Advanced extragonadal germ-cell tumors. Successful treatment with combination chemotherapy

Pure primary renal yolk sac tumour in an adult: extremely rare clinical finding

We present a rare case of an extragonadal retroperitoneal yolk sac tumour in an adult male, who presented with severe abdominal pain to his local hospital. Imaging revealed a large retroperitoneal soft tissue mass with no evidence of metastases. Initial biopsy demonstrated poorly differentiated carcinoma, favoured to be renal cell carcinoma. The patient underwent surgical resection following re-presentation with severe abdominal pain and significant interval enlargement of the mass. Laparotomy revealed a renal tumour that had ruptured through the left mesocolon into the peritoneal cavity. Postoperative histopathological examination revealed a yolk sac tumour involving the kidney, perinephric fat, renal sinus fat, renal hilar lymph node and colonic mesentery. Immunohistochemical staining for alpha-fetoprotein and glypican 3 was positive in the tumour cells without evidence of other germ cell elements, confirming the diagnosis of a pure yolk sac tumour. To our knowledge, this is an extremely rare case of a primary pure yolk sac tumour arising from the kidney in an adult.

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.

Primary mediastinal and retroperitoneal malignant germ cell tumors in children and adolescents: Results of the TGM95 trial, a study of the French Society of Pediatric Oncology (Société Française des Cancers de l'Enfant)

PURPOSE

To examine the clinical presentation, treatment and results in children and adolescents with primary mediastinal (PM) and retroperitoneal (RP) germ cell tumors (GCTs).

METHODS

The TGM95 trial for malignant GCTs was conducted in France between 1995 and 2005 to evaluate a strategy adapted to prognostic factors with cisplatin-based chemotherapy and surgical management. We reviewed patients with TGCTs at PM and RP sites.

RESULTS

Among 239 patients, there were 16 patients with PM and 5 with RP tumors, which represent 9% of all patients, highlighting the rarity of these extragonadal locations. A bimodal demographic distribution was observed (11/21 patients <5 years old and 7/21 patients >12 years old). A majority of patients presented with bulky tumors that required urgent care with neoadjuvant chemotherapy. In all patients, elevation of alpha-fetoprotein indicated a yolk sac tumor component. Human chorionic gonadotrophin was elevated in five patients (four adolescents), suggesting a choriocarcinoma or seminoma component. The diagnosis was based on elevation of these tumor markers in addition to imaging. Chemosensitivity was observed for a majority of patients. An aggressive surgical approach allowed a microscopic complete resection in 12/15 patients with PM tumors and 4/5 with RP tumors. Overall, 14/16 and 4/5 patients survived, respectively. Three adolescents died of tumor progression.

CONCLUSION

In children with mediastinal or RP GCTs, the prognosis is favorable when a strategy of delayed aggressive surgery is performed after cisplatin-based chemotherapy. Younger patients have a better prognosis. Relapses were observed only in adolescents and could not be cured.

CT in Primary Malignant Germ Cell Tumors of the Retroperitoneum

Malignant germ cell tumors may exist as a primary entity in the retroperitoneum. In a CT study of 14 males with this condition (2 seminomas and 12 non-seminomatous tumors) all masses were large, lobulated and of mixed density. Fat plane obliteration against adjacent structures was frequent. The aorta was embedded in 9 patients and the inferior vena cava was affected in 7, 2 of whom had signs of compromised caval blood flow. Distant metastases were found in the lungs (7 patients), liver (n = 4), posterior mediastinum (n = 3), and in brain and supraclavicular lymph nodes in one patient each. Serum biomarkers were elevated in 11 patients. An extragonadal germ cell tumor should be considered when CT of the abdomen reveals a large retroperitoneal mass with mixed density.

Long-term mortality in patients with germ cell tumors: effect of primary cancer site on cause of death

OBJECTIVES

To examine the effect of extragonadal tumor site on the risk for cardiovascular, hematopoietic malignancies, and solid cancer-related causes of death.

PATIENTS AND METHODS

Male patients diagnosed with germ cell tumors (GCTs) between 1973 and 2008 were identified from the Surveillance, Epidemiology and End Results database, and stratified by the site of primary cancer (mediastinal and nonmediastinal extragonadal vs. gonadal). Using competing risk analysis restricted to events that happened at least 5 years after diagnosis, we examined the possible effect of primary tumor site on the risk for death related to hematopoietic malignancies, cardiovascular disorders, and solid cancers in the study cohort.

RESULTS

Of 37,283 patients included in our analysis, 17,715 were diagnosed with nonseminomas and 19,568 with seminomas. Eight hundred and twenty four patients (2%) were diagnosed with primary mediastinal GCTs and 1,469 (4%) with nonmediastinal extragonadal tumors. Patients with mediastinal GCTs had an increased risk for death related to hematopoietic malignancies (hazard ratio [HR] = 8.84; 95% confidence interval [CI]: 3.16-24; P<0.0001) and cardiovascular disorders (HR = 4.45; 95% CI: 2.52-8.0; P<0.0001), but no significant difference in risk of dying of solid cancers (HR = 1.46; 95% CI: 0.36-5.9; P = 0.59) compared to patients with gonadal GCTs. Patients with nonmediastinal extragonadal GCTs had a significantly increased risk for dying of cardiovascular disorders (HR = 2.75; 95% CI: 1.67-4.51; P<0.0001), but not a significantly different risk for dying of hematopoietic malignancies (HR = 0.93; 95% CI: 0.13-6.84; P = 0.94) or solid cancers (HR = 1.45; 95% CI: 0.68-5.0; P = 0.23) compared with patients with gonadal GCTs.

CONCLUSIONS

Patients with GCTs and extragonadal primary sites have an increased risk for death from cardiovascular disease and hematopoietic malignancies compared to those with gonadal GCTs, and could benefit from more intense preventive measures to decrease the risk of death related to these disorders.

