Lymph Node Calcification after Radiotherapy in 2 Cases of Seminoma Testis

The appearance of calcifications in the site of lymph nodes involved by metastases of seminoma testis and irradiated is described in 2 out 59 patients with abdominal metastases (30 were treated more than 5 years ago and 22 of them are alive without evidence of disease).

Survival and Therapeutic Strategy in Germinal Tumors of Testicle

The paper retrospectively reviews the modalities and the long-term results of treatment of 200 consecutive patients with pure seminoma and of 125 patients with testicular carcinomas admitted to the Istituto Nazionale per lo Studio e la Cura dei Tumori of Milan from 1929 to Jan 1973. Radical orchiectomy with high ligation of the spermatic cord at the internal inguinal ring was performed in all previously untreated patients. Those who had had a scrotal operation performed elsewhere were radically reoperated upon. Lymphography and cobalt 60 telecurietherapy were introduced in 1960 and new treatment plans were employed for the irradiation of the deep lymphnodes. Since 1968 all operable carcinomas have undergone bilateral retroperitoneal lymphadenectomy and since 1964 all patients with advanced disease have been treated with chemotherapy (single agent or combination). Survival rates were calculated by the actuarial method. The new treatment modalities proved to be significantly superior to the old ones. In pure seminoma a 92 % cure rate was obtained in NO patients after prophylactic irradiation of retroperitoneal nodes (2,500-3,000 rad in 3 weeks). In N1-3 patients the cure rate was as high as 75% after radical irradiation of retroperitoneal nodes (3,500-4,000 rad in 4 weeks) as well as prophylactic irradiation of mediastinum and both supraclavicular fossae. Extended radical radiotherapy (combined with chemotherapy in some patients) cured 2/6 N4 and 3/8 Ml patients. According to the old modalities of treatment, figures were respectively 72% in NO cases, 40% in N1-3 and 0% in N4 and Ml patients. In carcinomas, the cure rate after retroperitoneal lymphadenectomy was 91% in N–- patients and 47% in N+ cases. In N+ patients post-operative radiation was also performed (4,000-5,000 rad in 5 weeks). After radiotherapy alone (without lymphadenectomy) the rates were 62% in NO and 28% in N1-2 patients. In primary inoperable patients (N3-4 and Ml) chemotherapy, with or without radiation, significantly prolonged the survival rate. It is concluded that radiotherapy is the treatment of choice for pure seminoma and in N4 and Ml cases a full course of chemotherapy must be combined with extensive irradiation. Retroperitoneal lymphadenectomy is mandatory in all operable cases of testicular carcinoma while adjuvant chemotherapy may further improve the prognosis in N+ cases. For inoperable carcinomas chemotherapy (plus radiotherapy) is the treatment of choice. The new multiple drug regimens are providing encouraging results.

Radiotherapy of Seminoma of the Testis. Report on 129 Patients

From 1958 to 1974, 129 patients with pure seminoma of the testis were admitted to the Institute of Radiology, University of Florence. Sixty-two were in Stage I, 36 in Stage II A, 23 in Stage II B, 3 in Stage III, and 5 in Stage IV. Para-aortic and ipsilateral iliac nodes were treated in all cases with doses ranging from 3000 to 4200 rads. In the treatment of the supradiaphragmatic area, uniform criteria were not adopted. Out of 124 cases in Stage I, II A and B, and III, 17 suffered a relapse; all relapsed cases died except for one. Site and cause of the failures were analyzed. Prophylactic irradiation of the mediastinum and supraclavicular area appears to lower the probability of recurrence in Stage II. Doses over 3500 rads may be necessary to destroy large metastases. The presence of nonseminomatous areas in a seminoma showing inadequate regression after radiotherapy must be suspected; an exploratory laparotomy should be indicated in such a case.

Long-term risk of cardiovascular disease in 5-year survivors of testicular cancer

PURPOSE

To evaluate the long-term risk of cardiovascular disease (CVD) in survivors of testicular cancer (TC).

PATIENTS AND METHODS

We compared CVD incidence in 2,512 5-year survivors of TC, who were treated between 1965 and 1995, with general population rates. Treatment effects on CVD risk were quantified in multivariate Cox regression analysis.

RESULTS

After a median follow-up of 18.4 years, 694 cardiovascular events occurred, including 141 acute myocardial infarctions (MIs). The standardized incidence ratio (SIR) for coronary heart disease was 1.17 (95% CI, 1.04 to 1.31), with 14 excess cases per 10,000 person-years. The SIR for MI was significantly increased in nonseminoma survivors with attained ages of less than 45 (SIR = 2.06) and 45 to 54 years (SIR = 1.86) but significantly decreased for survivors with attained ages of 55 years or older (SIR = 0.53). In Cox analysis, mediastinal irradiation was associated with a 3.7-fold (95% CI, 2.2- to 6.2-fold) increased MI risk compared with surgery alone, whereas infradiaphragmatic irradiation was not associated with an increased MI risk. Cisplatin, vinblastine, and bleomycin (PVB) chemotherapy (CT) was associated with a 1.9-fold (95% CI, 1.7- to 2.0-fold) increased MI risk, and bleomycin, etoposide, and cisplatin (BEP) CT was associated with a 1.5-fold (95% CI, 1.0- to 2.2-fold) increased CVD risk and was not associated with increased MI risk (hazard ratio = 1.2; 95% CI, 0.7 to 2.1). Recent smoking was associated with a 2.6-fold (95% CI, 1.8- to 3.9-fold) increased MI risk.

CONCLUSION

Nonseminomatous TC survivors experience a moderately increased MI risk at young ages. Physicians should be aware of excess CVD risk associated with mediastinal radiotherapy, PVB CT, and recent smoking. Intervention in modifiable cardiovascular risk factors is especially important in TC survivors. Whether BEP treatment increases CVD risk should be evaluated after more prolonged follow-up.

