Radiosurgery for the treatment of recurrent central neurocytomas

OBJECTIVE: Central neurocytomas are benign neoplasms with neuronal differentiation typically located in the lateral ventricles of young adults. Although the treatment of choice is complete surgical excision, patients may experience local recurrence. Adjuvant therapy for patients with residual or recurrent tumor has included reoperation, radiotherapy, or chemotherapy. To avoid the side effects of conventional radiotherapy in young patients, we present a series of patients with clear evidence of tumor progression who were treated with gamma knife radiosurgery. METHODS: Four patients (ages 20-49 yr; mean, 28 yr) who presented with an intraventricular mass on magnetic resonance imaging scans and underwent craniotomy for tumor resection were reviewed retrospectively. Histopathological analysis confirmed central neurocytoma in all cases. Each patient was followed up clinically and radiographically with serial magnetic resonance imaging. When radiographic signs of tumor progression were evident, patients were treated with radiosurgery. RESULTS: Complete radiographic tumor resection was achieved in all patients. There were no major postoperative complications. Local tumor progression was detected on magnetic resonance imaging scans 9 to 25 months after surgery (median, 17.5 mo). All patients achieved complete response to radiosurgery with reduction in tumor size. There have been no complications from radiosurgery. Follow-up ranged from 12 to 28 months (mean, 16.5 mo) after radiosurgery, and from 24 to 84 months (mean, 54.5 mo) after initial presentation. CONCLUSION: Radiosurgery with the gamma knife unit provides safe and effective adjuvant therapy after surgical resection of central neurocytomas. Radiosurgery may eliminate the need for reoperation and avoid the possible long-term side effects from conventional radiotherapy in young patients.     

Surgical Treatment of Spinal Ependymoma and Post-Operative Radiotherapy

Summary Introduction. With the advances in microsurgical and monitoring techniques, spinal ependymomas are gross totally resected more frequently. The use of adjuvant radiotherapy has become questionable with gross total resection and its role for residual neoplasm need to be redefined. A retrospective analysis of a series of patients was carried out to investigate our clinical outcome and selected use of postoperative radiotherapy. Clinical materials and methods Between July 1990 and May 1995, nineteen patients [M:F=12:7; age range: 21 to 71 years] with a spinal ependymoma were treated at University of Miami by the senior author. (BAG) Pre-operative MRI diagnosed the intraspinal tumor, and pathology reports demonstrated that each patient had a histologically confirmed ependymoma. At the time of diagnosis, the most common symptoms presented were pain (in 16 patients=84.2%). The pattern of progression of clinical symptoms was directly related to the location of the tumor. Each patient had an MRI immediately after surgery, approximately 6 months post-operatively, and then annually. Results All 19 patients underwent intradural microsurgical exploration with an attempted gross total resection (achieved in 16 patients=79%) of the ependymoma through a posterior approach. Direct neural tissue stimulation halted further resection in 2 patients with questionable tumor margins. Radiation therapy was employed as a surgical adjunct in 3 patients (15.8%) because of possible residual tumor. All patients were followed up postoperatively for an average of 50.6 months (range 6 months to 6 years). All patients are surviving to date. Surgical resection of these tumors led to significant alleviation of pre-operative symptoms. There has been no radiographic evidence of tumor recurrence or growth in any patient to date. Conclusion. Surgical resection of spinal ependymoma leads to significant improvement of pre-operative symptom. Surgical removal alone, with an attempt to grossly resect the tumor, should be the treatment of choice, with careful clinical and radiographic follow-up. Radiation therapy should only be considered as a surgical adjunct where gross total resection is not achieved.     

