBJECTIVE

Prophylactic mastectomy (PM) is often considered, but variably chosen by women at high inherited risk of breast cancer; few data exist on patient tolerance of intensive breast screening as an alternative to PM. We performed an evaluation of high-risk women's tolerance of a breast screening protocol using clinical breast examination, mammography, breast magnetic resonance imaging (MRI) and ductal lavage (DL), and of change in attitudes toward PM after screening.

DESIGN

A questionnaire assessing tolerance of screening procedures and change in opinion towards PM was designed and administered to 43 study participants, after a median follow-up of 13 months. Responses were evaluated according to patient characteristics, including type of study-prompted interventions, BRCA mutation status, and prior history of cancer, via univariate analysis.

RESULTS

Most patients [85.3% (68.9-95.1%)] were more opposed or unchanged in their attitudes towards PM after study participation, with only 14.7% (5.0-31.1%) less opposed (P = 0.017) despite a short-interval follow-up MRI rate of 71.7% and a biopsy rate of 37%. Lower rates of maximal discomfort were reported with mammogram [2.8% (0-14.5%)] and MRI [5.6% (0-18.7%)] than with DL [28.6% (14.6-46.3%)], with P = 0.035.

CONCLUSIONS

Most high-risk women tolerated intensive breast screening well; they were not more inclined towards PM after participating. Future studies should prospectively evaluate larger numbers of high-risk women via multivariate analysis, to determine characteristics associated with preference for breast screening vs. PM.

Overview of genetic testing in cancer

Until recently, hereditary tendencies toward multiple diseases, including cancer, were mainly determined by examining the family history of the affected individuals. However, the Human Genome Project has ushered in a genomics revolution and boosted the diagnostic testing industry with the emergence of genetic tests that may be used for the diagnosis and management of both inherited and noninherited malignancies. Genetic tests are already available to identify patients carrying cancer susceptibility genes and predict drug response, thus enabling physicians to carefully tailor a more personalized drug regimen that is more likely to result in a favorable outcome for the patient. However, before gene-based tests become widely available, thought leaders and society in general need to understand and discuss the major technical, ethical and economic ramifications of genetic testing. These issues are currently being reviewed by government, academia, regulatory agencies and professional societies using evidence-based principles.

Spontaneous Regression of Testicular Germ Cell Tumors

Spontaneous regression of testicular germ cell tumors (GCTs) is a well-recognized phenomenon but has been incompletely characterized. Many pathologists are not familiar with the findings that support a diagnosis of a "burnt-out" primary in a patient with metastatic GCT. We therefore report the clinical, gross, and histologic findings in 42 cases of testicular GCT that showed either complete (26) or greater than 50% scarring (16). Thirty-seven patients (88%) had either known GCT metastasis or some residual testicular GCT, and none had treatment before orchiectomy. The patients were 17 to 67 years old, with a median of 32. Thirty presented with symptoms of metastasis, 7 with a testicular mass, 2 with elevated human chronic gonadotropin, and 1 with testicular pain. In 2 patients the presentation was unknown. Two patients had prior orchiopexy; another had an intraabdominal testis, and 2 others had prior contralateral seminoma (20 and 42 years previously). Gross descriptions in 37 cases identified white to tan scars, 0.6 to 2.4 cm, in 33. These were circumscribed in 16, with 15 of these having nodular or multinodular configurations and 1 a band-like appearance. In 9 cases the scar was ill defined or stellate, and in 8 cases no further details concerning the scar configuration were available. In 4 cases no scar was apparent; 2 of these had received intraoperative biopsy. Microscopically, all cases showed circumscribed to irregular foci of scarring, distinct from the adjacent parenchyma, in association with widespread testicular atrophy. Other common features were lymphoplasmacytic infiltrates in the scars (37/42) and "ghost" tubules in scars (31/42). Less common features in the scars included angiomatous foci (22/42), siderophages (15/42), and coarse intratubular calcifications (6/42); in the surrounding testis they included intratubular germ cell neoplasia, unclassified (IGCNU) (22/42), Leydig cell prominence (18/42), and necrosis (5/42). Tubular microliths occurred in 13 cases, 12 peripheral to the scar and 1 within it. Metastases in 31 cases were: pure seminoma (17, 3 with residual testicular seminoma), mixed GCT with seminoma (4, 3 with residual testicular seminoma), mixed nonseminomatous GCT (4, 3 with residual testicular GCT), pure embryonal carcinoma (2), pure teratoma (2, 1 with residual testicular teratoma), and pure yolk sac tumor (2). In 5 cases with clinically diagnosed metastases, there was no histologic documentation of the nature of the metastatic tumor. Testicular tumors in the remaining 6 cases having residual primaries without concomitant metastases were pure seminoma (3), mixed GCT with seminoma (2), and pure embryonal carcinoma (1). The most specific histologic findings of a regressed GCT are a distinct scar in association with either IGCNU or coarse intratubular calcifications; however, many cases lack the latter 2 features. In such cases additional features supportive of regressed GCT include testicular atrophy, microlithiasis and, in the scar, lymphoplasmacytic infiltrates and prominent vascularity. Ghost tubules in many scars are not evidence of a non-neoplastic process but likely reflect regression of tumors with intertubular growth. Intertubular growth is a common finding in seminoma, which is the single most frequent type of regressed GCT, occurring either in pure or mixed form in the metastases of 68% (21/31) of the cases and identifiable in 62% (10/16) of persistent testicular tumors. We conclude that regression of testicular GCTs shows a distinctive constellation of findings that usually permits its recognition. In contrast, nonspecific atrophy lacks distinct scars, and scars from non-neoplastic causes lack most of the associated findings seen in our cases.