[Pure dysgerminoma of the ovary. 12 case reports]

Data from the files of 12 patients with pur ovarian dysgerminoma managed between January 1970 and december 1990 were evaluated. Pur ovarian dysgerminoma accounts for 2% of all ovarian malignancies and 28% of malignant germ cell tumors. A palpable pelvic mass was detected in three-fourth of patients. Echography objective ovarian tumor in all cases. Diagnosis was histological. Primary treatment was surgery followed by radiotherapy in 8 cases and chemotherapy in 2 cases. 2 patients developed local recurrences were irradiated and 1 patient developed distant metastases was given chemotherapy in association to radiotherapy. The 5 years survival rate was 91.7%.

CONCLUSION

Treatment of ovarian dysgerminoma remains controversial. However, patients with stage la who desire further childbearing can be safely treated with unilateral adnexectomy. For all other patients, radical surgery followed by radiation therapy or chemotherapy for the advanced stages and recurrents dysgerminoma is the treatment of choice. Prospective randomized clinical trials are needed for a well codified therapeutic strategy.

Synergism between radiotherapy and vascular risk factors in the accelerated development of atherosclerosis: a report of three cases

Radiotherapy is commonly used in the management of testicular tumors. However, to date the risk of radiation-induced vascular occlusive disease in men following radiotherapy for testicular cancer has not been regarded as a major factor in their long-term care. Several animal studies have shown the importance of established vascular risk factors such as hypercholesterolemia and hypertension in the pathogenesis of radiation-induced atherosclerosis. This report presents three cases of premature chronic iliofemoral arterial disease presenting 5,13, and 16 years following exposure to therapeutic irradiation for the treatment of testicular cancer. The patients were in the age group of 40-45 years and all demonstrated associated known atherosclerotic risk factors. The patients had received radiotherapy in the dose of 3,500-4,000 rads in a standard "dog-leg" fashion to the ipsilateral aortoiliac lymphatic chain. Our results showed that young men treated with radiotherapy for testicular cancer may be targeted from the outset for atherosclerotic risk factor reduction to minimize the risk of development of late chronic occlusive arterial disease. It may be that a cohort of men so treated with historical regimes of radiotherapy and now entering middle age should be screened for arterial disease and risk factor reduction.

Spontaneous pregnancy after 13 years of amenorrhea in a patient with a voluminous ovarian dysgerminoma and submitted to left adnexectomy and radiotherapy

The authors illustrate the case of a 17-year-old patient who was submitted to left adnexectomy in view of an ovarian dysgerminoma 24 cm in diameter and weighing 2,800 g. She was subsequently submitted to two cycles of radiotherapy. Following a period of amenorrhea lasting 13 years and characterized by high serum levels of gonadotropins, the patient had a spontaneous pregnancy and at 33 weeks of gestation delivered a live and vital fetus. Therefore the occurrence of post-radiotherapy amenorrhea, characterized by high serum gonadotropin levels, should not always be considered pathognomonic of precocious menopause. The possibility that radiotherapy causes only a temporary alteration in ovarian activity should also be taken into consideration.

[Central nervous system. Experience of the Bordeaux University Hospital Center and review of the literature]

PURPOSE

Retrospective analysis of 17 patients with intracranial germ cell tumors treated in a multidisciplinary consultation at the Bordeaux University Hospital a and literature review.

MATERIALS AND METHODS

Seventeen consecutive patients were treated from 1978 to 1995 for a primary intracranial germ cell tumor. Median age was 14 (range 3-29 years). There were two malignant teratoma, six proved germinoma and nine presumed germinoma (diagnostic based on biological, radiological and treatment criteria). All received radiotherapy from 30 to 60 Gy (median 40 Gy) in different volumes. Chemotherapy was administered in 15 cases, three after surgery and 12 after radiotherapy.

RESULTS

All tumours were in complete remission after initial treatment. The two malignant teratomas recurred in non-irradiated area after nine and 48 months, and the patients died. None of the germinoma recurred within a follow-up period of two to 17 years (median 65 months). Five and 10 year actuarial overall survival rates were the same: 84% for all histologies and 100% for germinomas. Only two patients developed school difficulties and six presented an hypopituitarism, of which one was consecutive to radiotherapy. Chemotherapy was well tolerated.

CONCLUSION

This retrospective study and literature analysis are in favor of limited dose and volume of radiation therapy associated with chemotherapy.

Fertility results after ovarian transposition for pelvic malignancies treated by external irradiation or brachytherapy

The aim of this study was to assess the fertility outcome after ovarian transposition with uterine conservation and pelvic irradiation therapy for pelvic cancer. A total of 37 consecutive cases were reviewed. Of these, 27 patients were treated for a clear cell adenocarcinoma of the vagina and/or the cervix (group 1), nine for an ovarian pure dysgerminoma and one for a para-uterine soft tissue sarcoma (group 2). The pregnancy rate was 15% (4/27) in group 1 and 80% (8/10) in group 2 (P=0.01). A total of 18 pregnancies was observed in 12 patients. Of these, 16 pregnancies were obtained spontaneously and two after in-vitro fertilization. Of the spontaneous pregnancies, 12 (75%) were observed with ovaries still in the abdominal cavity (not repositioned). These results show that the prognosis for fertility is excellent after ovarian transposition and irradiation in patients with morphologically normal genital tracts (group 2). The prognosis is not as good for patients treated for a clear cell adenocarcinoma of the vagina and/or the cervix who may have morphological and/ or functional anomalies of the genital tract, following exposure to diethylstilboestrol and brachytherapy (group 1). Furthermore, these results show that repositioning of the ovary is not essential to achieve pregnancy.

