Neoadjuvant intra-arterial chemotherapy followed by partial cystectomy for invasive bladder cancer]

From January, 1987 through January, 1990, partial cystectomy was performed for 4 (18%) of 22 patients with invasive bladder cancer who had received neoadjuvant intra-arterial chemotherapy. The criteria of patient selection for partial cystectomy were: 1) invasive bladder cancer showing good response (greater than or equal to PR) to neoadjuvant chemotherapy, 2) solitary or localized tumor that can be eradicated by segmental resection, and 3) tumor of stage T3 or less. As a rule, cisplatinum (100 mg/m2) and THP-adriamycin (40 mg/m2) were administered selectively to the internal iliac artery by one-shot infusion. Concurrently, sodium thiosulfate (10 g/m2), a neutralizing agent against cisplatinum, was administered intravenously. All four patients had achieved clinical complete responses by one or two courses of intra-arterial chemotherapy, and then underwent partial cystectomy with pelvic lymphadenectomy. Pathological examination revealed pTONO in two patients, and the remains were pT3aNO and pT3bN1. After the mean follow-up of 24 months, three of them are alive with no evidence of disease, and also with normal bladder and sexual functions. However, one with pT3bN1 tumor underwent total cystectomy 5 months later for local recurrence (pT4b) and had died of cancer 18 months later. Neoadjuvant intra-arterial chemotherapy followed by partial cystectomy should be the most applicable conservative therapy with high radicality for invasive bladder cancer, when: 1) the patient has localized invasive cancer showing good response (greater than or equal to PR) to neoadjuvant chemotherapy, 2) the tumor is stage T3a or less and without findings of tentacular invasion (INF gamma) by pre-operative biopsy, and 3) pre-operative multiple biopsy is performed as deeply as possible along the prearranged incision line.     

BEP (bleomycin, etoposide, cisplatinum) chemotherapy as an induction therapy of advanced extragonadal germ cell tumor]

Five patients with advanced extragonadal germ cell tumor (EGGCT) were treated with cisplatinum + vinblastine + bleomycin (BVP) or cisplatinum + etoposide + bleomycin (BEP) chemotherapy as an induction therapy. All patients had high levels of tumor markers and multiple distant metastasis in poor nutritious conditions. Two patients given BVP therapy died 6 and 9 months after the chemotherapy. By contrast, three patients given BEP therapy achieved complete remission and were surviving longer than one year without any evidences of disease. Granulocytopenic fever was seen soon after the first course of BEP therapy. Prophylactic granulocyte-colony stimulating factor (G-CSF) treatment, enabled two of them to receive full dose chemotherapy without any fever attacks. In conclusion, BEP chemotherapy is effective to EGGCT as well as far advanced testicular tumors and G-CSF treatment is useful for achievement of induction chemotherapy to advanced germ cell tumors.     

Surgical treatment of patients with stages I and II nonseminomatous testicular cancer

We analyzed treatment outcomes for 98 consecutive patients who underwent retroperitoneal lymphadenectomy for nonseminomatous germ cell testicular cancer between 1972 and early 1979. There were no surgical deaths. Major and minor complications occurred in 8 and 15 patients, respectively. Of the 57 patients with pathological stage I tumors 9 (16 per cent) had recurrences and were given chemotherapy, and all 57 are well 2 or more years after completion of treatment. Of the 12 patients with stage IIA disease who received no adjuvant treatment 5 had relapse, 2 of whom died. Relapse occurred in 13 of 14 patients with stage IIB disease who received no adjuvant treatment and 2 of 4 who received adjuvant radiation. All 3 patients with stage IIC tumor who received no adjuvant treatment had relapse. In contrast, none of the 7 patients with stage II disease who received adjuvant vinblastine and bleomycin with or without cisplatin had relapse. Our long-term survival rates are 100 per cent for patients with stage I and 88 per cent with stage II disease, and all of the patients who died either were treated before the introduction of cisplatin-based chemotherapy or did not complete the treatment protocol as recommended. In experienced hands retroperitoneal lymphadenectomy with chemotherapy, either as adjuvant or as needed for patients with stage I, IIA and IIB disease, remains the most cost-effective treatment for nonseminomatous testicular cancer and has the least short-term and long-term morbidity.     

