Epidemiology of male seminomatous and nonseminomatous germ cell tumors and response to first-line chemotherapy from a tertiary cancer center in India

Spectrum of Germ Cell Tumor (GCT): 5 Years' Experience in a Tertiary Care Center and Utility of OCT4 as a Diagnostic Adjunct

Germ cell tumors (GCT) are an intriguing group of neoplasm having myriad clinical and morphological presentation. More and more transcription factors are being evaluated for identification of same. To study the spectrum of GCTs in a tertiary care center and the use of a stem cell marker OCT4 as a diagnostic adjunct, a retrospective 5-year (2008-2013) study was carried out. Immunohistochemistry (IHC) with OCT4 was performed on all cases and IHC for α feto protein (AFP), CD30, and epithelial membrane antigen (EMA) as per requirement. Cohort included 73 cases (23 males and 50 females). Testicular and ovarian GCTs accounted for 95.83% and 35.71% respectively. In males, seminoma was the commonest (34.78%) followed by mixed GCT (26%). 17.85% of ovarian GCTs were malignant mostly constituted by dysgerminoma (18%). Benign mature cystic teratoma (MCT) constituted 50% of ovarian GCTs. OCT4 immunoexpression was seen in all cases of seminoma/dysgerminoma, embryonal carcinoma, immature teratoma, and seminomatous/embryomatous component of mixed GCTs. Pure yolk sac tumor (YST) and MCT were consistently negative. OCT4 was especially helpful in identification of mixed GCT. A panel of immunohistochemical markers would be a more ideal way to identify and clarify the components because correct identification of the components is important for therapeutic intervention and prognostication. OCT4 being a primordial germ cell marker predicts aggressive behavior and targeted therapy against this should be investigated.

End-of-Treatment FDG PET-CT (EOT-PET) in Patients with Post-Chemotherapy Masses for Seminoma: Can We Avoid Further Intervention?

Anjana JoelContext  Patients with seminoma present with advanced disease. End-of-treatment (EOT) positron emission tomography-computed tomography (PET-CT) is done to assess response and direct management of post-chemotherapy residual masses. Purpose  This article assesses the utility of EOT PET-CT in the management of post-chemotherapy residual lymph nodal masses seminoma. Materials and Methods  We analyzed all patients with seminoma who underwent an EOT PET-CT from January 2015 to January 2020 at our center and calculated the positive predictive value (PPV) and negative predictive value (NPV) of EOT PET-CT in the entire cohort of patients and among subgroups. Results  A total of 34 male patients underwent EOT PET-CT. Fourteen (41.2%) were stratified as good risk and 20 (58.8%) as intermediate risk. The median follow-up was 23 months (interquartile range: 9.75-53 months). In 23 patients there were residual masses of size more than 3 cm at the EOT PET scan. EOT PET was positive as per the SEMPET criteria in 18 (78%) out of 23 patients. None underwent retroperitoneal lymph node dissection. All four who underwent image-guided biopsy, showed only necrosis on pathology. One patient with positive mediastinal node (standardized uptake value 13.6) had granulomatous inflammation. There was no relapse or progression during this period of follow-up. The NPV for EOT PET-CT for the entire cohort, > 3 cm, and > 6 weeks cutoff were 100%, respectively. The PPV for EOT PET-CT for the entire cohort, > 3 cm residual mass, and > 6 weeks cutoff were 8.7, 11.11, and 6.67%, respectively. Conclusion  EOT PET-CT has a low PPV and high NPV in predicting viable tumor in post-chemotherapy residual masses among patients with seminomatous germ cell tumors. If required, EOT PET positivity can be confirmed by a biopsy or reassessed with a repeat PET-CT imaging to document persistent disease prior to further intervention.