Dysgerminoma of the ovary: a retrospective study

A retrospective analysis of 22 patients with ovarian dysgerminoma who were treated between 1980 and 1987 was carried out. The median age at presentation was 24.5 years. A total of 15 patients were in stage I, one patient was in stage II and six patients were in stage III. Bilateral ovarian involvement was present in four patients. Conservative surgery was carried out in nine patients and 11 patients underwent radical surgery. Two patients had biopsy only. Fourteen patients received adjuvant radiotherapy and three patients received salvage radiation for recurrent disease. The 10-year actuarial survival rate was 81.8%. All 15 patients in stage I were alive and disease-free at a median follow-up of 125 months. Four patients (one in stage II and three in stage III) died of progressive or recurrent abdominopelvic disease. Pelvic recurrence occurred after conservative surgery in two patients in stage IA who had a tumour size greater than 10 cm, but they were salvaged with radical surgery, chemotherapy and radiotherapy. There were seven patients aged 20 years or less. All were alive and disease-free at a median follow-up of 127 months.

Organ preservation in the treatment of brain tumors

Within the many histological forms, the preservation of function in the central nervous system has always been predominant. However, the limited or null therapeutic interval for high grade gliomas enables organ preservation in small neoplasms only. In case of favorable histology (e.g. dysgerminoma, low grade small glioma), organ preservation is feasible with adequate techniques. When local control is predominant (e.g. neoplasms of eye) the techniques are long known but applied in very few Centers.

Dysgerminoma: the role of conservative surgery

Twenty-five cases of pure ovarian dysgerminoma treated at UCLA Medical Center between 1958 and 1992 were reviewed retrospectively. Patterns of recurrence and overall survival were analyzed with regard to primary surgery (conservative versus nonconservative), use of adjuvant therapy, and stage of disease. Fourteen patients (56%) underwent conservative surgical therapy defined as preservation of the contralateral ovary, 10 patients (40%) had nonconservative primary surgery, and one patient (4%) had chemotherapy as primary treatment. Three patients (12%) received adjuvant chemotherapy and nine patients (36%) received postoperative radiation therapy. Fifteen patients (60%) had stage I disease, four (16%) stage II, and three each (12%) had stage III and IV disease. Nine patients (36%) experienced recurrence of disease. Seven of these nine patients (78%) had stage I disease and all seven had undergone conservative primary surgery with preservation of the contralateral ovary. Six of the seven had received no adjuvant therapy. Only one of these seven patients experienced recurrence in the preserved ovary. She was found to have a dysgenetic ovary and an XY karyotype. Three patients with recurrent disease had received radiation therapy after primary surgery. Twenty patients (80%) were alive without disease at follow-up, two patients (8%) were alive with disease, and three (12%) had died of disease. There was no statistically significant difference in recurrence rates between those patients treated with conservative surgery and those treated with nonconservative surgery, although the total number of patients with recurrences was greater in the former group. Our data suggest that a conservative surgical approach is the preferred treatment in patients with pure dysgerminoma of the ovary who desire future fertility. Lack of adjuvant chemotherapy or radiation therapy, rather than type of initial surgery, may be associated with a higher risk of recurrence.

Poikilothermia in a female patient with a germinoma in the basal ganglia

An unusual association of poikilothermia and a germinoma originating in the left basal ganglia is described in a 17-year-old female. The tumour was found extending into the hypothalamic structures. Following irradiation therapy, the patient gradually regained her regulation of body temperature.

Prognosis of human chorionic gonadotropin-producing seminoma treated by postoperative radiotherapy

PURPOSE

To clarify the controversy about the management and prognosis of human chorionic gonadotropin-producing seminoma, the records of 132 patients with abnormal human chorionic gonadotropin values treated with radiotherapy were analyzed.

METHODS AND MATERIALS

The records of 1169 patients with pure seminoma treated in 10 institutions were screened for serum or urinary human chorionic gonadotropin. One hundred and thirty two patients with elevated human chorionic gonadotropin were found: 96 Stage I, 20 IIA, 7 IIB, 8 III and 1 IV. Median age was 34 y., mean follow-up was 5.0 years [range 1-12 y]. All received infradiaphragmatic radiotherapy (median dose 30 Gy), 25 (2 Stage I, 11 IIA, 5 IIB and 7 III) supradiaphragmatic radiotherapy (median dose: 28.5 Gy) and 10 had also initial chemotherapy (3 Stage IIB 6 III and 1 IV). Patients were allocated to three groups according to human chorionic gonadotropin values: (a) moderate elevation: up to 10 times (104 pts), (b) high elevation: 10 to 100 times (20 pts), (c) very high elevation: over 100 times the upper limit of normal value (8 pts).

RESULTS

The proportion of Stage I, II and III was 76%, 19%, 5% in the ME group versus 50%, 35%, 15% in the high elevation group (p < 0.05). In the very high elevation group there were 7 Stage I and 1 Stage IV. Of 132 patients, six died (three dead of disease, two suicides, one acquired immunodeficiency syndrome). The 5 years overall survival probability was 94%. There were seven recurrences (initial stage: 1 Stage I, 2 IIB, 3 III and 1 IV). Of these, there were one in-field recurrence, 3 out of field and 3 in both sites. In 5 of 7, the human chorionic gonadotrophin level was again elevated at recurrence. The 5 years recurrence-free-survival probability was 94% (98% for Stage I, 100% for Stage IIA and 65% for Stage IIB and III [p < 0.001 between I and IIB + III, p < 0.05 between IIA and IIB + III]). Four of the 7 recurrences were salvaged by chimiotherapy +/- radiotherapy. In the high elevation and very high elevation groups, the 5 years recurrence-free-survival was 88%, vs. 96% for the moderate elevation group (p = 0.10).