Semen cryopreservation for patients with malignant or non-malignant disease: our experience for 10 years

PURPOSE: We report our experience in 10 years of sperm cryopreservation to reveal the present state of the cryopreservation project. MATERIALS AND METHODS: 42 germ cell tumor, 110 non-germ cell tumor and 2 non-malignant disease patients who visited our clinic for semen cryopreservation were retrospectively analyzed. RESULTS: Only 7 (20%) out of 35 unilateral testicular tumor patients who had received no chemotherapy met the WHO criteria for sperm concentration and motility. However, there were no patients with azoospermia. Three testicular tumor patients with previous chemotherapy and 4 retroperitoneal germ cell tumor patients had poor sperm concentrations and motilities. Twenty (52%) out of 38 non-germ cell tumor patients without previous chemotherapy met the WHO criteria. In contrast, only 9 patients (13%) met the WHO criteria among 72 patients with previous chemotherapy. Twenty-nine patients (40%) with chemotherapy were azoospermia. Totally, 74 (96%) of 77 tumor patients' semen without chemotherapy and 34 (45%) of 75 with chemotherapy were cryopreserved. Sperm from a patient with testicular torsion were cryopreserved. CONCLUSION: Most cancer patients without previous chemotherapy, regardless of underlying disease, had abundant motile sperm. However, half of the patients who had received chemotherapy did not have suitable sperm for freezing. It is important to inform young cancer patients of the cryopreservation project immediately after the diagnosis is made.     

Multimodality approach to treatment of carcinoma of the esophagus

We conducted a combined treatment pilot project in 17 patients with squamous cell carcinoma of the thoracic esophagus. Thirteen of the patients initially had stage I or II disease, and four had stage III disease. Each patient received three cycles of chemotherapy consisting of a high dose of cisplatin (100 mg/sq m), followed by continuous infusion of fluorouracil (1,000 mg/sq m/day for five days). Thirteen patients had a favorable response to the chemotherapy, and ten of the 11 responding patients with stage I or II disease were offered surgical resection. Total thoracic esophagectomies and cervical gastroesophagostomies were done in the six patients who accepted the surgical recommendation. Pathologically, five patients had stage I disease, and one had stage III disease (even in this patient the local tumor was confined within the wall of the esophagus). All six patients were alive, without evidence of disease, four to 34 months after diagnosis. Two patients with stage II disease had tumor progression, as did two of the four patients with stage III disease. Three of the nonresponding patients died of their disease two to seven months after diagnosis. The eight remaining patients, three of whom received irradiation after chemotherapy, were alive, but with evidence of persistent disease, one to seven months after entrance into the study.     

Long-term efficacy of two cycles of BEP regimen in high-risk stage I nonseminomatous testicular germ cell tumors with embryonal carcinoma and/or vascular invasion

OBJECTIVES: To report the long-term impact of two cycles of adjuvant chemotherapy on relapse rates and treatment-related morbidity in high-risk stage I nonseminomatous testicular germ cell tumors (NSGCTT I). MATERIAL AND METHODS: From April 1987 to September 1997, 40 stage I NSGCTT patients with evidence of vascular invasion and/or embryonal carcinoma (EC) in the orchidectomy specimen were treated with two courses of bleomycin, cisplatin, and etoposide (BEP). RESULTS: All patients but one (incidental death) were alive after an extended follow-up (median 113.2 months, range 63-189). No patients relapsed but two patients presented a second cancer in the remaining testis. Short-term toxicity was minimal and no long-term toxicity was observed. CONCLUSION: The present series, with extensive follow-up, demonstrated that the efficacy and toxicity of two cycles of BEP compared well with the results of surveillance strategies or RPLND in high-risk stage I NSGCTT.     

Clinicopathological features predicting nodal metastasis of testicular seminoma: results from 100 cases in a single institute

BACKGROUND/AIMS: To investigate the clinical and pathological features which predict nodal metastasis and/or the prognosis of testicular seminoma and to evaluate the current treatment strategy in a single institute. METHODS: We retrospectively analyzed 100 patients who had been pathologically diagnosed as having testicular seminoma in our institute. Ninety-one patients (91%) had stage I disease, 9 patients (9%) were stage II and none stage III. The median follow-up was 63.2 months (range 0.5-249). RESULTS: The duration between the tumor recognition and the first outpatient visit ranged from 0 to 144 weeks, with a median of 5 weeks, which did not influence the clinical stage. The tumor diameter and the preoperative serum lactate dehydrogenase (LDH) level were the significant predictors of stage II disease. Following orchiectomy, 68 patients (74.7%) with stage I disease received radiotherapy. Only 1 patient who had not received adjuvant radiotherapy died from the recurrent disease. The 5-year survival was 100% for the irradiation group but 95% for the surveillance group, although the difference was not statistically significant. All the stage II patients were successfully treated with chemotherapy following orchiectomy. CONCLUSION: The maximum tumor diameter and the preoperative serum LDH level were the significant predictors of nodal metastasis. Adjuvant radiotherapy in patients with stage I seminoma did not influence the survival. Systemic chemotherapy promised good survival for the seminoma, even with nodal metastasis, in this series. Our results support the good prognosis of testicular seminoma with the current treatment strategy.     