Outcome of testicular non-seminomatous germ cell tumours: report from a tertiary cancer centre in eastern India

Non-seminomatous germ cell tumour (NSGCT) is a rare but highly curable malignancy. The literature on the management and outcomes of NSGCT is scarce from India. Here, we report the demography and treatment outcomes of NSGCT treated at our centre. This is a retrospective analysis of testicular and retroperitoneal NSGCT patients treated from March 2011 to December 2019. Patients were staged appropriately with imaging, pre- and post-operative tumour marker. Patients received stage adjusted adjuvant treatment after high inguinal orchiectomy. Patients with advanced disease were risk stratified as per International Germ Cell Cancer Collaborative Group (IGCCCG) classification. A total of 100 patients were treated with a median age of 28 years (Range: 18–51). Primary site was testis in 92 and retroperitoneum in 8 patients. Testicular violation was present in 17 (18%) patients. The stage of the disease was I in 32, II in 19 and III in 49 patients, respectively. IGCCCG risk groups were good in 29 (46%), intermediate in 13 (21%) and poor in 21 (33%) patients. Eleven patients (24%) underwent retroperitoneal lymph node dissection amongst 45 with post-chemotherapy residual disease. After a median follow-up of 26.6 months (range: 2.2–100.7), 3-year event-free survival and overall survival (OS) were 70.7% ± 5.6% and 78.2% ± 5.4%, respectively. S3 tumour marker (p = 0.01) and non-pulmonary visceral metastasis (p < 0.001) emerged as independent poor prognostic factors for OS in multivariate analysis. To conclude, testicular NSGCT has very high cure rate. Two-third patients present with advanced disease and one-third of them had poor risk disease. S3 tumour marker and non-pulmonary visceral metastasis are poor risk factors for OS.

Primary mediastinal germ cell tumours: real world experience in the low middle income (LMIC) setting

PURPOSE

Primary mediastinal germ cell tumours (PMGCTs) are rare; with limited data available about their outcomes and optimal treatment in the low middle income countries setting. We studied the clinical profile of patients with PMGCT treated at our centre in order to estimate their survival outcomes and to identify prognostic factors affecting the same.

PATIENTS AND METHODS

Fifty-seven patients with PMGCTs treated between April 2001 and June 2019 were included. Baseline characteristics, details of first line chemotherapy, response rates, toxicity and surgical outcomes were noted. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method.

RESULTS

Among 57 male patients (seminoma = 20 and nonseminomatous = 37), the median follow-up was 10 months (range: 1-120 months). For mediastinal seminoma, 9 (45%) and 11 (55%) patients had good and intermediate risk disease, respectively. Nineteen patients (95%) received BEP (Bleomycin, etoposide and cisplatin) chemotherapy. 94.7% had partial responses and median event-free survival was not reached. All patients were alive and disease free at 2 years. For primary mediastinal nonseminomatous germ cell tumours (PMNSGCTs), all patients were poor risk. Thirty-four (91.8%) received BEP/EP chemotherapy as first line. Responses were PRM+ (partial response with elevated markers) in 7 (20.5%) and PRM- in 12 (35.2%). The incidence of febrile neutropenia was 50% and 55.8% in seminole and PMNSGCT, respectively. The median OS was 9.06 months and median PFS was 4.63 months for PMNSGCT. The proportion of patients alive at 1 year and 2 years were 35% and 24.3%, respectively.

CONCLUSION

Primary mediastinal seminomas are rarer and have better survival outcomes. Treatment of PMNSGCT is still a challenge and is associated with poorer survival outcomes.

Blood testis barrier revisited-Analysis of post-chemotherapy germ cell tumor orchidectomy and retroperitoneal lymph node dissection specimens

OBJECTIVE

To assess the response of chemotherapy on the primary tumor, compare it with the response in retroperitoneal disease, and study factors associated with pathological complete response.

METHODS

We conducted a retrospective audit of all high inguinal orchidectomies (HIOs) performed after chemotherapy between 2012 and 2019 at a tertiary cancer center in India. Patient characteristics and histopathological response were extracted from electronic medical records, and predictors of testicular disease response were assessed.