CONCLUSION

Based on this series of patients, human chorionic gonadotropin production is not an unfavorable prognostic factor in pure seminoma. Even in the subgroups with high or very high human chorionic gonadotropin levels (who had a higher proportion of advanced stages), the prognosis remained excellent. In Stage I and IIA seminoma with abnormal human chorionic gonadotropin levels, recurrence rate after post-operative radiotherapy alone is extremely low.

Renal tolerance to nonhomogenous irradiation: comparison of observed effects to predictions of normal tissue complication probability from different biophysical models

PURPOSE

A patient series was analyzed retrospectively as an example of whole organ kidney irradiation with an inhomogenous dose distribution to test the validity of biophysical models predicting normal tissue tolerance to radiotherapy.

METHODS AND MATERIAL

From 1969 to 1984, 142 patients with seminoma were irradiated to the paraaortic region using predominantly rotational techniques which led to variable but partly substantial exposure of the kidneys. Median follow up was 8.2 (2.1-21) years and actuarial 10-year survival (Kaplan-Meier estimate) 82.8%. For all patients 3-dimensional dose distributions were reconstructed and normal tissue complication probabilities for the kidneys were generated from the individual dose volume histograms. To this respect different published biophysical algorithms had been introduced in a 3-dimensional-treatment planning system.

RESULTS

In seven patients clinical manifest renal impairment was observed (interval 10-84 months). An excellent agreement between predicted and observed effects was seen for two volume-oriented models, whereas complications were overestimated by an algorithm based on critical element assumptions.

CONCLUSIONS

Should these observations be confirmed and extended to different types of organs corresponding algorithms could easily be integrated into 3-dimensional-treatment planning programs and be used for comparing and judging different plans on a more biologically oriented basis.

Treatment of stage I testis seminoma by radiotherapy: long-term results--a 30-year experience

PURPOSE

From 1956 to 1986, we have retrospectively studied 184 patients with a Stage I testis seminoma treated by orchidectomy and radiotherapy at the Institut Gustave Roussy.

METHODS AND MATERIALS

The 184 patients received adjuvant radiotherapy to the para-aortic and ipsilateral iliac nodes. Of the 184 patients, 133 received additional mediastinal and supraclavicular irradiation, 47 received supraclavicular without mediastinum irradiation, 98 patients received additional radiotherapy given to inguino-scrotal area. The mean dose of irradiation is 21 Gy which is the lowest dose published. The actuarial survival rate is, respectively, 96%, 93%, 83% and 77% at 5, 10, 15, and 20 years.

RESULTS

Four patients relapsed, and four died of progressive disease. Four patients presented cardiovascular disease, all of them had mediastinal irradiation, two were heavy smokers. Seventeen second malignancies were observed, six tumors in the contralateral testis. The actuarial risk of developing a second malignancy is 10% at 10 years, 21% at 20 years. The cure rate and relapse rate in our patients is the same as that obtained by higher dosage of irradiation.

CONCLUSION

We conclude that low dose of prophylactic irradiation in lumbo aortic and ipsilateral iliac lymph nodes is active and safe in the treatment of Stage I testis seminoma.

[A case of complete response with radiation and chemotherapy using cisplatin, etoposide and bleomycin]

A 37-year-old man, who had been treated with inguinal orchiectomy and radiotherapy of retroperitoneal and iliac lymph node for r-testicular tumor 6 months earlier, was admitted with a complaint of left leg pain in May 1992. CT scan of pelvic bone revealed osteolytic change of left pubic bone with soft tissue mass. Bone scintigram showed significant uptake of radioisotope on left pubic bone. Biopsy of left pubic bone confirmed histologic findings compatible with that of previous testicular cancer. He was treated with PEB chemotherapy (CDDP, Etoposide and Bleomycin) and radiation therapy. After treatment, the majority of the tumor mass disappeared on CT scan. On repeat biopsy specimens, significant fibrotic change was observed and no cancer cells were recognized. He is alive with no evidence of disease.

Results of a policy of surveillance in stage I testicular seminoma

PURPOSE

To determine what proportion of patients with Stage I testicular seminoma will be cured with orchidectomy alone.

METHODS AND MATERIALS

From August 1984 to December 1991 148 patients with Stage I testicular seminoma were entered on a prospective study of surveillance following orchidectomy. The eligibility criteria included a normal chest X ray, lymphogram, computed tomography (CT) of the abdomen and pelvis, and normal post-orchidectomy tumor markers (AFP and BHCG). Patients were followed with a clinical assessment (markers, chest X ray and CT abdomen and pelvis) at 4 to 6 monthly intervals.

RESULTS

With a median follow-up of 47 months (range 7-87 months), the actuarial relapse-free rate was 81% at 5 years. Twenty-three patients have relapsed with a median time to relapse of 15 months (range 2-61 months). Four patients (17%) relapsed at 4 or more years from diagnosis. Twenty-one of the 23 relapses occurred in the paraaortic lymph nodes, one patient relapsed in the mediastinum and ipsilateral inguinal nodes and one patient had an isolated ipsilateral inguinal node relapse. Nineteen patients were treated for relapse with external beam radiation therapy of which three developed a second relapse and were salvaged with chemotherapy. Four patients were treated for first relapse with chemotherapy and one developed a second relapse and died of disease. Age at diagnosis was the only prognostic factor for relapse, with patients age < or = 34 having an actuarial relapse-free rate at 5 years of 70% in contrast to a 91% relapse-free rate in those > 34 years of age.

CONCLUSIONS

We recommend that surveillance in Stage I testicular seminoma should only be performed in a study setting until further data regarding the risk of late relapse and the efficacy of salvage chemotherapy is available.