Cystic trophoblastic tumor: a nonaggressive lesion in postchemotherapy resections of patients with testicular germ cell tumors

Cystic trophoblastic tumor (CTT) is an uncommon lesion that is usually seen after chemotherapy in patients with testicular germ cell tumors. Its clinical significance has not been well studied. We identified 17 patients with CTT in retroperitoneal lymph node dissections (RPLNDs) after cisplatin-based chemotherapy for testicular germ cell tumors. None had other forms of persistent germ cell tumor except for teratoma, and no patient received additional chemotherapy after RPLND. At the time of RPLND, 7 patients were known to have had normal serum levels of beta-subunit of human chorionic gonadotropin (beta-hCG), whereas 5 had relatively mild elevations (1.6-165 mIU/mL, median, 8.0 mIU/mL). The CTTs consisted of circumscribed, small cysts, usually multifocal, lined by mostly mononucleated trophoblast cells with abundant eosinophilic cytoplasm, often with smudged nuclei and showing only infrequent mitotic figures. Although the epithelial lining was often stratified to several layers in thickness or formed intracystic papillary tufts, solid proliferations of trophoblast cells within the stroma were absent, as were clearly biphasic admixtures of mononucleated and multinucleated trophoblast cells. The cysts were either empty or contained fibrinoid material and were set in a hypocellular, fibrous stroma with adjacent teratoma. Stains for hCG highlighted rare cells. On follow-up of 15 patients, 11 were disease free (mean, 80 months). Three recurred with serum alpha-fetoprotein elevations at 25, 31, and 107 months, respectively, and one with beta-hCG elevation at 2 months. The latter patient, however, also had unresected mediastinal tumor postchemotherapy. We conclude that the finding of CTT in postchemotherapy resections does not warrant additional chemotherapy. Its clinical significance appears similar to that of residual teratoma.     

临床Ⅰ期睾丸非精原细胞瘤的监视治疗16例报告

１６例临床Ⅰ期睾丸非精原细胞瘤（ＮＳＧＣＴＴ）患者在单纯切除睾丸肿瘤后,不按常规行腹膜后淋巴结清扫,放疗,化疗,而采取监视治疗方案,即术后两周开始复查血清ＨＣＧ,ＡＦＰ,两月开始复查胸腹部ＣＴ、每两个月一次,连续２年以上,结果１２例无复发,复发的４例中有２例术后瘤标持续升高,另２例瘤标下降后分别在第４月、第８月再次升高,给予ＰＶＢ化疗后,４例患者瘤标恢复正常,病灶消失,认为监视治疗对临床Ｉ期ＮＳＧ     

