Clinical Characteristics and Treatment Outcomes of Patients with Primary Mediastinal Germ Cell Tumors: 10-Years' Experience at a Single Institution with a Bleomycin-Containing Regimen

Pure mediastinal seminoma about a case report

Mediastinal Seminoma is one of the malignant germ cell tumors of the mediastinum. It is a rare tumor that represents only 1%-4% of mediastinal tumors. We report the case of a patient treated at the Oncology Center of Oujda for a pure primitive seminoma of the mediastinum, with a review of the literature to assess the epidemiological, clinical, therapeutic, and prognostic characteristics of this pathology. This is a 25-year-old man whose aunt is being treated for breast cancer and who complained of persistent dry cough with asthenia without any other associated signs. The initial imaging revealed a voluminous locally advanced tumor process in the anterior and middle mediastinum. Tumor markers Alpha-fetoprotein (AFP) and beta-subunit of chorionic gonadotrophic hormone (BHCG) were normal, as well as testicular ultrasound. The CT- guided transthoracic biopsy with anatomopathological study and immunohistochemistry was in favor of a pure seminoma. The treatment consisted of primary chemotherapy with BEP protocol. The response was favorable with a significant reduction in tumor size estimated at 90%. The residual tumor was inoperable due to its intimate contact with the vascular structures and was treated with external radiotherapy at a total dose of 36 Gy. The evolution at 20 months after treatment was in favor of a good clinical and radiological evolution.

Analysis of prognostic factors and establishment of prognostic model for primary mediastinal germ cell tumors: a case controlled study

BACKGROUND

The overall prognosis of primary mediastinal germ cell tumors (PMGCTs) is poor and the associated prognostic factors are not fully understood. Our goal was to investigate the prognostic factors of PMGCTs and to develop a validated prognostic prediction model.

MATERIALS AND METHODS

A total of 114 PMGCTs with specific pathological types were included in this study. Clinicopathological characteristics of nonseminomatous PMGCTs and mediastinal seminomas were compared using the χ2 or Fisher's exact test. Independent prognostic factors of nonseminomatous PMGCTs screened using the univariate and multivariate Cox regression analysis were then used to generate a nomogram. The predictive performance of the nomogram was evaluated using the concordance index, decision curve, and the area under the receiver operating characteristic curve (AUC) and validated by bootstrap resampling. The Kaplan-Meier curves of independent prognostic factors were analyzed.

RESULTS

This study included 71 cases of nonseminomatous PMGCTs and 43 cases of mediastinal seminomas. The 3-year overall survival rates for nonseminomatous PMGCTs and mediastinal seminomas patients were 54.5 and 97.4%, respectively. The overall survival prognostic nomogram for nonseminomatous PMGCTs was established by integrating independent prognostic factors, including the Moran-Suster stage, white blood cell, hemoglobin, and platelet-lymphocyte ratio. The nomogram demonstrated good performance with a concordance index of 0.760 and the 1-year and 3-year AUC values of 0.821 and 0.833, respectively. These values were better than those of the Moran-Suster stage system. The bootstrap validation had an AUC of 0.820 (0.724-0.915) and showed a well-fitting calibration curve. Besides, patients with mediastinal seminomas showed favorable clinical outcomes and all the nine patients received neoadjuvant therapy and postoperative surgery achieved pathological complete response.

CONCLUSION

A nomogram based on staging and blood routine examination results was established to accurately and consistently predict the prognosis of patients with nonseminomatous PMGCTs.

Survival Outcomes of Patients With Primary Mediastinal Germ Cell Tumors: A Retrospective Single-institutional Experience

BACKGROUND/AIM

Primary mediastinal non-seminomatous germ cell tumors (PMNSGCTs) are occasionally complicated by a hematologic malignancy, as with somatic-type malignant tumors called germ cell tumors with somatic-type malignancy (GCTSTM) and are known to have a poor prognosis.

PATIENTS AND METHODS

Data obtained between September 1997 and February 2020 for patients with mediastinal germ cell tumor at our institution were retrospectively analyzed. Key outcome measures included survival rates and the clinical features of non-seminoma cases.

RESULTS

Of 16 patients, 9 had pure seminoma, and 7 had non-seminoma. At the median follow-up of 56.2 months, the 5-year survival rate was significantly higher in patients with seminoma (100%) than in those with non-seminoma (37%) (log-rank test, p=0.0153). Regarding PMNSGCT, two patients evolved into GCTSTM and three had concomitant hematological malignancies.