Primary mediastinal "thymic" seminomas

Over the last half century, our knowledge on germ cell tumors (GCT) has increased dramatically. Tumors that at one time were supposed to originate exclusively from certain anatomic areas are now thought to occur in ubiquitous distribution. Nevertheless, because of their similar histopathologic features, the conventional classic evaluation of these patients will require careful clinical history as well as complete physical and radiologic evaluation. The emphasis in this manuscript will be to highlight the occurrence and overall characteristics of one of the most common GCTs in the mediastinal region-seminoma. A more detailed discussion of mediastinal GCTs is well beyond the scope of this review.

Primary retroperitoneal dysgerminoma presenting as an adrenal tumor: a case report and literature review

Primary extragonadal germ cell tumors are rare and mostly occur in young men with predominance of nonseminomatous histology. We report an undescribed case of primary retroperitoneal dysgerminoma presenting as an adrenal tumor in a 17-year-old girl. Surgery was performed on a 10 × 9.5 cm sized adrenal gland tumor and the resected tumor showed unequivocal histological features of dysgerminoma. The diagnosis was confirmed by the tumor's germ cell immunophenotype. Postoperative ultrasonography, CT and PET over a 6-month period revealed no evidence of ovarian lesion. The patient is stable, but with a suspicious residual tumor after adjuvant chemotherapy.

Unusual scapular metastasis as initial manifestation of advanced nonseminomatous germ cell tumor of the mediastinum

Primary malignant germ cell tumors of the mediastinum are relatively rare, occurring predominantly in young male adults, and have a poor prognosis. We present a case of a 27-year-old man who initially experienced a persistent, intractable painful sensation over the right lower scapula despite taking an analgesic agent for 2 months. A scapular x-ray film and a whole-body bone scan showed an expansile osteolytic lesion. Excisional biopsy of the scapula revealed a metastatic carcinoma, suggestive of nonseminomatous germ cell tumor origin. Further examination of the whole abdomen and bilateral testes were negative. Chest computed tomography and magnetic resonance imaging showed a primary tumor mass in the anterior mediastinum. Chemotherapy with cisplatin, bleomycin, and etoposide was administered for six courses. The mediastinal tumor mass was markedly reduced in size and remission without evidence of tracer uptake by [(18)F]fluorodeoxyglucose positron emission tomography examination. Six months after chemotherapy, the patient received advanced surgical intervention to remove the mediastinal tumor, the pathologic features of which were similar to the previous scapular lesion. He was doing well at 1-year follow-up.

[Usefulness of PET in the diagnosis and response to treatment of extragonadal germinal tumor with atypical presentation]

Primary tumors of extragonadal origin are rare, with fewer than 1000 cases described in the literature. Although the exact incidence of EGTs is unknown, clinical data suggest that roughly 3% to 5% of all germ cell tumors. We expose a case report of EGT with unusually clinic presentation. We present our diagnostic and therapeutic experience in this injuries.

Diagnosis, staging, and clinical characteristics of the patient with mediastinal germ cell carcinoma

When an anterior mediastinal mass is found in a young male patient, mediastinal germ cell tumors should always be one of the leading diagnostic considerations. The staging evaluation and diagnostic procedures should be performed rapidly. Every patient with a mediastinal germ cell tumor should be approached with curative intent, and appropriate treatment should be initiated as soon as the brief diagnostic procedure has been completed. Currently, treatment is curative in most patients (> 80%) with pure mediastinal seminoma, even in patients with huge mediastinal tumors and evidence of distant metastases. Although the cure rate is lower for patients with nonseminomatous germ cell tumors, the overall cure rate of 35% to 40% makes these tumors one of the most effectively treated advanced cancers. Further details regarding the treatment of mediastinal germ cell tumors are presented elsewhere in this issue.

Extragonadal germ cell tumors in Taiwan: an analysis of treatment results of 59 patients

BACKGROUND

Extragonadal germ cell tumors (EGCT) are rare. They are biologically distinct from their testicular counterparts. Information regarding these tumors from the Far East is limited. More investigations are warranted to define the optimal treatment.

METHODS

Retrospective review of the medical records of 59 patients with EGCT treated between 1983 and 2001 at a large, tertiary care institute in Taipei.

RESULTS

The study population comprised 54 males and 5 females, ranging in age from 1 to 68 years old (median age, 21 years). Primary tumors occurred in the mediastinum (n = 27), retroperitoneum (n = 6), central nervous system (CNS; n = 24), and other sites (n = 2). Patients received surgery, chemotherapy, radiotherapy, or a combination of treatment modalities as the primary treatment. Three patients with mediastinal seminoma achieved complete remission (CR) and are alive with no evidence of disease (NED), with a median follow-up of 118 months. Of 24 patients with mediastinal nonseminomas, 8 (33%) are alive with a median disease-free survival (DFS) period of 33 months. Two of six patients with retroperitoneal nonseminomas obtained CR and are alive with NED at 41 and 110 months, respectively. Of 24 patients with intracranial germ cell tumors, 16 had germinoma and 13 (81%) achieved CR with NED at 8-228 months (median duration, 104 months). Four of eight patients with CNS nongerminomas remain in CR and are alive with a median DFS period of 48 months. Four patients with mediastinal nonsemonimas treated with salvage chemotherapy died.

CONCLUSIONS

The treatment results of our patients with seminomatous EGCT are comparable to those of Western countries. However, the treatment results of patients with nonseminomatous EGCT are not as good. The reason for this discrepancy needs to be explored for a better treatment outcome of for patients in Taiwan with EGCT.

Prognostic variables for response and outcome in patients with extragonadal germ-cell tumors

BACKGROUND

This investigation evaluates prognostic variables in patients with seminomatous and non-seminomatous extragonadal germ-cell tumors (EGCT) in order to identify relevant factors for long-term outcome following cisplatin-based chemotherapy.