泌尿男生殖系统淋巴瘤的临床特征及预后分析

目的探讨泌尿男生殖系统淋巴瘤患者的临床特征,并对其预后进行分析。方法回顾性分析2014年8月至2019年8月北京友谊医院收治的9例泌尿男生殖系统淋巴瘤患者的临床资料。男5例,女4例。平均年龄62(50~69)岁。肿瘤位于肾脏3例,膀胱2例,睾丸4例。首发症状:肾肿瘤3例中2例为发热(1例伴腹痛及体重减轻),1例为体检发现肾盂占位;膀胱肿瘤1例为肉眼血尿伴腹痛,1例为尿急、尿痛;4例睾丸肿瘤均为睾丸无痛性肿大。5例行CT检查见低密度肿物伴轻中度强化,4例睾丸肿瘤行B超检查提示不规则、不均质肿块内见血流信号。术前诊断均为泌尿男生殖系统肿瘤。6例接受手术,3例行病灶穿刺获取病理。9例中4例接受手术治疗联合化疗,2例仅接受化疗,2例仅接受手术治疗,1例未治疗。肾肿瘤3例中,1例行B超引导下病灶穿刺活检术,术后予环磷酰胺+阿霉素+长春新碱+泼尼松+利妥昔单抗(R-CHOP)方案静脉化疗;1例肾盂占位性病变者行腹腔镜肾输尿管全长切除术,术后予R-CHOP方案静脉化疗;1例行B超引导下病灶穿刺活检术,术后患者拒绝进一步治疗。2例膀胱肿瘤者均行TURBT,术后均拒绝放化疗。4例睾丸肿瘤者中,3例行患侧睾丸切除术,1例行B超引导下病灶穿刺活检术;3例行R-CHOP方案化疗,1例于外院行化疗及对侧睾丸放疗,具体方案不详;4例均行鞘内注射化疗药物(甲氨蝶呤15 mg+阿糖胞苷50 mg+地塞米松5 mg)预防中枢神经系统浸润。结果本组9例术后恢复顺利,无手术及穿刺相关并发症发生。术后病理诊断均为非霍奇金淋巴瘤,其中8例为弥漫性大B细胞淋巴瘤,1例睾丸淋巴瘤为间变性大细胞淋巴瘤。按照Ann Arbor分期标准进行临床分期,确诊时Ⅰ~ⅡE期4例,ⅢE~ⅣE期5例。国际预后指数(IPI)评分0~2分6例,≥3分3例。随访时间平均18(6~66)个月。7例存活,其中3例完成化疗者中,2例完全缓解(睾丸淋巴瘤ⅡE期IPI评分1分和ⅣE期IPI评分2分各1例),1例部分缓解(肾盂淋巴瘤ⅣE期IPI评分3分);3例拒绝化疗者未见肿瘤复发或进展(膀胱淋巴瘤2例和肾盂淋巴瘤1例,均为ⅠE期IPI评分1分);1例化疗2个周期后因出现细菌真菌混合感染性肺炎停止化疗(睾丸淋巴瘤ⅢE期IPI评分3分)。肾淋巴瘤ⅢE期IPI评分3分1例和睾丸淋巴瘤Ⅲ期IPI评分2分1例,分别于确诊后6个月、17个月因肿瘤进展死亡。结论泌尿男生殖系统淋巴瘤以弥漫大B细胞淋巴瘤为主,临床表现特异性差,诊断时应根据症状及影像学表现与其他常见肿瘤进行鉴别,避免误诊误治。组织病理学是诊断的金标准,R-CHOP方案化疗为首选治疗手段。     

Nerve-sparing retroperitoneal lymph node dissection for advanced testicular cancer after chemotherapy

BACKGROUND: Nerve-sparing techniques are commonly used in retroperitoneal lymph node dissection (RPLND) in patients with early stage testicular germ cell tumors to preserve postoperative ejaculation. The indications for nerve-sparing procedures have been extended to patients who have residual retroperitoneal tumor postchemotherapy with an increase in the incidence of local recurrence. Here, we report on 26 Japanese men with advanced testicular cancer who underwent nerve-sparing RPLND after partially successful chemotherapy. METHODS: Between January 1995 and December 2000, 26 patients with metastatic or recurrent testicular cancer underwent nerve-sparing RPLND after chemotherapy. Eight patients had seminoma and 18 had non-seminoma. Three patients received high-dose chemotherapy with carboplatin (250 mg/m2 per day x 5 days), etoposide (300 mg/m2 per day x 5 days) and ifosfamide (1.5 g/m2 per day x 5 days) in combination with peripheral blood stem cell transplantation. RESULTS: In all cases, lumbar splanchnic nerves were preserved macroscopically during the operation, at least unilaterally. Twenty-two patients (84.6%) achieved antegrade ejaculation during a mean follow-up at 3.9 months (range: 1-7 months). Three patients have fathered children. Only one patient suffered a retroperitoneal recurrence during a median follow-up at 25.8 months (range: 6-76 months). CONCLUSION: Nerve-sparing procedures for RPLND are appropriate for patients with metastatic testicular cancer, even after chemotherapy. The procedure preserves ejaculatory function in the majority of the patients without increasing the risk of local recurrence. Nerve-sparing RPLND improves the quality of life in patients who require postchemotherapy RPLND to treat residual tumor.     