Prognosis of intracranial germ cell tumours: effectiveness of chemotherapy with cisplatin and etoposide (CDDP and VP-16)

A co-operative study for patients with intracranial germ cell tumours was performed to analyze their prognosis and the effectiveness of Cisplatin/Etoposide (CDDP/VP-16) chemotherapy. A total of 46 patients; 30 primary and 16 recurrent cases were registered from 15 participating neurosurgical institutions in Japan. Based on histological criteria and tumour markers, they were classified into three groups; germinoma, germinoma with syncytiotrophoblastic giant cell (STGC), and non-germinomatous malignant tumour. Sixteen patients were treated with CDDP/VP-16 chemotherapy alone and the other 30 patients were treated by a combination of surgery and/or radiation in addition to chemotherapy. Eleven out of 13 patients (85%) with germinoma showed a complete (n = 10) or partial (n = 1) response to CDDP/VP-16 chemotherapy even if their tumours were recurrent and there was evidence of CSF dissemination. For the germinoma with STGC and non-germinomatous malignant tumour, a high response rate; 100% for the former and 78% for the latter, could also be achieved in both the primary and the recurrent cases except in those cases of immature teratoma. Their survival times were still different between them. Two-year survival was 50% in germinoma with STGC and 48% in non-germinoma, while it was 88% in germinoma cases.

[Improved prognosis of intracranial germ cell tumors by intensified therapy: results of the MAKEI 89 therapy protocol]

Germ cell tumors of the central nervous system are histological identical to the extracranial tumor sites. According to the localisation germ cell tumors of the CNS are different in symptoms, diagnostic approaches, kind and location of metastases and stratification of therapy. Since 1986 patients with intracranial germ cell tumors are registered in the ongoing study for non-testicular germ cell tumors (MAKEI) of the German Society of Pediatric Oncology and Hematology, and are treated in accordance to therapy guidelines for extracranial sites. In MAKEI 89 therapy strategy was revised with a reduction of radiotherapy and an increased cumulative cisplatinum dose from 200 mg/m2 to 400 mg/m2. Patients with germinoma receive after histologic diagnosis radiotherapy consisting of 30 Gy craniospinal irradiation and 15 Gy tumorboost. Malignant non-germinoma receive after diagnosis by tumor marker in CSF and/or serum 2 courses bleomycin 15 mg/m2 day 1-3, Etoposide 150 mg/m2 day 1 + 2 and cisplatinum 20 mg/m2 days 4-8 (BEP), continued by 2 courses Vinblastine 3 mg/m2 day 1 + 2, Ifosfamide 1500 mg/m2 days 1-5 and cisplatinum 20 mg/m2 days 1-5 (VIP), followed by 30 Gy craniospinal irradiation and 20 Gy tumor boost. In teratoma first line therapy is complete resection. In incomplete resected cases adjuvant chemotherapy according to histological grading is administered. Until 31st January, 1993 101 patients (pts) were registered, containing 69 protocol pts. Diagnosis in protocol pts was teratoma in 8 cases, 2 pts died postnatal because of extended disease, 2/8 pts relapsed, but were salvaged by chemotherapy. 40 pts offered germinomas.(ABSTRACT TRUNCATED AT 250 WORDS)

Postirradiation sarcoma in a patient treated for testicular seminoma

A patient with a sarcoma of the left groin at a site where a prior seminoma had been irradiated is presented. Very few postirradiation sarcomas are described in patients treated with radiation therapy for testicular cancers, even if an increased risk of second malignancies has been reported. In contrast with the highly aggressive clinical course of postirradiation sarcomas, an early discovery of the lesion allowed a radical surgical approach with a presumable cure of the patient. A continuous and precise follow-up of patients irradiated for seminoma is suggested.

Testicular seminoma stage I: treatment results and long-term follow-up (1968-1988)

Sixty-nine patients with stage I testicular seminoma were referred to the Northern Israel Oncology Center between 1968 and 1987. Sixty-four patients were irradiated postoperatively and five patients had surveillance alone. Complete follow-up was available for all patients, with a median follow-up of 86 months (range 9-239 months). The last follow-up was in December 1988. Actuarial survival was 94% to 5, 10, 15, and 20 years. Six patients relapsed following completion of irradiation. All the recurrences occurred outside the radiation field. Three of the relapsed patients could be salvaged with cisplatinum-based chemotherapy and are alive at 4, 7, and 10 years following second-line treatment. Acute or chronic side effects were mild and manageable. Seven patients developed second primary cancers, two within and six outside the radiation field. While surveillance policy alone in stage I testicular seminoma may be successful in terms of patient outcome, it requires prolonged observation, good compliance of patients, and intensive use of resources. Thus, until proved otherwise, infradiaphragmatic radiotherapy should further remain the optimal routine treatment in seminoma patients with stage I disease.

Post-orchiectomy radiotherapy for stages I and II testicular seminoma

PURPOSE

In 1984 the following changes were made in the management of testicular seminoma at The University of Texas M.D. Anderson Cancer Center: (1) abdominopelvic computerized tomography replaced the bipedal lymph-angiogram for evaluating retroperitoneal nodes; (2) elective mediastinal radiation was totally abandoned; (3) patients with abdominal adenopathy < 10 cm were classified as having Stage IIA disease. This report evaluates the impact of these management policy changes on disease outcome.

METHODS AND MATERIALS

Between 1960 and 1991, 350 patients with Stages I or II testicular seminoma received post-orchiectomy radiation. The 241 patients treated prior to 1984 constitute our old series, and the 109 patients treated since then are our new series. The outcomes in the new series were compared to those in the old series.