PATIENTS AND METHODS

Patients from six countries treated at 11 centers in Europe and the USA from 1975 to 1996 were evaluated retrospectively. Uni- and multivariate analyses of prognostic variables for survival and for response to chemotherapy were performed.

RESULTS

Data were available for 635 EGCT patients, 104 with seminomatous and 524 with non-seminomatous EGCT (n = 7 not specified). For non-seminomatous EGCT the following independent adverse factors were identified: presence of either liver, lung or central nervous system metastases, primary mediastinal tumor or elevation of pretreatment beta-human gonadotropin; for extragonadal seminoma (only univariate) adverse factors were: presence of liver metastases, two or greater metastatic sites or International Germ Cell Cancer Collaborative Group (IGCCCG) grouping (intermediate versus good). Integration of these variables produced the following prognostic risk groupings: 'excellent prognosis', all seminomatous EGCT (89% 5-year survival rate); 'intermediate low', 'intermediate high' and 'poor', all non-seminomatous EGCT with a 69, 55 and 17% 5-year survival rate, respectively. The decreased survival among the different groups was due to a lower rate of favorable objective remissions and a higher rate of relapses. Classification and regression tree (CART) modeling confirmed histology and location of primary tumor as the major prognosticators. For the subgroup of patients with mediastinal non-seminoma, the 2-year survival rate ranged from 34 to 84%. Multivariate testing for the probability to respond to chemotherapy revealed non-seminomatous histology, primary mediastinal tumor site, and the presence of liver, lung or CNS metastases as independent adverse factors.

CONCLUSIONS

In EGCT, prognostic variables for the outcome and for the response to chemotherapy could be identified, which in part differ from gonadal GCT. The proposed model might help to better understand the specific prognosis of EGCT and to tailor risk-adapted treatment strategies. In addition, CART analysis demonstrated the heterogenous prognosis of patients with mediastinal non-seminoma.

Extragonadal germ cell tumors of the mediastinum and retroperitoneum: results from an international analysis

PURPOSE

To characterize the clinical and biologic features of extragonadal germ cell tumor (EGCT) and to determine the overall outcome with currently available treatment strategies.

PATIENTS AND METHODS

Of an unselected population of 635 consecutive patients treated from 1975 through 1996 at 11 cancer centers, 341 patients (54%) had primary mediastinal EGCT, and 283 patients (45%) had retroperitoneal EGCT. Five hundred twenty-four patients (83%) had a nonseminomatous germ cell tumor (GCT), and 104 patients (16%) had a seminomatous histology.

RESULTS

After platinum-based induction chemotherapy with or without secondary surgery, 141 patients (49%) with mediastinal nonseminomas (median follow-up, 19 months; range, 1 to 178 months) and 144 patients (63%) with retroperitoneal nonseminoma (median follow-up, 29 months; range, 1 to 203 months) are alive (P =.0006). In contrast, the overall survival rate for patients with a seminomatous EGCT is 88%, with no difference between patients with mediastinal or retroperitoneal tumor location (median follow-up, 49 months; range, 4 to 193 months; respective 70 months; range, 1 to 211 months). A significantly lower progression-free survival rate was found in seminoma patients treated with initial radiotherapy alone compared with chemotherapy. Nonseminomatous histology, presence of nonpulmonary visceral metastases, primary mediastinal GCT location, and elevated beta-human chorionic gonadotropin were independent prognostic factors for shorter survival. Hematologic malignancies (n = 17) occurred without exception in patients with primary mediastinal nonseminoma. Sixteen patients developed a metachronous testicular cancer despite the use of platinum-based chemotherapy.

CONCLUSION

Whereas patients with pure seminomatous EGCT histology have a long-term chance of cure of almost 90% irrespective of the primary tumor site, 45% of patients with mediastinal nonseminomas are alive at 5 years. This outcome is clearly inferior compared with patients with nonseminomatous retroperitoneal primary tumors.

Second-line chemotherapy in patients with relapsed extragonadal nonseminomatous germ cell tumors: results of an international multicenter analysis

PURPOSE

Relapsed extragonadal germ cell tumors patients (EGGCT) are treated with identical salvage chemotherapy regimens, as are patients with metastatic testicular cancer. This investigation evaluates the results of second-line chemotherapy in nonseminomatous EGGCT and tries to identify prognostic factors for survival.

PATIENTS AND METHODS

We conducted a retrospective review of 142 patients treated at eleven European and American centers between 1975 and 1996. All had received cisplatin-containing regimens as induction treatment.

RESULTS

Twenty-seven of 142 patients (19%) were long-term disease-free, 11% with primary mediastinal and 30% of patients with primary retroperitoneal disease. Median follow-up since start of salvage treatment was 11 months (range, 1 to 157) for all patients and 45 months (range, 6 to 157) for surviving patients. Forty-eight patients (34%) received high dose chemotherapy with autologous bone marrow transplant at relapse, and 10 of these patients (21%) are continuously disease-free. Primary mediastinal location (P =.003), sensitivity to cisplatin (P =.003), elevated beta-HCG at relapse (P: =.04), and normal LDH at diagnosis (P =.01) were shown to be significant negative prognostic factors for overall survival in univariate; mediastinal location [relative risk ratios (HR) = 1.9; 95% confidence intervals (CI), 1.2 to 3.0] and sensitivity to cisplatin [HR = 2.4; 95% CI, 1.1 to 5.2] were significant negative prognostic factors in multivariate analysis.

CONCLUSION

Although current salvage strategies will cure between 20% and 50% of recurrent metastatic testicular cancer, relapsed nonseminomatous EGGCT patients appear to have an inferior survival rate, in particular in case of primary mediastinal location. Mediastinal primary tumor and inadequate response to cisplatin-based induction chemotherapy have been identified as independent negative prognostic factors, both associated with an approximately two-fold higher risk for failure of salvage treatment.