High-dose chemotherapy with peripheral blood stem cell transplantation for advanced testicular cancer

BACKGROUND: The present study was performed in order to investigate the efficacy and safety of high-dose chemotherapy for the treatment of patients with advanced testicular cancer. METHODS: Seven patients were treated with high-dose carboplatin, etoposide and cyclophosphamide followed by peripheral blood stem cell transplantation. Five patients received one cycle and two patients received two cycles of the high-dose chemotherapy. RESULTS: Of the seven patients, one achieved a complete response and four achieved partial responses with markers negative. As a result of subsequent surgery for residual tumors, three of the four partial responders showed no residual cancer cells. One patient who did not undergo surgery received radiotherapy after the high-dose chemotherapy and the residual tumors disappeared. All five patients who had either a complete or partial response are still alive and without evidence of disease at 12, 27, 30, 37 and 40 months. One patient is alive with disease at 7 months and one died of progressive disease at 6 months. The hematologic recovery after high-dose chemotherapy was rapid and non-hematologic toxicities were usually mild and manageable. CONCLUSIONS: High-dose chemotherapy followed by peripheral blood stem cell transplantation is safe and effective for use in patients with far-advanced testicular cancer, particularly when the high-dose chemotherapy is conducted as the initial treatment. Further larger and long-term follow-up studies are needed to define the role of high-dose chemotherapy on testicular cancer.     

Late results of surveillance of clinical stage I nonseminoma germ cell testicular tumours: 17 years' experience in a national study in New Zealand

OBJECTIVE: To re-evaluate a national prospective study in New Zealand after 17 years to define whether orchidectomy alone and surveillance for nonseminoma germ cell testicular tumour (NSGCTT) is a sound policy and matches the results achieved by other treatment protocols. PATIENTS AND METHODS: Between 1980 and 1997, 248 men with stage I NSGCTT, from six New Zealand centres, were managed by orchidectomy alone and surveillance, with treatment of relapses using combination chemotherapy. RESULTS: Seventy of the 248 patients (28%) relapsed; 42 of 92 (46%) with vascular and/or lymphatic invasion (VLI) in the primary tumour relapsed, whereas only 26 of 151 (17%) without this feature relapsed (P<0.001). VLI was the only identifiable risk factor for relapse in this series. Only one relapse occurred >28 months after orchidectomy. Despite poor compliance in some patients (12%) their survival was not prejudiced. Three patients died from disease despite chemotherapy at relapse. At 17 years and a median follow-up of 53 months, 242 of the 248 men are disease-free and the disease-specific survival rate is 98%. CONCLUSIONS: This study shows that orchidectomy alone and treatment of relapses produces excellent long-term results without the adverse effects associated with retroperitoneal node dissection or elective chemotherapy for high-risk cases.     

Vinblastine, actinomycin D, bleomycin, cyclophosphamide and cis-platinum for advanced germ cell testis tumors: Brazilian experience

Disseminated germ cell testicular cancer proved to be highly sensitive to platinum-containing chemotherapy regimens. We present data concerning the treatment of advanced seminoma and nonseminomatous tumors in a developing country. We treated 30 patients with advanced germ cell testis tumors with 3 or 4 cycles of vinblastine, actinomycin D, bleomycin, cyclophosphamide and cis-platinum. Surgical resection of residual masses was done 30 days after completion of chemotherapy in 18 patients. The histology of the primary tumor was seminoma in 13 patients and nonseminomatous tumors in 17. Toxicity was mild and no treatment-related deaths occurred. All 13 patients (100 per cent) with seminoma and 12 of 17 patients (71 per cent) with nonseminomatous tumors had a complete response to chemotherapy, and 1 of 17 patients was free of disease after a debulking operation and additional chemotherapy. A total of 3 patients with seminoma and 2 with nonseminomatous tumors had recurrences 5 to 8 months after an initial complete response and received additional chemotherapy (VP-16 regimen) with or without radiotherapy. Complete clinical response was achieved in 4 of 5 patients. Median followup was 24 months (range 8 to 38 months) in the 13 patients with seminoma and 28 months (range 9 to 58 months) in those with nonseminomatous tumors, and 13 (100 per cent) and 12 (71 per cent), respectively, are alive without evidence of disease. These data suggest that the protocol of vinblastine, actinomycin D, bleomycin, cyclophosphamide and cis-platinum is highly effective and minimally toxic in the treatment of disseminated germ cell testicular cancer, inducing an 83 per cent long-lasting clinical remission. Seminomas seem to be equally or even more sensitive than nonseminomatous tumors to this platinum-containing chemotherapy regimen. Recurrence after initial complete response can be treated successfully with regimens containing VP-16.     