RESULTS

The distribution of patients by stage was Stage I, 282 (old series, 190; new series, 92); Stage IIA, 55 (old series, 39; new series, 16); Stage IIB, 13 (old series, 12; new series, 1). The freedom-from-relapse at 5 years correlated with stage: Stage I, 97%; Stage IIA, 87%; Stage IIB, 69%. Elevated post-orchiectomy chorionic gonadotropin levels or involvement of the spermatic cord were adverse for disease relapse in Stage I but not Stage II disease. Patients with Stage I disease fared extremely well in both series (freedom-from-relapse 97%); the outcome for patients with Stage IIA was significantly worse in the new series (5-year freedom-from-relapse 73% vs. 92%) because of a 20% actuarial incidence of apparently solitary left supraclavicular nodal relapse. Although elective mediastinal radiation in the old series prevented this failure pattern, such treatment appeared to significantly decrease the survival of patients older than 40 years.

CONCLUSIONS

(1) Abdominopelvic computerized tomography scanning is adequate for the evaluation of abdominal lymph nodes in patients with seminoma; (2) Post-orchiectomy radiation to the para-aortic and ipsilateral hemipelvic regions remains the treatment of choice for patients with Stage I disease; (3) Patients with Stage IIA disease experience a 20% relapse rate especially in the left supraclavicular fossa and we recommend elective radiation to this site delivered concomitantly with para-aortic irradiation.

Static and dynamic vascular impact of large artery irradiation

PURPOSE

To evaluate functional post-radiotherapy arterial change in a select patient population.

METHODS AND MATERIALS

Thirty-five seminoma patients were identified in the Radiation Oncology departmental records at Indiana University Medical Center. In this group the ipsilateral pelvis is treated with the contralateral pelvis available for evaluation as a matched control. Additionally, this group is generally young and unlikely to have pre-existing vascular disease, and shows excellent radiocurability with historically standard radiotherapy. Nineteen patients volunteered for a noninvasive vascular evaluation which included: Doppler ultrasound, segmental leg pressures, pulse volume recordings, and post-exercise testing. Average age at treatment was 36 (range 14-68) with an average follow-up of 8.8 years (range 1-20) with five patients now over 15 years post-treatment. The majority of the patients received 2500-2600 cGy.

RESULTS

Three of 19 patients had abnormal vascular evaluations. Of these, two had bilateral abnormalities not felt to be solely associated with irradiation. The remaining patient showed both resting and post-exercise ipsilateral vascular abnormalities. Irradiation was the only identifiable etiologic agent for this patient's vascular abnormality.

CONCLUSION

Subclinical vascular change attributable to low dose radiotherapy was identified in one of 19 patients (5%). Considering the radiocurability of seminoma patients this incidence is acceptable. In light of this slight, yet documented, arterial abnormality occurring with low dose radiotherapy, we recommend additional study of high dose radiotherapy patients to determine the incidence and morbidity of radiation-induced arteriopathy in this group.

Post-orchiectomy management in stage I testicular seminoma: elective irradiation or surveillance?

Fifty-six patients with stage I testicular seminoma were treated at this institute between January 1982 and December 1988. Post-orchiectomy elective radiotherapy to ipsilateral iliac-inguinal and para-aortic lymph nodes was delivered in 54 cases. An overall 3 year survival rate of 96% was observed in this series. Four patients (7%) relapsed (one junctional recurrence in iliac node region, two mediastinal/hilar nodes and one skeletal metastasis). Salvage chemotherapy proved successful in two out of three cases with nodal relapse. No dose limiting acute or late radiation related complications were noticed. No definite correlation was found between the patients who relapsed and various known adverse prognostic factors. We recommend elective irradiation of the draining lymph nodes in stage I seminoma, particularly at centres where surveillance is not feasible.

Does decreased skeletal uptake of 99mTc-methylene bisphosphonate in irradiated bone indicate the absence of bone metastases?

Reduced uptake of 99mTc-methylene bisphosphonate (99mTc-MBP) was found in irradiated bone in all of 13 tumour-free patients who had undergone radiotherapy (30-40 Gy) due to seminoma 3-8 years prior to bone scintigraphy. Decreased uptake of 99mTc phosphate compounds can not per se be interpreted as a sign of absence of metastases or reduced tumour burden.

[Is lymphography still relevant in seminoma?]

In the radiotherapist's point of view lymphography and computed tomography scan compete for staging and therapy planning of testicular seminoma. We investigated whether lymphogram can be replaced by computed tomography scan. 114 patients with histologically confirmed seminoma of the testis were treated by radiotherapy at the Nürnberg Community Hospital (n = 65) and the University of Erlangen (n = 49) from 1978 through 1991. Radiological staging included both computed tomography scan and lymphography in all cases. The results of both methods were similar in 79%. Computed tomography scan led to an upstaging in 4% while lymphography was negative. 17% of the patients showed negative results considering computed tomography scan while lymphogram was positive. In accordance with these data treatment portals or doses were altered in 21%. Using the M.D. Anderson Hospital clinical staging system a stage IIa (micrometastasis < 2 cm) is not safely identified by computed tomography scan. Just lymphography can safely identify a stage IIa patient. On the other hand, lymphography shows a very high amount of false positive interpretations. However, two conclusions are made: 1. Using a conventional technic (radiation of para-aortal and ipsilateral iliac region, dose about 30 Gy HD) lymphogram can be superseded by computed tomography scan. 2. In the case of reducing treatment volume and/or dose lymphogram should be added to computed tomography scan.

Radiotherapy and chemotherapy in testis tumors

Testis tumor is rare but interesting tumor as it is a true model of curable solid tumor in adults. The use of chemotherapy constitutes one of its most successful applications. Seminoma are characterized by a great sensitivity to radiation which remains the additional adjuvant treatment for early tumors. For dysgerminoma, the authors discuss the wait and see policy for early tumors and the role of chemotherapy for advanced diseases.

Surveillance in stage I seminoma of the testis

In a health care system with adequate personnel and resources, careful surveillance, rigorously performed, following guidelines set out in the prospective trials is an appropriate alternative to adjuvant irradiation for patients with stage i seminoma of the testis.