Testicular cancer

The following article provides a comprehensive review of male germ cell tumors; the pathology and the clinical manifestations of the tumors are discussed, as are the modern concepts of clinical staging. Patients with bulky stage II and stage III non-seminomatous germ cell tumors are treated with chemotherapy. The new international classification system has provided a very useful way to categorize these patients by prognosis. Patients with good- or intermediate-risk tumors may be treated with 3 courses of cisplatin, etoposide, and bleomycin (BEP) or 4 courses of etoposide and cisplatin (EP), and more than 90% of these patients will survive. Randomized trials have shown that, if only 3 courses of chemotherapy are to be given, the substitution of carboplatin for cisplatin and the omission of bleomycin are deleterious to outcome. Patients who still have a significant residual mass and normal markers after treatment should undergo a surgical resection of the residual tumor. Patients who are classified by the international classification system as having poor-risk tumors have about a 50% likelihood of survival, and many of these patients will require surgical resection of a residual tumor after chemotherapy. No randomized trial has proved a regimen to be superior to that of 4 courses of BEP. Currently, an ongoing trial is evaluating the effect of the early use of high-dose therapy in combination with hematopoietic rescue in patients with these types of tumors. Patients with small-volume stage II tumors are generally treated with retroperitoneal lymph node dissection (RPLND). About 25% of the patients selected for this procedure will actually have pathologically negative nodes. Those with positive nodes may elect to receive adjuvant chemotherapy (2 courses of BEP), which will almost always prevent relapse. An alternate approach for patients willing to comply with monthly follow-up is surveillance, with chemotherapy deferred until relapse is noted. About 50% of these patients will be cured with surgery (as many as 75% have microscopic disease only). With careful follow-up, those destined to relapse can be treated promptly and at a time when they have small-volume tumors and an excellent prognosis if they go on to receive chemotherapy. Patients with clinical stage I nonseminomatous germ cell tumors may also undergo RPLND, although an acceptable alternative for these patients is surveillance. The advantages and the disadvantages of each approach are discussed. The overall risk of recurrence is about 30%, but there have been patient groups defined that may vary in risk from 10% to 15% up to 50% or more. Patients with advanced seminoma are treated with chemotherapy. When this procedure is used, outcomes are favorable and all patients are either in good- or intermediate-risk groups, according to the international classification system. Patients with small-volume stage II tumors are treated with radiotherapy. Radiation is also generally used for the treatment of clinical stage I patients, although surveillance is growing in prominence as a means to treat these patients. Late effects of treatment are also discussed in this article. Ejaculatory function can be preserved in most patients who have early stage tumors and who undergo RPLND and in some patients who undergo surgery after chemotherapy. The most troubling effect of chemotherapy is the development of etoposide-induced leukemia, a unique--and fortunately rare--clinical entity.

Extragonadal germ-cell tumors: a ten-year experience

Extragonadal germ-cell tumors (EGCT) are uncommon and biologically distinct from their gonadal counterparts. Thirty-seven patients who had EGCT were treated over a ten-year period at the Regional Cancer Centre, Trivandrum, India. There were 26 men and boys and 11 women and girls. The sites of primary tumor were mediastinum (n=18), central nervous system (n=5), sacrococcygeal region (n=4), retroperitoneum (n=2), and other sites (n=8). After combined modality therapy, 13 of 18 patients who had mediastinal EGCT--1 of 2 with retroperitoneal, 1 of 4 with sacrococcygeal, 0 of 5 with central nervous system, and 2 of 8 patients with tumor in other sites-were alive with no evidence of disease at a median follow-up of 16 months. The overall 5-year survival rate was 40%. Histologic subtype and elevated marker levels were the significant prognostic factors on univariate analysis.

Initial management of primary mediastinal seminoma: radiotherapy or cisplatin-based chemotherapy?

Primary mediastinal seminoma is an uncommon neoplasm, the optimal management of which is still debated. Radiotherapy produces a 65% disease-free survival rate. We assess whether these results have been improved with the advent of cisplatin-based chemotherapy. Data from 14 patients treated at the Institut Gustave-Roussy were reviewed. 9 had received cisplatin-based chemotherapy (Group 1): their outcome was compared with that of 5 patients treated with radiotherapy without chemotherapy (Group 2). We also reviewed data from the English literature using strict criteria, and report results concerning patients who received cisplatin-based chemotherapy and those who received radiotherapy. 8 of the 9 patients (89%) in Group 1 are long-term disease-free survivors and only 3 of 5 patients in Group 2. The patient who died in Group 1 was the only one who refused surgical resection of residual masses after chemotherapy. The review of the literature revealed that 59 of 68 (87%) patients initially managed with cisplatin- or carboplatin-based chemotherapy and for whom sufficient data are available, are long-term survivors and free of disease. Some of these patients had also received radiotherapy. Only 64 of 103 (62%) treated with thoracic radiotherapy without chemotherapy were long-term disease-free survivors. The disease-free survival rate of 51 patients who received cisplatin-based chemotherapy (excluding those who received carboplatin) was 86%. The difference in survival between patients administered cisplatin-based chemotherapy and those who underwent radiotherapy is apparently not due to unbalanced prognostic factors, the effect of time or non-specific medical management. We conclude that cisplatin-based chemotherapy allows long-term disease-free survival in approximately 85% of patients. These results seem to be higher than those obtained without cisplatin-based chemotherapy. However, a randomised study is required for definitive conclusions, but it is very unlikely that such a study will be performed due to the rarity of this neoplasm. Another alternative would be a meta-analysis based on individual data.

Mediastinal non-seminomatous germ cell tumours (MNSGCT) treated with cisplatin-based combination chemotherapy

BACKGROUND

Primary mediastinal non-seminomatous germ cell tumours (MNSGCT) constitute a rare malignancy. This study was performed to review our experience with cisplatin-based chemotherapy in patients with MNSGCT.