Management of testicular cancer--16 years' experience from southwest Finland

OBJECTIVE: This study investigated the outcome of testicular cancer treatment in Finland. MATERIAL AND METHODS: Data on 88 testicular cancer patients treated in Turku University Central Hospital between 1976 and 1992 were studied to analyse outcome and survival. RESULTS: The histological diagnosis was seminoma for 39 patients and non-seminoma for 49 patients. Two seminoma patients relapsed (5%) and one patient died of progressive disease (3%; initially stage II seminoma). Eleven non-seminoma patients relapsed (22%), nine of whom were cured with chemotherapy. Four non-seminoma patients died of progressive disease (8%; initially one stage I non-seminoma and three stage III non-seminomas). The median time to relapse after the completion of treatment was 9 months (range 3-50 months). Non-seminoma patients had significantly more relapses than seminoma patients (p = 0.03). Most relapses (73% of the non-seminoma relapses) were found among the stage I non-seminoma patients who had not received adjuvant chemotherapy, while none of the stage I seminoma patients relapsed (p = 0.007). CONCLUSIONS: Close surveillance is important for all non-seminoma patients to guarantee the early detection and treatment of recurrent disease. Treatment and surveillance should be covered by national guidelines and be conducted in centres with special interest in this rare but mostly curable cancer.     

Position of surveillance therapy in clinical stage I testicular non-seminoma

Since the initiation of a 'surveillance' therapy the role of retroperitoneal lymph node dissection as standard treatment in the management of patients with clinical stage I nonseminomatous germ cell testicular tumor (NSGCTT) continues to be debated. Noninvasive staging techniques (CT scans, lymphography, ultrasound and serologic tumor markers) help to identify more accurately patients with distant metastases. 'Surveillance' alone as a possible treatment modality following orchidectomy in selected patients with clinical stage I NSGCTT requires cooperative and reliable patients. In our urological clinic surveillance alone is not justified any longer because of a noncompliance rate of 10% and a relapse rate of 30%, although the early detection of small-volume metastatic disease, lymphadenectomy and polychemotherapy result in a high rate of cure. Any patient should be excluded from 'wait and see' protocols if metastatic prognostic factors such as vascular infiltration of the primary tumor or local tumor stage greater than pT1 are identified.     

Long-term Results of Adjuvant Irradiation or Surveillance in Stage I Testicular Seminoma

Background : Excellent treatment results are obtained for stage I testicular seminoma treated with orchiectomy and prophylactic radiotherapy. In patients with stage I nonseminomatous testicular tumors, surveillance alone is successful, however, this treatment option for stage I testicular seminomas is controversial. There have been few reports of long-term follow-up of surveillance alone for patients with stage I testicular seminoma.
Methods : To assess the appropriateness of this treatment option, a retrospective survey of stage I testicular seminoma was undertaken. Twenty-seven patients who underwent prophylactic radiation therapy (RT group) and 41 patients followed only by surveillance (S group) after high orchiectomy were evaluated. Their follow-up consisted of frequent clinical examinations, abdominal CT scans, chest x-rays and serum tumor markers.
Results : In the RT group, with a median follow-up period of 15 years, 1 patient (3.6%) had a recurrence in the lung at 4 months after orchiectomy and died, but the remaining 26 are alive with no evidence of disease (NED). In the S group, with a median follow-up period of 7.3 years, 5 (12.2%) relapsed in the retroperitoneal lymph nodes, but all are alive with NED following chemotherapy. The remaining 36 are all alive without recurrence (follow-up period, 38 to 132 months). Although the relapse rate in the S group was relatively higher than in the RT group, there was no significant difference between the 2 groups.
Conclusion : If a frequent follow-up protocol is administered and followed by the patient, surveillance alone may be a recommended management for stage I testicular seminoma.     