Pancreatic insufficiency secondary to abdominal radiotherapy

Delayed post-irradiation steatorrhoea secondary to acute pancreatic insufficiency is rare. We describe a case occurring in a patient 23 years following radical abdominal radiotherapy for testicular seminoma.

Increased incidence of sarcoma in patients treated for testicular seminoma

In a nationwide cancer registry analysis of second primary malignancies in 6187 men with testicular cancer in the period 1943-1987, 13 sarcomas were found, yielding a 4-fold increase of the relative risk (RR). The majority of sarcomas occurred in men with seminoma, and the increased incidence was seen irrespectively of time since the diagnosis of testicular cancer. The interval between the testicular cancer and the sarcoma varied from 5-34 years. After investigation of the hospital records and re-examination of the histological specimens, 3 patients were excluded. In spite of this, the RR was still considerably increased (at least 3-fold). Seven of the 10 sarcomas were found to be located within the field of the radiation treatment administered and three at the periphery. The absolute number of these secondary sarcomas is low, but the risk of developing such neoplasms and other malignancies should, even so, be kept in mind in the follow-up of testicular cancer patients.

[Organ saving therapy of bilateral testicular tumor]

Of 368 patients with unilateral testicular cancer, 12 (3.3%) suffered from a second malignant germ cell tumor; five tumors occurred synchronously, seven were treated by bilateral orchiectomy, five were treated by unilateral organ sparing surgery with enucleation of the germ cell tumor in a pilot study. Enucleation was performed for four seminomas and one embryonal carcinoma; an associated carcinoma was found in situ in three cases. The average follow-up time for patients treated conservatively is 22 months; no local recurrence has been detected. Testosterone synthesis is sufficient to obtain normal serum androgen levels. Organ sparing surgery for testicular cancer is possible if the following prerequisites are met: pT 1-tumor, no infiltration of the rete testis, biopsies of the tumor bed are negative, biopsies from peripheral parenchyma are taken and any associated carcinoma in situ is irradiated with 20 Gy.

[Is organ saving surgery of testicular tumor justified?]

Eight patients with malignant germ cell tumours of residual testes had organ-conserving surgery. The largest diameters of the tumours were 9-32 mm. In seven patients conservation of the organ was successful without local or systemic progression (n = 5), two patients needed chemotherapy for concurrent or subsequent metastatic spread. In one case the testis had to be removed because of functional loss. Improved surgical techniques and increased knowledge of the importance and treatment of testicular intraepithelial neoplasm (carcinoma in situ) made this approach of enucleating resection possible; it permits the maintenance of endogenous androgen production in a small group of patients. The generally good prognosis of malignant testicular tumours means that in certain circumstances surgical treatment of the primary tumour can be limited.

Radiotherapy of germinomas involving the basal ganglia and thalamus

Nine patients with histologically confirmed germinomas of the basal ganglia and thalamus (GBT) were treated by radiotherapy. The average dose of 52.5 Gy was delivered to the tumor bed, 37 Gy to the whole brain and 24.8 Gy to the CNS axis. The local control, which was verified by CT scan, was achieved in all patients. All patients are alive 11 to 96 months after radiotherapy. As with other intracranial germinomas, geminomas of the basal ganglia and thalamus respond well to radiotherapy and the prognosis is good after treatment.

[Surveillance after orchiectomy for stage I testicular seminoma]

The results of treatment by orchiectomy and radiotherapy for stage I testicular seminoma are excellent with cure rates exceeding 95% and relapse rates less than 5%. However, after the development of successful surveillance programs for stage I nonseminomatous testicular cancers, the role of radiotherapy has been questioned by some authors and they proposed a "surveillance policy" for these patients. The purpose of this study was to determine the percentage of patients cured by orchiectomy alone, percentage who ultimately required therapy for occult metastases, site of recurrence, and over-all cure rate and treatment morbidity. And these data were compared with those of adjuvant radiotherapy group retrospectively. Twenty seven patients were treated with adjuvant radiotherapy (RT group). Since 1986, 23 patients with stage I testicular seminoma entered the "surveillance only" protocol at our institution (S group) with a follow-up between 14 and 70 months (median 43 months). Informed consent for the policy of surveillance was obtained. Follow up consisted of physical examination, determination of serum tumor markers and chest X-ray bimonthly for 2 years, every 3 months for 1 year, every 6 months for 2 years and annually thereafter to 10 years. CT scans were performed every 4 months for 3 years, every 6 months for 2 years. Two patients in S group (8.7%) relapsed at 4 and 7 months after orchiectomy with nonbulky retroperitoneal disease (less than 5 cm in diameter), whereas only 1 (3.7%) irradiated patients did so after 4 months.

Orchidectomy followed by radiotherapy in 176 stage I and II testicular seminoma patients: benefits of a 10-year follow-up study

Results are presented for 176 patients with stage I and II primary testicular seminoma treated at the Dr. Daniel den Hoed Cancer Center (DDHCC) between 1975 and 1985. The median follow-up time was 7 years and 4 months. One-hundred and seventy-four (99%) of these patients were treated primarily with radiotherapy after extensive staging. According to the Royal Marsden Staging Classification, 132 patients (75%) were stage I, 8 (5%) were stage IIA, 21 (12%) were stage IIB, 9 (5%) were stage IIC and for 6 stage II patients a further subdivision was not possible. At 5 years the actuarial relapse-free survival and the actuarial survival were 95 and 99%, respectively, for stage I, and 77 and 91% for stage II. Prophylactic irradiation of the mediastinum has not been performed for stage II patients. Five stage II patients relapsed in the mediastinum. Four out of these five relapses were cured with chemotherapy, and in one case, in combination with radiotherapy, at the time of relapse. These results indicated that prophylactic irradiation of the mediastinum appeared to be unnecessary for stage II patients. Tumour markers were not useful in the discovery of metastases. Five years after treatment no relapses were seen. Therefore, it is proposed that a maximum follow-up of 5 years is sufficient to measure disease-free survival.