PATIENTS AND METHODS

Patients with MNSGCT treated with cisplatin-based combination chemotherapy between 1978-1995 in three university hospitals in Spain were retrospectively studied.

RESULTS

There were 25 males and two females with a median age of 26 years (range 4-71). Fifteen patients had disease confined to the mediastinum and 12 had metastatic disease. All patients were treated with cisplatin chemotherapy regimens (PVB: 7, BEP: 6, and other regimens 12) and considered for residual mass surgery (RMS) when indicated. Eleven patients (40.7%) were rendered disease-free with initial treatment: four with chemotherapy alone, one with surgery plus adjuvant chemotherapy and six with chemotherapy plus RMS. Three of these patients relapsed at two, six and seven months. The remaining 16 had unfavourable responses (five partial response, three no change, seven progressive disease and one toxic death). Eleven patients received salvage treatment but none of them achieved a durable response. After a median follow-up of 77 months (range 1-168), 10 patients remain alive. Actuarial survival at five years is 31.7%. No patients in this series developed a haematological malignancy. Chromosomal analysis showed that 2 out of 10 patients (20%) had a 47XXY karyotype.

CONCLUSIONS

Only patients who achieved disease-free status are likely to be cured. Therefore, new up-front strategies are needed for the treatment of MNSGCT.

Blood flow-independent accumulation of cisplatin in the guinea pig cochlea

Considerable interindividual variability in the ototoxic effect of cisplatin has become the unpredictable dose-limiting factor in its use as curative as well as palliative therapy. The drug accumulates in highly vascular areas in the cochlea, causing dose-related hair cell loss. The purpose of this study was to assess blood flow-dependent aspects of cisplatin absorption in the cochlea in order to better understand factors that may influence cisplatin-induced ototoxicity. The effect of reduced cochlear blood flow on the ototoxic action of cisplatin was studied in guinea pigs. Before cisplatin administration the cochlear vasculature in each animal was unilaterally pre-constricted, by the application of 2% epinephrine to the round window. A 20-30% reduction in cochlear blood flow, assessed by laser Doppler flowmetry, was maintained before and after intravenous infusion of 0.1% cisplatin. Cisplatin infusion affected cochlear blood flow but not vessel conductivity. The cochlear blood flow decrease, maintained by local epinephrine application to the round window during cisplatin infusion, did not alter the cisplatin-induced hearing loss. In addition, the concentration of free cisplatin in scala tympani perilymph did not differ between epinephrine-treated and non-treated ears. Our results indicate that cisplatin transport into the cochlea is not an energy-dependent process in the lateral wall vasculature.

Cisplatin-based chemotherapy of primary extragonadal germ cell tumors. A single institution experience

BACKGROUND

Extragonadal germ cell tumors account for only 2-5% of all germ cell neoplasms in adult males. Because these tumors are rare and, in part, biologically distinct from their testicular counterparts, their optimal management continues to be defined.

METHODS

The medical records of 51 patients with extragonadal germ cell tumors were reviewed. All patients were treated with cisplatin-based chemotherapy at a single institution between 1981 and 1994.

RESULTS

Thirty-five patients had nonseminomatous germ cell tumors and 16 had pure seminomas. Sixteen tumors arose in the mediastinum (12 nonseminomas, 4 seminomas), and 35 in the retroperitoneum (23 nonseminomas, 12 seminomas). Six of 12 patients (50%) with mediastinal nonseminomas survived with no evidence of disease (NED) at 33-137 months (median, 96 months); all had undergone surgery as part of their treatment. Fifteen of 23 patients (65%) with retroperitoneal nonseminomas are alive with NED at 2-145 months (median, 39 months). Fifteen of 16 patients (94%) with extragonadal seminomas survived with NED at 2-141 months (median, 66 months), and 1 patient died from late irradiation-related toxicity. Three patients with retroperitoneal nonseminomas developed a testicular seminoma at 35, 42, and 77 months, respectively; all are currently disease free.

CONCLUSIONS

Mediastinal and retroperitoneal nonseminomas have distinct clinical features. As in other series, clinical outcome is somewhat inferior for mediastinal nonseminomas compared with retroperitoneal nonseminomas. Regardless of the site of presentation, the vast majority of patients with extragonadal seminomas can expect cure. It remains controversial, however, whether retroperitoneal germ cell tumors are metastatic from a primary testicular germ cell tumor.

Successful treatment of metastatic choriocarcinoma after DMP 840

A 17-year-old male with retroperitoneal choriocarcinoma metastatic disease in the lungs has had shrinking of pulmonary metastases and primary tumor with four treatment courses of DMP 840. β-HCG appeared normal prior to resection of the necrotic primary tumor and a single remaining pulmonary metastasis, which was also necrotic. The patient remains free of tumor recurrence of 8 months following surgery. Further evaluation of DMP 840 in patients with germ cell tumors is indicated.

Etoposide: twenty years later

Since the beginning of its clinical development 20 years ago, etoposide has become an important and widely used agent in clinical oncology. Its integral role in the treatment of germ cell tumors and small-cell lung cancer seems unlikely to diminish in the future, and its use in non-Hodgkin's lymphoma and in various high dose regimens will probably continue to increase. Active investigation continues regarding the optimal dose and schedule of etoposide, and it is likely that these investigations will result in further improvement of its clinical activity in patients with sensitive tumor types. Continued clinical investigation may result in the identification of active etoposide containing combination regimens for ovarian cancer, breast cancer, and some of the childhood malignancies. Exciting possibilities for the future include exploration of etoposide in combination with the topoisomerase I inhibitors, as well as the development of drugs to reverse drug resistance. During the next 10 years, the applications and importance of this unique drug will continue to increase.