Risk prediction models for familial breast cancer

A positive family history of breast cancer, reflecting genetic susceptibility, is one of the strongest risk factors for the disease. A number of breast cancer susceptibility genes have been identified to date, with the most important being BRCA1 and BRCA2. Risk prediction models can be used to identify individuals likely to carry BRCA1 and BRCA2 mutations and individuals at high risk of developing the disease. This information can then be used to target genetic testing, screening and interventions more effectively. In this article, the authors review the risk models that have been developed for familial breast cancer and discuss their applicability, strengths and weaknesses, and present examples of classifying women into risk categories according to the predictions by the various models. The review concludes with a discussion of the ways in which risk models could be improved in the immediate- and long-term future.

Effects of counseling Ashkenazi Jewish women about breast cancer risk

The goal of this study was to determine whether genetic counseling or psychosocial group counseling provided to Ashkenazi women can reduce breast cancer worry, cancer risk perception, and interest in having genetic testing. Women (N=211) were randomized to receive individual genetic risk counseling, to receive a group psychosocial group counseling, or to serve as a control group. The authors found that both counseling methods reduced cancer worry, lowered perceptions of breast cancer risk, and decreased interest in having genetic testing. Counseling can help women gain a more accurate perception of their risk, expose them to the benefits and limitations of genetic testing, and reduce their worry about cancer.

Risk of Contralateral Testicular Cancer: A Population-based Study of 29 515 U.S. Men

BACKGROUND

Although risk estimates for synchronous and metachronous contralateral testicular cancers vary widely, many clinicians recommend routine biopsy of the contralateral testis for patients diagnosed with unilateral testicular cancer. We evaluated the risk of contralateral testicular cancer and survival in a large population-based cohort of men diagnosed with testicular cancer before age 55 years.

METHODS

For 29 515 testicular cancer cases reported to the National Cancer Institute's Surveillance, Epidemiology and End Results Program from 1973 through 2001, we estimated the prevalence of synchronous contralateral testicular cancer, the observed-to-expected ratio (O/E) and 15-year cumulative risk of metachronous contralateral testicular cancer, and the 10-year overall survival rate of both synchronous and metachronous contralateral testicular cancer, using the Kaplan-Meier method for the two latter assessments. Age-adjusted multivariable analyses were used to examine risk according to histologic type of the original cancer.

RESULTS

A total of 175 men presented with synchronous contralateral testicular cancer; 287 men developed metachronous contralateral testicular cancer (O/E = 12.4 [95% confidence interval {CI} = 11.0 to 13.9]; 15-year cumulative risk = 1.9% [95% CI = 1.7% to 2.1%]). In the multivariable analysis, only nonseminomatous histology of the first testicular cancer was associated with a statistically significantly decreased risk of metachronous contralateral testicular cancer (hazard ratio [HR] = 0.60, 95% confidence interval [CI] = 0.46 to 0.79; P<.001). Increasing age at first testicular cancer diagnosis was associated with decreasing risk of nonseminomatous metachronous contralateral testicular cancer (odds ratio = 0.90, 95% CI = 0.86 to 0.94). The 10-year overall survival rate after metachronous contralateral testicular cancer diagnosis was 93% (95% CI = 88% to 96%), and that after synchronous contralateral testicular cancer was 85% (95% CI = 78% to 90%).

CONCLUSIONS

The low cumulative risk of metachronous contralateral testicular cancer and favorable overall survival of patients diagnosed with metachronous contralateral testicular cancer is in accordance with the current U.S. approach of not performing a biopsy on the contralateral testis.