Seminoma with Isolated Central Nervous System Relapse, and Salvage with Craniospinal Irradiation

We report a case of a patient with isolated central nervous system relapse of classical seminoma, refractory to intrathecal and systemic chemotherapy, but successfully salvaged with craniospinal axis irradiation. A 44-year-old man with bulky Stage II classic seminoma obtained complete remission with four cycles of cisplatin etoposide combination chemotherapy, but relapsed with lumbar vertebral metastases with epidural spinal cord compression 5 months after completion of primary treatment. He underwent laminectomy, local radiotherapy, and salvage chemotherapy. Two months later he developed cranial nerve palsies, and magnetic resonance imaging confirmed leptomeningeal disease. After brain radiotherapy, systemic and intrathecal chemotherapies were begun but tumor recurred around the cauda equina, producing paraparesis. The patient received salvage craniospinal irradiation, with resolution of paraparesis and cranial nerve palsies. Thirty months after completion of craniospinal radiotherapy, he remains in complete remission. We suggest consideration of craniospinal axis irradiation as salvage therapy in patients with isolated central nervous system relapse of seminoma.     

颈胸段脊柱骨肿瘤术后再手术

目的 探讨颈胸段脊柱骨肿瘤术后再手术的因为及其手术策略.方法 2000年7月至2008年1月,对14例颈胸段脊柱骨肿瘤术后患者施行再手术.软骨肉瘤5例,骨巨细胞瘤5例,血管肉瘤、侵袭性骨母细胞瘤、副神经节瘤、动脉瘤样骨囊肿各1例.经前后联合入路行单个椎节切除6例、两个椎节切除2例、三个椎节3例,经后外侧入路行单个椎节切除1例、两个椎节切除2例.除2例三个椎节切除分二期进行外,其余均为一期完成.前路采用钛网或植骨、骨水泥加带锁钉板内固定系统或单棒内固定,后路采用钉棒内固定系统重建.术后血管肉瘤患者接受化疗和局部放疗,其余患者接受局部放疗.结果 术后所有患者局部疼痛均有不同程度缓解,脊髓神经功能改善.3例脑脊液漏,经引流、换药处理后愈合,2例Horner综合征和1例声音嘶哑于术后2～5周自行恢复.随访18～108个月,平均45个月.7例患者分别于术后12～22个月再次复发,其中5例分别于术后30～38个月瘫痪、死亡,2例带瘤生存.结论 颈胸段脊柱骨肿瘤术后再手术的主要因为是肿瘤局部复发或肿瘤残存.复发与肿瘤病理类型、切除方式和相关综合治疗的衔接有关.应该珍惜第一次手术机会,力争将肉眼可见的肿瘤彻底切除.与初次手术相比,再手术具有更高的风险及难度,术者应熟悉颈胸段脊柱的解剖结构.     

Contemporary management of pineoblastoma

Pineoblastomas (PBs) represent the most aggressive of the pineal parenchymal tumors. Routine treatment consists of operative management of obstructive hydrocephalus and cerebrospinal fluid studies followed by maximal resection and adjuvant chemotherapy/radiotherapy, resulting in a median survival of 20 months. Important prognostic factors for survival of patients with PB include extent of resection, age at presentation, disseminated disease, and craniospinal radiotherapy. Novel strategies being evaluated for the treatment of PB include high-dose chemotherapy with autologous stem cell therapy, stereotactic radiosurgery, and histone deacetylase inhibitors.     

High-Grade Gliomas

High-grade gliomas (HGGs) should be treated with maximal, safe surgical resection followed by 57–60 Gy of partial-field external beam or intensity-modulated radiotherapy to a 2 cm margin surrounding the resection cavity. The standard of care for newly diagnosed glioblastoma includes concurrent temozolomide (TMZ) during radiotherapy and adjuvant TMZ for six or more cycles. The optimal role of chemotherapy in anaplastic gliomas is unresolved. Carefully selected patients with anaplastic gliomas can be treated with combination chemotherapy (procarbazine, lomustine, vincristine; PCV) or TMZ as initial therapy after surgical resection, adjuvant therapy after radiotherapy, or at recurrence in patients with anaplastic glioma. Patients with recurrent glioblastoma can be treated with intravenous bevacizumab or dose-intense regimens of TMZ, but selection of optimal candidates for either therapy is unresolved. Other currently available targeted biologic agents are not part of routine management of patients with HGGs. Combination therapeutic trials of antiangiogenic and other targeted agents are ongoing in patients with HGGs. The way forward for patients with HGGs will involve treatments targeting the molecular abnormalities that are important to tumor initiation and growth. All patients with HGGs should be evaluated for clinical trial eligibility at diagnosis and upon recurrence.     