Humoral hypercalcemia associated with a dysgerminoma

A 16-year-old girl sought medical attention at the Mayo Clinic because of a 4.5-kg weight loss, hypercalcemia, and a pelvic mass. Preoperatively, the level of the beta-subunit of human chorionic gonadotropin was 147 IU/liter. After a brief period for observation and hydration, abdominal exploration revealed a stage III dysgerminoma; total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. Within the dysgerminoma, syncytial giant cells expressed human chorionic gonadotropin-positive immunostaining in the cytoplasm. Postoperatively, the value of the beta-subunit of human chorionic gonadotropin decreased rapidly. The patient received whole-abdomen irradiation 4 weeks postoperatively, after which the level of calcium returned to normal. The patient has been free of disease for more than 7 years.

Value of retroperitoneal lymph node dissection in advanced testicular seminoma

Seven patients with advanced seminoma of the testis (stages II C and III) were treated with 3 induction cycles of VAB-6 chemotherapy. Three patients had complete remission after chemotherapy and are alive disease free at 32, 38, and 40 months with no additional treatment. Four patients were subjected to retroperitoneal lymph node dissection for residual retroperitoneal masses measuring 2-4 cm after chemotherapy, which revealed fibrosis in 2 patients and metastatic seminoma in the other 2. Patients with metastatic residual masses were given postoperative radiation therapy to the retroperitoneum and are alive disease free at 33 and 34 months, while those with fibrosis are alive disease free at 30 and 52 months, respectively, with no additional treatment.

Stage I seminoma of the testis: is post-orchidectomy surveillance a safe alternative to routine postoperative radiotherapy?

Experience with the management of 128 patients with Stage I testicular seminoma over a 10-year period, 1980-1989, is presented. Fifty-six patients were treated with post-orchidectomy radiation therapy and 72 patients were put on surveillance. Patients thought to be at higher risk of relapse were generally treated with radiotherapy. There have been no tumour related deaths in this series; 5.4% of the irradiated group and 18% of patients on surveillance have relapsed to date. All relapses have been salvaged with further therapy and are currently in complete remission. In this interim analysis, surveillance appears to be a safe alternative to adjuvant radiation therapy provided regular, prolonged follow-up can be ensured. Surveillance is, however, time consuming and resource demanding, and should be undertaken only as part of a formal clinical study. Adjuvant post-orchidectomy radiotherapy should be considered the treatment of choice until further long-term data are available.

The role of radiotherapy in the treatment of primary mediastinal seminoma

Nine patients with primary mediastinal seminoma were treated with radiotherapy. All patients achieved complete response on chest radiography. None of the three patients treated with whole mediastinal irradiation relapsed. Four of the six patients with involved-field irradiation had marginal relapses, suggesting the efficacy of the whole mediastinal irradiation.

The role of radiotherapy in patients with advanced seminomatous germ cell tumors. Controversies in management. Part 2

The role of radiotherapy in the management of advanced seminomatous germ cell tumors remains controversial. The authors review the available literature, and recommend radiotherapy for stage II seminoma with bulky abdominal metastases (greater than 10 cm) under the following circumstances: As primary therapy only if the patient cannot or will not be treated with chemotherapy; as an adjuvant following chemotherapy in patients with residual masses of any size. Similar recommendations are made regarding the role of radiotherapy in the management of extragonadal seminoma outside the central nervous system.

The recurrence of primary intracranial germinomas. Special reference to germinoma with STGC (syncytiotrophoblastic giant cell)

Twenty three cases of primary intracranial germinomas including five cases of germinomas with syncytiotrophoblastic giant cells are studied and analyzed, with special reference to the recurrence under radiotherapy. The follow-up period for all cases was 7 months to 12 years (average: 5.8 years) with that for pure germinomas ranging from 8 months to 12 years (average: 5.7 years) and that for germinomas with syncytiotrophoblastic giant cells ranging from 7 months to 11 years (average: 6.3 years). Late recurrence was observed in three cases (3/23, 13%), developing outside of the initial irradiation field. With regard to recurrence, significant correlation to radiation fields was evident, while it was not to radiation doses. Furthermore, germinoma with syncytiotrophoblastic giant cells showed a more significant tendency to recur than pure germinoma. The radiotherapy of germinomas is discussed and the clinical features of germinoma with syncytiotrophoblastic giant cells are presented.

Post radiation monomelic amyotrophy

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[Radiation therapy of intracranial germinoma]

The appropriate radiation dose and field for the treatment of intracranial germinoma were investigated in 33 patients. Recurrences were observed in 4 cases treated with local field irradiation only, and all of them were recognized at the margin of the radiation field or under the dose (less than 25 Gy) area. This suggests that whole cranial irradiation (dose of 25 to 30 Gy) should be added even if the tumor is solitary. The effective dose for cerebrospinal dissemination appears to be 25-35 Gy, but prophylactic CNS irradiation seems unnecessary for patients who have not undergone surgical procedures. Changes in mental status were seen in 5 patients (26.3%). Doses of over 59 Gy may be related to this complication.

Radiation therapy for testicular seminoma: controversies in the management of early-stage disease

Subdiaphragmatic irradiation remains the standard treatment for patients with stage I and IIA testicular seminoma. Elective mediastinal irradiation is not indicated. In well-selected patients with stage I disease, aggressive surveillance may be a reasonable alternative to elective irradiation. We believe that bipedal lymphangiography is useful in staging, radiation field design, and follow-up. Other controversies in the radiotherapeutic management include the optimal radiation dose and appropriate target volume.