High dose chemotherapy with ifosfamide, carboplatin, and etoposide combined with autologous bone marrow transplantation for the treatment of poor-prognosis germ cell tumors and metastatic trophoblastic disease in adults

BACKGROUND

A Phase I-II trial to assess the toxicity and efficacy of a tandem high dose chemotherapy combining ifosfamide, carboplatin, and etoposide in germ cell tumors and metastatic trophoblastic disease was performed.

METHODS

Thirty-nine patients, with a total of 22 testicular tumors, 9 extragonadal germ cell tumors, 3 ovarian germ cell tumors, and 5 cases of metastatic trophoblastic disease, received tandem high dose therapy combining ifosfamide (7500-12,500 mg/m2), carboplatin (875-1225 mg/m2), and etoposide (1000-1250 mg/m2), followed by bone marrow reinfusion. Among the 39 patients, 33 were refractory to cisplatin- or carboplatin-based regimen and the response of 37 could be evaluated; 69 cycles of this tandem high dose therapy were administered.

RESULTS

The overall response rate was 46%, including a complete response (CR) rate of 35%. Of 21 patients with testicular tumors who could be evaluated, 10 (47%) achieved a CR. No CRs were obtained in patients with refractory extragonadal germ cell tumors. Nine partial responders after the first cycle became complete responders after the second. Nine (23%) of the patients were long term survivors (> 18 months), 7 of them in continuous CR. Side effects primarily were renal toxicity and enterocolitis. Seven patients (18%) died of therapy-related be explored and the maximum tolerated doses of this three-drug regimen remain to be determined.

CONCLUSION

This tandem therapeutic regimen is able to overcome resistance to a platinum-based regimen in highly refractory germ cell tumors and gestational trophoblastic disease and to cure a number of patients.

[Therapeutic intensification and hematopoietic stem cell autotransplantation in the treatment of solid tumors in adults: principles, realization and application to the treatment of germ cell, trophoblastic, breast, ovarian and small-cell bronchial tumors. 1]

Autologous bone marrow transplantation for the treatment of solid tumors in adults remains an uncommon therapeutic approach. The feasibility of such high-dose therapies is clearly proved, especially with the advent of hematopoietic growth factors and the rescue by the peripheral stem cells to reduce the duration of the chemotherapy-induced myeloid aplasia. The question is to exactly define the place of high-dose therapy in the land of solid tumors. For the treatment of primary chemoresistant gonadal germ-cell tumors, the possibility to cure the patients and the interest of high-dose therapy with autologous bone marrow transplantation are clearly demonstrated. As consolidation for the treatment of poor prognosis tumors, the place of high-dose therapies remains moot. For the treatment of chemoresistant extragonadal germ-cell tumors, especially for primary mediastinal tumors, the level of resistance to cisplatin-based chemotherapy regimens is generally too high to be overcome by intensive therapies given as single course or as tandem courses. However in association with debulking surgery, this therapeutic approach has to be considered for some patients. In the treatment of poor prognosis breast cancer, high-dose therapy with autologous bone marrow transplantation or with peripheral stem cells support is able to convert some patients with partial response into complete responders. However, the consequences on overall survival and on disease-free survival are not evident. For metastatic breast cancer and for poor-prognosis tumors (inflammatory breast cancer, axillary metastatic nodes > or = 8), the interest of high-dose therapy has to be determined by randomized studies. These studies are ongoing in USA and in Europe. For the treatment of poor-prognosis ovarian cancer, the situation is more difficult to appraise. Once again, randomized studies have to be done to precisely define the place of high-dose therapy. In the land of small-cell lung carcinomas, high-dose therapy is actually forsaken by most of authors, even for limited diseases. The results of previous studies are disappointing. Moreover, occult medullary micrometastases involvement is frequent, once again even in limited diseases. However new therapeutic associations, as the ICE regimen (IFM, Carboplatin, VP-16) delivered as single or tandem therapy, have to be studied, especially as early consolidation therapy for the treatment of limited small-cell lung carcinomas.

Extragonadal germ cell tumors. A 14-year Toronto experience

BACKGROUND

Extragonadal germ cell tumors (EGCT) represent only 2-5% of adult germ cell malignancies. Because they are rare and biologically distinct from testis cancer, their natural history and optimal management continue to be defined. The clinical characteristics, treatment, and outcome of 40 patients are presented here.

METHODS

Patients were identified through the medical records of four University of Toronto teaching hospitals. All patients were treated in specialized oncology units between 1978 and 1993.

RESULTS

Thirty-seven males and three females age 16-54 years (median, 24 years) with primary mediastinal (n = 24), retroperitoneal (n = 7), CNS (n = 7), and widespread (n = 2) EGCT were identified. Eight of nine patients (88%) with mediastinal seminoma are alive with no evidence of disease (NED) at 4-132 months (median, 45 months). After combined modality therapy, only 8 of 15 patients (53%) with mediastinal nonseminomas achieved complete remission (CR); 1 experienced relapse and died, resulting in 7 of 15 patients (47%) with NED at 45-86 months (median, 70 months). All three patients with retroperitoneal seminomas achieved CR and all have NED at 77, 103, and 120 months, respectively. Two of four patients with retroperitoneal nonseminomas have died, and the other two are alive at 36 and 54 months. Seven patients with CNS germinomas (seminoma) achieved CR after craniospinal radiation therapy, but one subsequently died after local relapse. The overall survival rate was 87% (median, 74 months). One patient with widespread choriocarcinoma died and the other achieved CR.

CONCLUSIONS

Regardless of site of presentation, extragonadal seminomas have a greater than 80% 5-year disease-free survival rate. Mediastinal nonseminomas are biologically distinct, with a poorer prognosis. Treated with cisplatin-based chemotherapy followed by aggressive resection, approximately 50% of patients survive. CNS seminomas have a good prognosis. Nonseminomas of the CNS are extremely rare and were not represented in the current series. These findings concur with other reported series.