Predictors of quality of life in women with a bilateral prophylactic mastectomy

The purpose of this study was to assess the quality of life in women who had previously undergone a bilateral prophylactic mastectomy and to determine what factors predict quality of life in this population. Women in Ontario who had undergone prophylactic mastectomy between 1991 and 2000 were asked to complete several questionnaires that assessed current psychosocial functioning, including the Quality of Life Index (QLI). The mean score for the QLI was 23.34 (range 9.53-30.00). QLI scores were negatively correlated with cancer-related distress, body image difficulties, and psychological distress. Conversely, QLI scores were positively correlated with social support. Significant predictors of quality of life included psychological distress and one subscale of body image (vulnerability). Vulnerability and psychological distress are important predictors of quality of life in women who have previously undergone bilateral prophylactic mastectomy.

The problems with risk selection; scientific and psychosocial aspects

Between 9,000 and 18,000 new cases of breast cancer per year in the United States are associated with a genetically defined predisposition. Mutations in BRCA1 and 2 account for greater than 60% of inherited breast cancer. Mutations in additional undiscovered high and low penetrance genes may account for the other 40% of inherited breast cancer cases and possibly a subset of familial breast cancer cases that lacks an autosomal-dominant pattern of inheritance. False-negative rates resulting from gene sequencing of BRCA1 and 2 may be as high as 10%-15%, making the identification of high-risk individuals a complex and often futile process for both patient and physician. As a consequence of technical limitations in BRCA1 and 2, genetic testing and the lack of comprehensive breast cancer prediction models that take into account both genetic and environmental factors, we are unable to quantify future breast cancer risk for many patients. This uncertainty often leads to the exclusion of high-risk individuals in screening and prevention trials, which is perhaps most evident in breast cancer screening trials incorporating the use of magnetic resonance imaging (MRI) to identify early cancers. These studies demonstrate that MRI increases the sensitivity of a screening protocol in mutation carriers and succeeds at detecting earlier stage cancers. Eligibility criterion for most of these trials was documented mutations in BRCA1 and 2 or future breast cancer risk predicted by family history or models, thereby possibly excluding women at significantly elevated risk that testing failed to identify or whose risk is not adequately reflected based on current models used in risk assessment. We may be turning very high-risk women away from screening trials, recommending yearly mammography and clinical breast exam, when neither will be adequate for detecting their cancers early. In addition, the impact of risk-reducing strategies including bilateral prophylactic oophorectomy (BSO) and tamoxifen has not been analyzed in these studies. For example, a 40-year-old BRCA2 carrier may only have a 10% and 50% lifetime risk of ovarian and breast cancer, respectively, and interventions including tamoxifen and breast MRI screening may significantly reduce the risk of both getting breast cancer and dying from it, thereby obviating the need for early screening or prophylactic surgeries, permitting these women to defer the quality of life struggles until they are older. A larger sample size is needed to determine the degree to which different subgroups of high-risk patients will benefit from MRI screening, with particular attention to women who have undergone BSO or who are taking tamoxifen. The challenges in risk selection are numerous and produce more questions than answers with regard to screening and management of high-risk individuals. In the future, we hope that early detection tools, risk-reduction strategies, and risk assessment preclude the need for prophylactic surgeries, inappropriate selection of patients for screening, and the associated decisions that compromise our patients' quality of life.

Risk Assessment: Controversies and Management of Moderate- to High-Risk Individuals

With the current understanding of sporadic and familial breast cancer, it is now possible to identify individuals who have a moderate or high risk of breast cancer. For these individuals, it is useful to perform formal cancer risk assessment and develop an individualized risk reduction plan, including a tailored plan for cancer screening, preventive therapy, and/or prophylactic surgery. Assessment using a predictive model such as the Gail model is particularly useful in individuals at increased risk for sporadic breast cancer. In addition, assessment of risk based on histologic appearance of benign or premalignant breast lesions can be used to identify individuals for whom more aggressive risk reduction strategies are warranted. For individuals who are at risk for familial cancer syndromes, other predictive models are more appropriate. For this extremely high-risk group, genetic testing for mutations in familial cancer susceptibility genes is helpful to identify individuals who would benefit from even more aggressive cancer risk reduction strategies. Strategies to identify the levels of risk for breast cancer, including the identification of moderate, high, or very high risk groups are discussed. Management options for these groups are presented, including who to consider for more aggressive screening, chemoprevention, or prophylactic surgery. Current recommendations for screening, chemoprevention, and surgery for each risk group are presented. The ability to identify individuals at high risk for breast cancer now enables clinicians to intervene to reduce the risk of breast cancer. Aggressive screening, preventive therapy, and prophylactic surgery in moderate- to high-risk individuals should, in the future, significantly reduce the incidence of invasive breast cancer.

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

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