CONCLUSION

Patients with PMNSGCTs, GCTSTM complications, and hematologic malignancies showed poor survival, suggesting the need for the development of treatment strategies.

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.

Clinicopathological Features and Prognosis of Primary Mediastinal Malignant Germ Cell Tumors: A Retrospective Single-Institution Analysis

Background

Given the lack of evidence-supported guidance for therapeutic recommendations of primary mediastinal malignant germ cell tumors (PMMGCTs), our study aimed to investigate the clinicopathological features, treatment strategies, and prognostic factors of PMMGCTs.

Methods

We carried out a consecutive retrospective evaluation on a series of patients diagnosed with PMMGCTs in Peking Union Medical College Hospital from January 2000 to August 2020.

Results

A total of 58 patients were eligible, consisting of 51 males and seven females. There were 15 patients with seminomas, 39 with nonseminomatous germ cell tumors (NSGCTs), and four with mixed germ cell tumors (GCTs). The 5-year overall survival was 45%, with a median survival time of 32.37 months. Except for the lost follow-up of seven patients, a univariate analysis of overall survival on the remaining patients showed significant differences in pathological type (mixed GCTs were regarded as NSGCTs) (p=0.036), tumor size (>11cm) (p=0.006), and other sites metastases (OSM) (p=0.001), respectively. Multivariate Cox regression analysis revealed that OSM and surgical resection were independently associated with overall survival in all kinds of PMMGCTs.

Conclusion

OSM was an independent risk factor for patients with PMMGCTs. Surgery was proved to contribute to long-term survival. More in-depth clinical evidence is urgently needed to guide the treatment of PMMGCTs.

Nomograms for Predicting Prognosis of Primary Mediastinal Seminoma: A Population-Based Study

Objectives

Primary mediastinal seminoma (PMS) was an uncommon carcinoma, and the appropriate treatment remained controversial due to the low incidence. We aimed to investigate the demographics and tumor biological characteristics to determine the potential effective treatment and predict the prognosis.

Methods

Patients diagnosed with PMS were selected between 1975 and 2016 from Surveillance, Epidemiology, and End Results (SEER) database. Kaplan–Meier analysis and Cox proportional hazard model were conducted to determine the prognostic factors, and nomograms were employed to visually predict the prognosis. Concordance index (C-index), calibration curve, and receiver operating characteristic (ROC) curve were conducted to validate the prediction model.

Results

A total of 476 patients were included with a median age of 31 years (range, 2–76 years), and a median size of the tumor was 11.6 cm (range, 0.2–24.0 cm). The 5- and 10-year overall survival (OS) rates were 70.4% and 68.4%, respectively. Age, the extent of the primary site, metastatic status, and surgery performance were independent prognostic factors. Not received surgery was considered a poor prognostic factor for OS (HR, 1.86; 95% CI, 1.13–3.03; P=0.013). The C-index was 0.733 (95% CI, 0.685–0.781) and 0.819 (95% CI, 0.737–0.901) for internal and external validation for predicting OS, respectively. The area under the ROC curve (AUC) was 0.743 (95% CI, 0.681–0.804) for predicting OS (sensitivity, 0.532; specificity, 0.887) in the training cohort.

Conclusions

The nomogram could efficiently predict the survival of patients with PMS. Surgery was the potential effective treatment, and chemotherapy was strongly recommended for patients over 40 years.

Primary mediastinal germ cell tumors - A retrospective analysis of >30 years of experience in a single institution

Background

This study was performed to clarify the treatment outcome of patients with primary mediastinal germ cell tumors (PMGCTs), focusing on the clinical manifestations and management during definitive therapy and long‐term follow‐up.

Methods

In this study, we retrospectively reviewed the medical records of patients with PMGCTs treated at Shinshu University School of Medicine, and examined the clinical profiles and treatment outcomes of 22 patients (mean age of 29 years) with primary mediastinal GCTs treated at our hospital between 1983 and 2019.