Combined choriocarcinoma and yolk sac tumor arising in Barrett's esophagus

A patient with primary adenocarcinoma with yolk sac and trophoblastic differentiation occurring in Barrett's esophagus is reported. Yolk sac differentiation at this site has not been described previously. The diagnosis of germ cell differentiation initially was suggested by the finding of elevated serum tumor marker levels. The patient experienced disease remission after cytotoxic chemotherapy. Germ cell differentiation may be difficult to identify in small biopsy samples, which may not be representative of the tumor as a whole. The finding of germ cell differentiation defines therapy and predicates for a relatively good prognosis, which is contrast to adenocarcinoma. Because of the significance of germ cell differentiation in the selection of appropriate therapy, immunostaining for germ cell tumor markers is suggested in all patients with adenocarcinoma who are younger than 50 years.

Extragonadal germ cell tumor originating in iliac fossa

Extragonadal germ cell tumors usually originate in midline body structures. We describe the first case of an extragonadal germ cell tumor that arose atypically in the right iliac fossa, a nonmidline pelvic region. Based on this case report and a review of the literature, we suggest a modification of Abell's criteria for the diagnosis of retroperitoneal extragonadal germ cell tumors.

Alternating combination chemotherapy in patients with extragonadal germ cell tumors. A Southwest Oncology Group study

BACKGROUND

Extragonadal germ cell tumors (EGGCT) are uncommon, occur primarily in the mediastinum and retroperitoneum, and have been noted to have variable response rates to cisplatin-based chemotherapy regimens.

METHODS

The Southwest Oncology Group (SWOG) has completed a prospective trial of combination chemotherapy followed by surgical removal of residual disease in patients with this type of germ cell neoplasm. Chemotherapy consisted of alternating cycles of vinblastine, bleomycin, and cisplatin with etoposide, bleomycin, doxorubicin, and cisplatin. Four cycles of therapy were given followed by surgical removal of residual disease where appropriate.

RESULTS

Fifty patients were entered into the trial, and 41 were eligible, with 4 patients excluded by pathology review. Of the 41 eligible patients, 24 had mediastinal tumors, 15 had retroperitoneal tumors, and 2 had unknown primary sites. Complete response rates (chemotherapy +/- surgery) for the various sites were as follows: mediastinum, 18 of 24 (75%); retroperitoneum, 10 of 15 (67%); and unknown primary, 2 of 2 (100%). At 2 years, the disease-free survival rate for all patients was 87%. At a median follow-up of 6.8 years, 26 of 41 patients (63%) are alive. The toxicity of the chemotherapy regimen was substantial, with neutropenic fever developing in 17 of 41 patients (41%) during treatment. Additional side effects included nausea and vomiting (76%), mucositis (27%), and pulmonary toxicity (5%).

CONCLUSIONS

This prospective trial of chemotherapy in patients with EGGCT demonstrates a significant response in patients with either mediastinal or retroperitoneal tumors and a 4-year survival rate of more than 60% and 70%, respectively.

High-risk germ cell tumors in men. High response rate and severe toxicity with cisplatin, vinblastine, bleomycin, and etoposide

BACKGROUND

In an attempt to improve the complete remission and cure rate of advanced, bulky, high-risk germ cell cancer in men, a "high-dose" cisplatin, vinblastine, bleomycin, and etoposide (PVeBV) regimen was introduced.

METHODS

Ten men with biopsy-proven germ cell tumors who had one or more poor prognostic features were treated with PVeBV.

RESULTS

Six of the 10 had complete remissions and are long-term survivors. The most devastating toxicity, which resulted in the death of three patients, was progressive respiratory failure. It was postulated that renal tubular injury prolonged the renal clearance of bleomycin, intensifying the patient's pulmonary exposure to this drug and increased the susceptibility to pulmonary injury at lower than expected cumulative doses of bleomycin.

CONCLUSIONS

Modifications of the regimen to reduce toxicity without diminishing the efficacy should be considered before PVeBV is adopted for general use.

Long term results of treatment in patients with extragonadal germ cell tumours

From 1979 to 1991 56 patients with extragonadal germ cell tumours (EGCT) received cisplatin based chemotherapy. From 16 patients with seminomatous EGCT 13 achieved complete remission (CR) with chemotherapy alone, 2 with additional radiotherapy with final CR rate of 94%. 5 (31%) patients developed relapses and at a median follow-up of 38 (5-103) months 11 (69%) are alive and 10 (62%) have no evidence of disease (NED). Only 7 patients with non-seminomatous EGCT reached CR with chemotherapy alone and 8 more with additional chemotherapy or surgery. Overall CR was 37% and 3 (20%) relapses have been observed. At a median follow-up of 26 (3-114) months 14 (35%) are alive and remain free of disease, 26 (65%) have died. By univariate analysis seminomatous EGCT patients had a significantly greater likelihood of achieving a CR, for non-seminomatous EGCT BEP induction chemotherapy was superior to VAB-6, and NSEGCT patients with serum levels > 2000 ng/ml had worse prognosis. Current staging systems are insufficient to predict the treatment outcome in EGCT.