侵袭性胸腺瘤手术治疗预后因素的随访

目的 观察侵袭性胸腺瘤的手术治疗效果,并分析影响患者预后的相关因素.方法 回顾性分析2000年1月至2009年12月接受手术治疗的59例侵袭性胸腺瘤患者的临床及随访资料.患者为连续病例,男性34例,女性25例;年龄18～72岁,平均49岁.根治性手术44例,姑息切除或活检15例.Masaoka分期:Ⅱ期18例,Ⅲ期30例,Ⅳ期11例;Ⅱ期患者术后未接受辅助放疗或化疗,Ⅲ、Ⅳ期患者术后接受辅助放疗和(或)化疗26例,未接受辅助放疗或化疗15例.分析手术方式、Masaoka分期、辅助放疗和(或)化疗与患者预后的关系.结果 本组59例患者随访时间1～111个月,平均54个月;失访3例,失访率6.1%.全组局部复发或全身转移19例,死亡14例,3年、5年生存率分别为86.8%、70.8%.单因素分析显示接受完全性切除手术、Masaoka分期较早及术后接受辅助放疗和(或)化疗的患者有较高的生存率(P＜0.05).多因素分析显示是否完全性切除、术后接受辅助放疗和(或)化疗是影响患者预后的独立因素(P＜0.05).结论 Masaoka分期与侵袭性胸腺瘤患者预后相关;完全性切除手术及术后辅助放化疗可显著提高患者生存率;部分复发患者再次手术后亦可获得长期生存.     

Treatment of esophageal cancer: the continued need for surgical resection

We conclude that preoperative radiotherapy and chemotherapy is very likely to improve the length of survival in patients with squamous cell carcinoma undergoing surgical resection and decreases the incidence of symptomatic local recurrence requiring additional palliative treatment. A favorable tumor response to adjuvant therapy, however, did not significantly improve the survival curves in our study, does not guarantee complete tumor regression, and should not be cited as a basis for elimination of esophagectomy in treatment protocols. Adenocarcinoma treated with surgical resection has a better prognosis than similarly treated squamous cell carcinoma, but has a poorer prognosis than squamous cell carcinoma treated with preoperative adjuvant therapy and surgical resection.     

Established data and practical recommendations concerning pre- and postoperative chemotherapy of rectal cancer

Adjuvant chemotherapy appears to be active in stage II-III rectal cancers; the NSAPB R01 trial demonstrated a survival advantage for patients receiving chemotherapy using the MOF protocol and 3 meta-analyses are in favor of the efficacy of adjuvant chemotherapy in rectal cancer. Three randomized trials have also demonstrated that combinations of radiation and chemotherapy are superior to surgery alone or adjuvant radiotherapy and demonstrated the major role of systemic chemotherapy combined with radiotherapy. However this efficacy of adjuvant chemotherapy alone or combined with radiation therapy is still debated and specific trials must be conducted to test the value of chemotherapy using more active regimens than those previously tested and taking into account the quality of surgery and radiotherapy; such trials are in progress, especially the trial conducted by the EORTC and the FFCD. The efficacy of neoadjuvant chemotherapy has never been clearly demonstrated, although a combination of radiotherapy and chemotherapy as first-line treatment for locally advanced rectal cancer and in the case of synchronous metastasis seems to facilitate surgical resection. It is a reasonable and tolerable approach with manageable toxicity which gives substantial results in 2/3 of patients. This strategy also allows better selection of patients likely to benefit from surgical resection of their primary tumor and in some cases of their synchronous metastases. However, the efficacy of perioperative treatments should not decrease the quality of the surgical resection and especially mesorectal excision as well as the need for high quality pathological examination which must be very thorough with analysis of a sufficient number of lymph nodes. The efficacy of combined treatment in advanced rectal cancers is a major argument in favor of the multidisciplinary coordination required for optimal treatment of patients with rectal cancer.     