Results

Five patients were diagnosed with pure seminoma and 17 had nonseminomatous GCT. A total of 21 patients were treated with cisplatin‐based chemotherapy and 15 patients (68.2%) underwent thoracic surgery after chemotherapy. Although all cases of nonseminomatous GCT were negative for tumor markers after cisplatin‐based chemotherapy, two cases showed variable GCT cells and two had somatic components (angiosarcoma and rhabdomyosarcoma) in resected specimens. Three relapsed soon after surgery. Growing teratoma syndrome developed during chemotherapy in four cases. Urgent thoracic surgery was performed in three patients, but one case was inoperable. The calculated 10‐year overall survival rates were 100% in mediastinal seminoma and 64.7% in NSGCT. During follow‐up, second non‐GCT malignancies developed in three patients (colon cancer, 190 months; thyroid cancer, 260 months; non‐small cell lung cancer, 250 months after the initial chemotherapy) and one patient with primary mediastinal seminoma was associated with multiple type I endocrine tumors.

Conclusions

Our experiences demonstrated that long‐term survival and/or cure can be achieved with adequate chemotherapy followed by local surgical treatment even in patients with mediastinal GCTs. However, the clinical manifestations and biological behaviors during and/or after chemotherapy were complex and varied. In addition, the development of secondary malignancies should be taken into consideration for long‐term follow‐up. Clinicians should be aware of the various clinical features and secondary malignancies in primary mediastinal GCTs.

Neutrophil-to-lymphocyte ratio in primary mediastinal germ cell tumors: A retrospective analysis of >20 years single institution experience

OBJECTIVES

To obtain information on outcome stratified by histology, extent and primary treatment patients' data with primary malignant mediastinal germ cell tumors treated between 1998 and 2018 were retrospectively analyzed.

METHODS

The primary treatment for localized malignant mediastinal germ cell tumors was neoadjuvant bleomycin + etoposid + cisplatin (BEP) ± surgery (n = 22); or surgery ± adjuvant BEP (n = 16). For disseminated disease (n = 21) first line BEP ± second line chemotherapy were administered. For nonseminomas (NS) the NLR at start of BEP was analyzed in relation to disease-free survival (DFS), progression-free survival (PFS), and overall survival (OS).

RESULTS

After neoadjuvant treatment the 5-year DFS was 100% for seminomas (S), and 63.4% for NS. The 5-year OS was 100% for S, and 76.9% for NS. The 5-year DFS and OS after surgery ± BEP for S was 72.9% and 100%, for NS was 75% and 87.5%, respectively. The 5-year PFS and OS of metastatic patients for S was 60% and 80%, while the median PFS and OS of NS were 5.7 and 11.1 months, respectively. Objective response (P = 0.006) and low NLR (P = 0.043) were independent prognostic markers of longer OS.

CONCLUSIONS

We confirmed the good outcome of BEP-treated S, while NS had poorer prognosis. Previously published prognostic models for NS were validated. Based on NLR and response a new prognostic model was developed.

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.

Surgery for malignant lesions of the chest which extensively involved the mediastinum, lung, and heart

OBJECTIVE

Radical resection for thoracic malignancies that invade the great vessels or heart structure is an uncommon, high-risk operation. To help surgeons determine therapeutic strategy, we reviewed the patient characteristics and outcomes of combined thoracic and cardiovascular surgery for thoracic malignancies.

METHODS

Surgical resections of lung cancer, mediastinal tumor and pulmonary artery sarcoma invading great vessels or heart structures were reviewed from the literature.

RESULTS

Pneumonectomy was often performed for lung cancer invading the aorta, superior vena cava, and left atrium. Complete resection (R0), no mediastinal lymph node metastasis and without using cardiopulmonary bypass led to a good prognosis. Induction therapy was often performed for complete resection. Regarding mediastinal tumors, thymic epithelial tumors or germ cell tumors occasionally invaded the great vessels or heart structures. For these malignancies, multimodality therapy was often performed, and complete resection could be one of the prognostic factors. The resection of primary pulmonary artery sarcoma (PPAS) is also a combined thoracic and cardiovascular surgery. The primary treatment for PPAS is surgical resection; specifically, pulmonary endarterectomy and pneumonectomy, because PPAS has substantial resistance to chemotherapy or radiotherapy. The prognosis of PPAS is poor, but surgical resection has potential for long-term survival.

CONCLUSION

Although these surgeries are uncommon and invasive for the patients, selecting appropriate patients, aggressive multimodality therapy, and performing combined thoracic and cardiovascular surgery can contribute to a good outcome.