Conservative management of testicular endodermal sinus tumor in childhood

Endodermal sinus tumor is the most common testicular neoplasm in childhood. The management of children with this neoplasm remains controversial. We have treated prospectively 5 children with stage I endodermal sinus tumor with limited surgery and no adjuvant therapy. The median patient age at diagnosis was 21 months (range 5 to 24 months). All children underwent an inguinal orchiectomy with high ligation of the spermatic cord. Retroperitoneal node dissection was not performed in any case and no child received adjuvant chemotherapy or radiation therapy. All patients were well without evidence of recurrent disease at a median followup of 46 months (range 19 to 72 months). Because these tumors usually are localized at the time of diagnosis, rarely spread to the retroperitoneal nodes and have a biological marker in most cases, and because good salvage chemotherapy is available for patients with relapse, we believe that nonmetastatic testicular endodermal sinus tumors in children can be managed with radical orchiectomy alone. Retroperitoneal node dissection is not necessary and adjuvant therapy is not indicated if markers return to normal. Further treatment should be reserved for the rare child with relapse.     

Seminoma of the testis at Groote Schuur Hospital, 1973-1984

The clinical records of 47 patients with testicular seminoma treated between 1973 and 1984 were reviewed. The mean age was 41 years. There were relatively few blacks and patients of mixed race--4% and 17% respectively. The incidence of associated testicular maldescent was statistically significantly higher among the black and mixed-race patients (40%) than among the white patients (8%). Forty-three patients underwent retroperitoneal irradiation after orchidectomy, with a 5-year survival rate of 87% at a median follow-up of 52 months. There were no relapses at follow-up in 27 stage I patients; 1 of 8 patients with stage IIA and B (non-bulky) disease relapsed after 12 years, and relapses occurred in all 5 patients with stage IIC (bulky) seminoma. Retroperitoneal and mediastinal irradiation has controlled disease in 2 patients with stage III disease without bulky metastases. One patient with stage IV seminoma treated with irradiation relapsed. One of the patients with stage I disease has developed a major bowel complication following 3,000 cGy fractionated irradiation. Our experience with cis-platinum-based chemotherapy includes noting its effectiveness in a patient with unresectable locally advanced testicular seminoma. We recommend retroperitoneal irradiation after orchidectomy for patients with stage I and IIA/B disease and cis-platinum combination chemotherapy after orchidectomy for those with more advanced disease.     

Germ cell tumor associated primitive neuroectodermal tumors

PURPOSE: This retrospective review was done to assess the prognosis and response in patients presenting with primitive neuroectodermal tumor admixed with germ cell tumor. MATERIALS AND METHODS: Of the 40 patients treated at our institution from 1984 to 1999, 15 had initial stage I and 25 had initial metastatic disease. Median followup after the diagnosis was 25 months (range 4 to 142). RESULTS: Of the 40 patients 15 presented with clinical stage I disease, including 9 treated with retroperitoneal lymph node dissection and 6 who elected surveillance. Seven of the 9 patients had normal lymph nodes and all continuously had no evidence of disease. Two of the 9 patients had lymph nodes involved with teratoma with or without primitive neuroectodermal tumor. Retroperitoneal relapse in 5 of the 6 patients on surveillance was treated with cisplatin based chemotherapy followed by post-chemotherapy retroperitoneal lymph node dissection. Residual primitive neuroectodermal tumor was noted in 4 of the 5 patients and only 3 of 6 are currently without disease at a median followup of 17 months (range 15 to 69). A total of 25 patients presented with metastatic disease, of whom 23 underwent cisplatin based chemotherapy. Only 3 patients achieved complete remission with chemotherapy alone and 2 of the 3 subsequently relapsed. Of the remaining 20 patients 16 underwent post-chemotherapy retroperitoneal lymph node dissection, including 11 with primitive neuroectodermal tumor in the resected specimen. Two of these 11 patients have continuously had no evidence of disease, while an additional 3 currently have no evidence of disease after further therapy. Teratoma was present in the resected specimen in 5 of 16 patients, of whom 2 have continuously had no evidence of disease, while an additional 2 currently have no evidence of disease after further surgical resection. Therefore, 11 of 25 patients who presented with metastatic disease currently have no evidence of disease at a median followup of 19 months (range 2 to 111). CONCLUSIONS: Primitive neuroectodermal tumor in the orchiectomy specimen has adverse prognostic significance. This condition in the retroperitoneum is potentially curable by retroperitoneal lymph node dissection but rarely eradicated by chemotherapy. Therefore, we recommend retroperitoneal lymph node dissection for all clinical stage I cases with primitive neuroectodermal tumor in the orchiectomy specimen. Patients who present with metastatic primitive neuroectodermal tumor should be treated aggressively with surgical resection as an integral part of the therapeutic strategy.