Irradiation therapy for gallbladder carcinoma: recent advances

Abstract. Purpose: Gallbladder carcinomas were usually considered to be radioresistant. So far, the role of radiotherapy has not been adequately evaluated. The aim of this report is to assess the value of radiotherapy in carcinoma of the gallbladder. Methods: We reviewed publications concerning the role of radiation therapy in gallbladder carcinoma from 1974 to 2000. External radiation therapy, intraoperative radiation therapy, and brachytherapy were evaluated in two different groups: one group of patients underwent surgery, with apparently complete resection of the tumor; and another group underwent palliative treatment. Results: Local control of the tumor and reduction of tumor size were reported in several publications. Collected data suggested a slight improvement in survival after adjuvant or palliative radiotherapy. The best benefit was obtained in tumors resected with only microscopic residual tissue. If possible an intraoperative "boost" (15 Gy) is recommmended on the gross lesion, residual lesion, or tumor bed. Additional postoperative external radiotherapy (45–50 Gy) must be delivered. Conclusion: Radiotherapy appears to be a safe procedure that slightly improves the survival time of patients treated for gallbladder carcinoma. Further trials are needed to assess the role of combined radiotherapy and chemotherapy. Received: January 9, 2001 / Accepted: August 1, 2001     

胸段食管鳞癌的多学科综合治疗

食管癌患者就诊时大多已为中晚期,第七版UICC食管癌新分期Ⅲ期以上肿瘤单纯手术切除往往疗效不满意,系统性的多学科治疗至关重要.越来越多的证据表明术前同期放化疗是最为有效的诱导治疗方式,可使肿瘤降期并提高根治性切除率;针对食管鳞癌中常见的多组、多野淋巴结转移患者,术前诱导化疗不失为可行的选择.对于已根治性手术切除的局部进展期肿瘤,术后辅助放疗或有助于弥补手术清扫范围的不足以加强局控;术后辅助化疗的作用亦有待进一步深入研究.胸段食管鳞癌与西方国家常见的食管下段腺癌有本质的不同,需要积累更多的前瞻性临床研究,以形成适合我国食管癌患者的综合治疗模式.     

Surgical treatment of malignant thoracic schwannomas

The objective of this study is to evaluate the results after surgical treatment of malignant tumors arising from the peripheral nerves of the thorax under consideration of adjuvant therapy modalities. PATIENTS AND METHODS: Between 1988 and 1998, 9 patients (6 males, 3 females) underwent surgical treatment for MTNSO and 35 pts. for benign neurogenic tumors. The mean age in patients with malignant tumors was 45 years (range, 25 to 73 years). 3 pts. with MTNSO (33.3%) had neurofibromatosis (von Recklinghausen's syndrome) compared to 8.6% (3/35) in patients with benign neurogenic tumors. RESULTS: In patients with MTNSO partial chest wall resections (n = 4) including sternectomy (n = 1), lung resections (n = 2), paravertebral (n = 1) and mediastinal tumor resection (n = 1) and palliative resection of pleural recurrence (n = 1) were performed. Radical resection was achieved in 5 pts. (55.5%). There was no postoperative mortality. 3 patients (33.3%) had postoperative complications: wound infection (n = 2) and wound dehiscence due to fall with consequent pleural infection (n = 1). Adjuvant therapy was performed in two pts. (adjuvant radiotherapy/chemotherapy for metastatic disease n = 1; adjuvant chemotherapy/adjuvant radiotherapy after resection of recurrent tumor n = 1). Early recurrence is documented in 2 pts. (after 3 and 6 months). Two pts. are alive and free of disease at three years, and the patient after sternectomy with recurrent disease at 20 months. Three pts. died 8, 9 and 26 months after the primary surgical procedure. The first postoperative examination (at three months) in the remaining patient showed no evidence for recurrent disease. CONCLUSION: Patients with MTNSO have an unfavourable prognosis and local recurrence is frequent even after radical surgical therapy. Therefore an adjuvant treatment in these patients may be justified, even if the value of these therapy modalities is not proved yet. A tumor-free long-term survival especially after complete surgical resection is possible in selected cases.     