Primary mediastinal germ cell tumors. Results of a French retrospective study

Eighty-seven patients with primary mediastinal germ cell tumors treated between 1983 and 1990 were studied. Among the 23 patients classified as pure seminoma, eight (35 percent) underwent surgery followed by radiotherapy (n = 6), radiotherapy and/or chemotherapy (n = 2); two patients underwent radiotherapy; 13 patients (57 percent) underwent induction cisplatin-based chemotherapy (ten complete responses) followed by radiotherapy (n = 9), second line chemotherapy (n = 2) and surgical resection of residual tumor (n = 2). On completion of treatment, 22 patients (96 percent) with seminoma were free of disease. The two-year Kaplan-Meier survival rate of these patients was 86 percent. Among the 64 patients with nonseminomatous germ cell tumor, 19 patients (30 percent) underwent surgery as first treatment (ten complete resections) followed by chemotherapy (n = 17) and radiotherapy (n = 5). On completion of treatment, 12 of 19 patients were disease free. Forty-five patients (70 percent) underwent induction cisplatin-based chemotherapy (ten complete responses), and 22 of them underwent resection of residual tumor (19 complete resections). Twenty-three patients were treated with first line chemotherapy without postchemotherapy surgery (three complete responses). In summary, 33 patients (52 percent) with nonseminomatous germ cell tumors became free of disease, and seven patients (21 percent) relapsed after achieving a complete response. The two-year Kaplan-Meier survival rate of the nonseminomatous germ cell tumor patients was 53 percent (87 percent if a complete response), with a median survival of 28 months. Despite a worse prognosis than nonseminomaous tumors from other primary sites, this series of mediastinal germ cell tumors has confirmed the efficacy of therapy.

Mediastinal germ cell tumour associated with Klinefelter syndrome. A report of case and review of the literature

A 14-year-old boy with Klinefelter syndrome (KS) and a large mediastinal tumour is presented. Human chorionic gonadotropin and oestradiol were markedly increased. An attempt at radical resection was performed. Histological examination revealed a malignant germ cell tumour of mixed histologic pattern composed of choriocarcinoma and components of mature teratoma. Four courses of cisplatin, bleomycin, and etoposide were given. The patient is without any evidence of tumour recurrence 20 months after diagnosis. A review of the literature revealed another 40 cases of primary mediastinal germ cell tumour (PMGCT) associated with KS. Compiled data from larger series demonstrate that at least 8% of male patients with PMGCT have KS, 50 times the expected frequency. In contrast to PMGCT in patients without KS, all tumours were of nonseminomatous histology, and the average age was considerably lower, Tumours in prepubertal boys were associated with precocious puberty.

Management of extragonadal germ-cell tumors and the significance of bilateral testicular biopsies

Forty-nine patients with assumed extragonadal germ-cell tumors (retroperitoneum: 39, mediastinum: 8, CNS: 2) were included in the present study. The patients were treated with 'high' (40 mg cisplatin/m2 and 200 mg etoposide/m2 daily x 5) or 'conventional' (20 mg cisplatin/m2 and 100 mg etoposide/m2 daily x 5) doses of cisplatin and etoposide together with bleomycin, depending on the presence or absence of poor prognosis factors. Forty-six patients were evaluable for response and 3 patients were classified as non-responders (1 early death, 2 toxic deaths). Eighty percent obtained complete remission and 76% are alive without evidence of disease after a median observation time of 41 months (88% of patients with primary tumor in the mediastinum, 72% with tumor in the retroperitoneal area, 87% of patients with seminoma and 71% with non-seminoma, respectively). In 48 patients testicular biopsies were performed. In 42% of patients with primary retroperitoneal tumors, carcinoma in situ testis (CIS) was diagnosed. None of the patients with tumors in mediastinum or CNS had CIS in the testicles. The therapeutic outcome for patients with extragonadal germ-cell tumors is now similar to that of patients with very advanced testicular cancer when considered in relation to the presence of prognostic factors. The coexistence of CIS and retroperitoneal tumor could indicate that these tumors are not truly extragonadal or that these lesions have a common malignant progenitor.

Does extragonadal presentation impart a worse prognosis to abdominal germ-cell tumours?

The prognostic significance of extragonadal rather than gonadal presentation of germ-cell tumour in 51 patients presenting between 1979 and 1988 with abdominal tumours was compared with that of 51 control patients with testicular primary tumours matched for bulk fo disease, serum tumour marker concentration, age and year of treatment. Very large volume tumour was found at initial staging in 24 extra-gonadal cases (47%) and high tumour markers in 29 (57%). Actuarial survival at 2 and 5 years was 82% and 70% for cases and 78% and 63%, respectively, for controls. These outcomes were not significantly different and the relative hazard of death for cases compared with controls was 0.7 (95% confidence intervals 0.3-1.5). Thus the presentation of germ-cell tumours with a retroperitoneal mass does not itself adversely influence prognosis compared with testicular presentation with equivalent disease extent. However it is rare for extragonadal presentation to be associated with small volume disease.

Extragonadal and poor risk nonseminomatous germ cell tumors. Survival and prognostic features

One hundred forty-nine patients with poor risk nonseminomatous germ cell tumors (NSGCT) treated between 1975 and 1988 were studied. Patients were considered poor risk if they had an extragonadal primary site or testicular NSGCT with low predicted probability of achieving a complete response (CR). Primary sites were the testis (99 patients), retroperitoneum (18 patients), and mediastinum (32 patients). Patients with mediastinal NSGCT had lower human chorionic gonadotropin (HCG) (P less than 0.0001) and lactate dehydrogenase (LDH) levels (P less than 0.0001), and more frequent yolk sac elements (P = 0.002). CR rates were 38% for mediastinal, 61% for retroperitoneal, and 38% for testicular primary sites. Mediastinal NSGCT patients more frequently required resection of residual malignancy to attain a CR (6 of 12). Mediastinal NSGCT had the worst event-free survival (P = 0.02). Cox regression analysis identified brain or liver metastases as the most important predictor of event-free survival in poor risk patients. Retroperitoneal NSGCT often have a poor outcome due to advanced presentation, but the likelihood of a CR to therapy can be predicted using criteria applicable to testicular primary tumors. Therefore, not all retroperitoneal NSGCT are poor risk, and retroperitoneal tumors are probably of occult testicular origin. Mediastinal NSGCT have distinct clinical and pathologic features, do not respond as well to chemotherapy, relapse more frequently, and have the worst survival. The likelihood of a CR cannot be predicted using criteria developed for primary testicular tumors, suggesting that mediastinal primary NSGCT is a distinct clinical entity.