RESULTS

Of the 260 retroperitoneal lymph node dissections (RPLNDs) performed in the study period, 37 HIOs (14.23%) were carried out after chemotherapy. The median age of presentation was 28 years (16-41). Histopathology was divided into a viable tumor, mature teratoma, and necrosis/scarring. Residual disease was seen in 17 RPLND (46.0%) and 18 HIO (48.6%) specimens respectively. Of these 18, three patients had a residual viable tumor in the testis, and the remaining had a mature teratoma. Clinico-radiological assessment showed an average reduction of 61% in testicular disease size following chemotherapy. On orchidectomy histopathological assessment, the median tumor size was 9, 4, and 1.5 cm in specimens with a viable tumor, mature teratoma, and necrosis/scarring, respectively.

CONCLUSIONS

A low threshold for upfront chemotherapy in patients with a high disease burden may be considered as tumors within the testis respond to chemotherapy in more than half of the patients. Discordance rates of residual cancer in RPLND and HIO specimens exist but post-chemotherapy tumor size in testis correlates with the presence of a residual viable tumor.

Prognostic factors and outcomes of nonseminomatous germ cell tumours of testis-experience from a tertiary cancer centre in India

Germ cell tumour of the testis is the most common cancer in young men in the western world. India has the lowest incidence globally, and hence Indian data are sparse. We report the outcomes of patients with nonseminomatous germ cell tumours of testis treated at a tertiary cancer centre in South India over a period of 10 years. Patients with a histopathological diagnosis of nonseminomatous germ cell tumours of the testis from 1 January 2006 to 31 December 2016 were included in the study. Patient demographics, tumour characteristics and treatment details were retrieved from case records. Kaplan–Meier method was used to estimate progression-free survival (PFS) and overall survival (OS). Cox regression model was used to analyse the prognostic factors.

One hundred and nineteen patients with nonseminomatous germ cell tumours of the testis were included in the study. The median follow-up was 81 months. The estimated 4-year OS and progression-free survival were 87.1% and 84.5%, respectively. The four-year OS for good, intermediate and poor-risk groups was 93.6%, 87.5% and 52.6%, respectively. The PFS at 4 years was 91.4%, 87.8% and 47.4% for good, intermediate and poor-risk groups, respectively. The presence of nonpulmonary visceral metastasis and biochemical response after chemotherapy were significant predictors for OS and PFS in multivariate cox proportional hazards regression. The survival figures are comparable to the rest of the world except in the poor prognostic risk group. The inferior survival noticed in this group of patients may be due to the lack of good salvage procedures. High-dose chemotherapy with stem-cell support may be considered more often for this group of patients.

Factors that impact the outcomes in testicular germ cell tumors in low-middle-income countries

Germ cell tumors (GCTs) are one of the most common tumors in adolescents and young adults. There is paucity of data on GCT from low-middle-income countries (LMIC). The present study was conducted to assess the demographic features, clinical manifestations, pathology, and outcomes of GCT patients treated at our center. Patients with testicular GCT above the age of 18 years, treated at our center from 2001 to 2015 were included in the study. Data were extracted retrospectively from the case records. Event-free survival (EFS) and overall survival (OS) were calculated using the Kaplan-Meier method and the variables were compared using the log-rank test. The study included 421 patients among whom 128 (30%) had a histological diagnosis of seminoma and 293 (70%) had non-seminomatous germ cell tumor (NSGCT). Metastatic disease at presentation was observed in 83/128 (65%) with seminoma and 254/293 (87%) with NSGCT. According to the International Germ Cell Cancer Collaborative Group (IGCCCG) risk stratification for metastatic disease, good- and intermediate-risk seminoma were observed in 55/83 (66%) and 28/83 (34%) patients, respectively, and good-, intermediate-, and poor-risk NSGCT were observed in 82/254 (32%), 76/254 (30%), and 96/254 (38%) patients, respectively. The median follow-up was 32.3 months (range 0.03-200 months). The 3-year OS for the entire cohort was 80.3%. The 3-year OS for seminoma was 91.4%, and for NSGCT was 75.3%. Factors significantly associated with inferior EFS and OS on multivariate analysis included poor performance status, scrotal orchidectomy, carboplatin-based regimen, NSGCT histology, and treatment default. Patients with testicular GCT in India present in an advanced stage and higher IGCCCG risk compared to Western data. Factors unique to LMIC like treatment default, bulky disease, dose compromise, and scrotal orchidectomy have a negative impact on the outcome.