Chimiothérapie (néo)adjuvante du cancer colique

The use of adjuvant chemotherapy for patients with stage III colon cancer is justified by the relatively high risk of recurrence. The combination therapy with 5-fluorouracil, folinic acid and oxaliplatin during 6 months is the reference treatment after surgical resection for stage III colon cancers. While beneficial for stage III patients, the role of adjuvant chemotherapy is unestablished in stage II colon cancers. Patients with high-risk stage II disease can be considered for adjuvant chemotherapy. MSI is a marker of a more favorable outcome in patient with stage II colon cancer. MSI testing is recommended for patient with high-risk stage II because it must influenced adjuvant therapy decision in stage II disease. Bevacizumab and cetuximab have failed to show a benefit in the adjuvant treatment of colon cancer. Better tools are needed to identify patients at highest risk of recurrence who stand to get the most benefit from adjuvant chemotherapy in terms of efficacy and safety. Question regarding the benefit of adjuvant chemotherapy in older patient is difficult to answer.     

Spindle and giant cell carcinoma of the bladder. Report of 3 cases

3 cases of spindle and giant cell carcinoma are reported. 2 patients with T3N0M0 and T3N1M0 tumors underwent radical cystectomy. They died 8 and 9 months after cystectomy for local recurrence and tumor metastases. Neither radiotherapy nor chemotherapy were effective in these 2 patients. 1 patient with T1NXM0 disease underwent resection of the tumor through cystotomy. Although she had neither adjuvant chemotherapy nor radiotherapy, she is well without recurrence 6 years after surgery. Early surgical resection of the tumor may be the only currently accepted therapy of spindle and giant cell carcinoma of the bladder.     

Is gross-total resection sufficient treatment for posterior fossa ependymomas?

OBJECT: The goals of this study were to analyze outcomes in patients with posterior fossa ependymomas, determine whether gross-total resection (GTR) alone is appropriate treatment, and evaluate the role of radiation therapy. METHODS: All patients with newly diagnosed intracranial ependymomas treated at Barrow Neurological Institute between 1983 and 2002 were identified. Those with supratentorial primary lesions, subependymomas, or neuraxis dissemination were excluded. Forty-five patients met the criteria for the study. Gross-total resection was accomplished in 32 patients (71%) and subtotal resection (STR) in 13 (29%). Radiation therapy was given to 25 patients: 13 following GTR and 12 after STR. The radiation fields were craniospinal followed by a posterior fossa boost in six patients and posterior fossa or local only in the remaining patients. With a median follow-up period of 66 months, the median duration of local control was 73.5 months with GTR alone, but has not yet been reached for patients with both GTR and radiotherapy (p = 0.020). The median duration of local control following STR and radiotherapy was 79.6 months. The 10-year actuarial local control rate was 100% for patients who underwent GTR and radiotherapy, 50% for those who underwent GTR alone, and 36% for those who underwent both STR and radiotherapy, representing significant differences between the GTR-plus-radiotherapy and GTR-alone cohorts (p = 0.018), and between the GTR-plus-radiotherapy and the STR-plus-radiotherapy group (p = 0.003). There was no significant difference in the 10-year actuarial local control rate between the GTR-alone and STR-plus-radiotherapy cohorts (p = 0.370). The 10-year overall survival was numerically superior in patients who underwent both GTR and radiotherapy: 83% compared with 67% in those who underwent GTR alone and 43% in those who underwent both STR and radiotherapy. These differences did not achieve statistical significance. Univariate analyses revealed that radiotherapy, tumor grade, and extent of resection were significant predictors of local control. CONCLUSIONS: Gross-total resection should be the intent of surgery when it can be accomplished with an acceptable degree of morbidity. Even after GTR has been confirmed with postoperative imaging, however, adjuvant radiotherapy significantly improves local control. The authors currently recommend the use of postoperative radiotherapy, regardless of whether the resection is gross total or subtotal.     

Guidelines for the surgical management of soft-tissue sarcoma. Report of the Canadian Sarcoma Group

The Canadian Sarcoma Group was formed in 1985 by interested surgeons, oncologists and pathologists. In the evaluation of new protocols, standard surgical guidelines have been developed which incorporate the concepts of multimodality therapy, particularly radiotherapy and chemotherapy. Also defined are the procedures performed: biopsy, marginal resection, wide local excision, radical resection and the principles to be considered when doing a diagnostic biopsy and a curative resection, particularly with limb salvage in mind. To optimize local control of the disease, centres treating sarcomas should have access to computed tomography, radionuclide scanning, to radiation and medical oncologists, and members of other surgical specialties. This team approach increases survival by 10% and also provides the best circumstances in which to study adjuvant therapy. Surgical guidelines are also essential in order to compare the results of different clinical trials.     

Desmoid tumor of rectus muscle of abdomen in a woman of childbearing age: what can we do?

The desmoid tumor (DT) is a soft tissue neoplasm most frequently localized in the anterior abdominal wall typically in females of childbearing age. Because its particular incidence in women who had recently been pregnant, it was correlated with delivery's trauma stimulating proliferation of muscolo-aponeurotic tissues. Complete surgical resection is the recommended treatment approach to prevent recurrence. Many authors emphasize the role of radiotherapy in regression of DT and in controlling local recurrence in patient who had incomplete resection. Many others emphasize the role of chemotherapy or antiestrogenic compounds, even though tumour does not express estrogen receptors. DT, otherwise, is neoplasm with high rates of recurrence after surgery but it never develops distant metastases, so that function and structure-sparing surgery may be a reasonable choice in young women when possible without leaving macroscopic residual disease. Furthermore literature data suggest that the presence of incomplete histological surgical resection does not correlate with local recurrence and that pregnancy does not represent a risk factor. In women of childbearing age, even after non radical histological DT primary resection, adjunctive radiotherapy, chemotherapy or antiestrogen therapy could be avoided and clinical observation alone may be considered.     

Prognostic factors in intracranial ependymomas in children

OBJECT: The occurrence of intracranial ependymomas in children is relatively infrequent, and their prognostic factors are still controversial, especially regarding histological composition. METHODS: A retrospective study was conducted of 37 children treated during the last 20 years for intracranial ependymomas at the H?pital de la Timone. Both univariate and multivariate statistical analyses were performed to assess the prognostic relevance of patient age and sex, extent of tumor removal, location of the tumor (supratentorial compared with infratentorial, median compared with lateral), tumor histological composition, and adjuvant therapies in affecting the 5-year progression-free survival (PFS) rate and overall survival (OS) rate. The following histopathological features, either alone or in combination, were analyzed: endothelial proliferation, necrosis, loss of differentiating structures (present compared with absent), the number of mitotic figures per 10 hpf, and cellularity (number of nuclei/5 hpf). In addition, immunohistochemical detection of Ki-67 antigen was performed and the Ki-67 labeling index (LI) evaluated in all cases. The 5-year OS and PFS rates were 45% and 25%, respectively (median follow up 34 months). Four patients died of disease without remission (median 163 days) and disease in 21 patients relapsed: 18 in situ and three both in situ and distantly. On univariate analysis total surgical resection and median infratentorial location were associated with a better outcome (p < 0.002) for both OS and PFS. Loss of differentiating structures was associated with poor prognosis (p < 0.008) and the combination of necrosis, endothelial proliferation, and mitotic index greater than 5 was also a negative predictive factor for both OS (p < 0.002) and PFS (p = 0.02). The PFS time was shorter in patients younger than 4 years of age and in patients in whom a Ki-67 LI greater than 1 was found (p = 0.03 and 0.006, respectively). Adjuvant radiotherapy and chemotherapy were not relevant to prognosis. Moreover, among the 15 patients in whom total excision was achieved, OS was better in those who did not receive adjuvant therapies. In contrast, adjuvant therapies significantly enhanced PFS time in patients in whom tumor excision was incomplete. CONCLUSIONS: This study and analysis of the literature further highlight that total tumor removal is the treatment of choice for ependymomas in children. Postoperative measurement of residual tumor is required, especially because a subgroup of patients might be treated by surgery alone. Median infratentorial ependymomas have to be distinguished from the lateral type. Appropriate and reproducible histological parameters and Ki-67 LI are of interest as predictors of outcome.     

Primary mediastinal nonseminomatous germ cell tumors. Results of a multimodality approach

Before cisplatin-based chemotherapy, long-term survival after resection of primary mediastinal nonseminomatous germ cell tumors was unusual. We reviewed the case histories of 48 patients who underwent multimodality treatment for mediastinal nonseminomatous germ cell tumor between 1976 and 1988. Twenty-eight patients received initial therapy at Indiana University and 20 were referred after having had unsuccessful initial therapy elsewhere. In 44 patients (92%) the levels of either one or both serum tumor markers were elevated at the time of diagnosis. Five patients had choriocarcinoma, three embryonal carcinoma, 12 yolk sac carcinoma, four teratocarcinoma, 22 mixed cell type, and two had an unclassified type. Twenty-two of the 28 patients in our initial therapy group had a complete response to treatment, as defined by normal serum tumor markers and absence of residual tumor. In this group, 16 patients had resection of residual disease after chemotherapy, four had total or near total resection before chemotherapy, and only two had chemotherapy alone. Seventeen patients are surviving after this treatment with a median survival of 64 months and a 57% 5-year Kaplan-Meier survival rate. Only two of the 20 patients who were referred for salvage chemotherapy had a complete response. Both required resection of residual disease after salvage chemotherapy. Only one patient survived after this treatment. There was no significant treatment morbidity or mortality. A multimodality approach to primary mediastinal nonseminomatous germ cell tumor with intensive cisplatin-based chemotherapy, emphasis on normalizing serum tumor markers, and aggressive resection of residual disease now offers survival to a significant number of patients.     

Recent strategy for the management of advanced testicular cancer

Testicular cancer is the most common cancer in young men and the cure rate has been approximately 80% since the introduction of cisplatin in the 1970s. BEP therapy (including bleomycin, etoposide and cisplatin) has become a standard induction therapy instead of PVB therapy (cisplatin, vinblastin and bleomycin). However, the patients with incomplete responses to cisplatin‐based first‐line therapy or with relapsed disease have an extremely poor prognosis. For such difficult‐to‐treat patients, there are some proposed treatment options such as ifosfamide‐containing salvage chemotherapy or high‐dose chemotherapy (HDCT). HDCT with bone marrow rescue has been carried out as salvage or induction chemotherapy. However, a randomized control trial did not show the superiority to conventional first line therapy or salvage therapy. Therefore, a new anticancer agent was tested for cisplatin‐refractory or resistant testicular cancer. The development of combination therapy with new anticancer agents such as paclitaxel and irinotecan seems to be effective for these patients. TIP therapy including paclitaxel, ifosfamide and cisplatin would be a standard second line therapy for the patients with BEP failure. Residual tumor resection including retroperitoneal lymph node dissection integrated with induction and salvage chemotherapy still remains to play an important role to achieving a cure for advanced testicular cancer because there is no modality to predict residual viable cancer cells or teratoma element in the residual tumors. In the present review, we discuss and focus on the recent treatment strategy of advanced testicular cancer.