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The authors present the results of a retrospective epidemiologic study on testicular cancer in the Slovak Republic (1993-2002). They analysed the epidemiological features (incidence, mortality, survival, etc.) together with the possible risk factors and diagnostic and therapeutic approaches.
A group of 103 patients operated for lung metastases in the Surgical clinic of the FNsP of L. Dérer and in the II Surgical clinic of L. Pasteur is assessed in this work. Minor operations of atypical resection prevailed among the resections. The postoperative mortality in the whole group was 1.9%. The best long-term survival rates were reached in tumors primarily treated by chemotherapy and followed by the lung metastasectomy. All patients in this group suffered from testical tumors and their long-term survival rate was 69%. In tumor cases, where the metastasis was primarily removed by surgery, the long-term survival rate correlated with the literature data of 30%. When the prognostic factors were considered, the number of removed metachrone metastases being less than 3, appeared statistically significant from the point of view of the patient survival. Based on the evaluated results, it can be concluded that surgical treatment of the lung metastases performed within the interdisciplinary oncological concept, currently remains a generally accepted therapeutic procedure.
Metastatic prostate cancer is primarily treated by endocrine manipulation. Complete androgen blockade with analogue of luteinizing hormone releasing hormone (LHRH) or surgical castration and antiandrogens seem to have no advantage over the LHRH analogues or surgical castration alone. The progression to a hormone-refractory state is still a challenging issue for urologists because of the lack of standard therapy.
Worldwide increase of the incidence of testicular tumors was also reflected in the increasing number of these malignancies in the Slovak Republic. Lack of the accurate information about the occurrence of testicular tumors in Slovakia has helped to create a new multicentric retrospective study based on occurrence, histology, risk factors, diagnosis and treatment of this malignancy in Slovakia. The analysed study group consists of 1010 patients with testicular cancer, diagnosed from the beginning of 1993 to the end of 1997. Identification and histological data about the patients were obtained from the heads of departments of urology in Slovakia. In this study considerable differences were found between information obtained from departments of urology and information published by the National Cancer Register of the Slovak Republic. Ascertained information is higher than the one published by the National Cancer Register from the last five officially concluded years.
INTRODUCTION: The therapeutic procedures in the management of testicular cancer are determined by histological findings in the removed testis and by the extent of the disease at the time of diagnosis. However, all advanced tumors could be treated by primary chemotherapy regardless of the histological findings. The current imaging techniques (ultrasound of the testis, abdominal and chest CT examination) and laboratory tests (determination of serum tumor markers AFP and hCG) provide sufficient evidence for the presence of cancer. When the diagnosis of advanced tumor is evident, it is possible to start the treatment without orchiectomy. The aim of this study was to evaluate the advantages of neo-adjuvant chemotherapy with delayed orchiectomy in the management of advanced testicular cancer. MATERIAL AND METHODS: A total of 36 patients with advanced germ cell testicular cancer underwent primary PVB or BEP chemotherapy without previous orchiectomy. Mean age of patients was 32 years. Detailed medical, surgical and urological examination showed pulmonary metastases and/or extensive abdominal tumorous masses imitating acute abdominal crisis and impaired drainage of the kidney due to ureteral obstruction. Searching for the origin, testicular tumor was detected. Eleven patients had a bulky disease in the retroperitoneum (Stage IIC), two had enlarged retroperitoneal lymph nodes (Stage IIB), two had enlarged mediastinal lymph nodes (Stage III) and other 16 patients had also pulmonary metastases, and 5 pts had pulmonary metastases only. The patients were treated with cisplatin-containing combination chemotherapy. Following completion of chemotherapy, orchiectomy was performed alone or simultaneously with retroperitoneal lymph node dissection (RPLND) and/or lung metastasectomy in cases with persistent residual mass. Following orchiectomy the patients were regularly checked and in cases with viable malignant tumor found in the testis sequential chemotherapy was administered. Similarly when the relapse of the disease was detected, the patients were treated with sequential chemotherapy. RESULTS: Complete disappearance of metastases was observed in 12 patients following chemotherapy alone. The residual mass persisted in 24 patients (in 22 out of them in the retroperitoneum and in two patients also in the lungs) and was removed surgically. The viable tumor in the removed tissue was found in one patient. Delayed orchiectomy was performed simultaneously with surgical removal of residual mass in the retroperitoneum in 24 patients and as a separate procedure in 12 patients who have been considered to be complete responders following chemotherapy alone. Residual viable tumor in testicular specimen was found in three patients, necrotic or fibrotic tissue in 18, and mature teratoma in 15 patients. Overall survival of the patients was 26/36 (72.7%) at mean of 56.9 months (range 7-145 months, median 50 months) since the start of the treatment. CONCLUSIONS: In patients with advanced germ cell testicular cancer preference must be given to the early beginning of intensive chemotherapy without the need of tissue diagnosis of primary tumor that should be obtained by orchiectomy. Benefit of this therapeutic approach is the timely management of acute abdominal and/or pulmonary symptoms of life-threatening distant metastases.
OBJECTIVES: The incidence of bilateral testicular tumors (BTT) had increased over the preceding decade. The aim of the present study is to analyse a group of patients with BTT and to high-light the need for long-term follow-up of patients treated in a single centre. MATERIAL AND METHODS: 27 (2.8%) out of 960 patients with germ-cell testicular tumors (GCTT), treated between 4/1977 and 8/2001, developed bilateral disease. All of them underwent radical orchiectomy (in one patient was done delayed orchiectomy after primary chemotherapy due to advanced disease). Additional treatment was planned according to the histologic type and clinical stage of the disease, and previous treatment as well. The survival data were reviewed. RESULTS: 24 out of 27 patients (88.9%) developed the 2nd tumor metachronously (median interval 66 months, range, 4-197 months) and three (11.1%) had synchronous BTT. Only 7 patients (25.9%) had identical histological types on both sides (6 of them with pure seminomas, one with embryonal carcinoma). Two of three synchronously developed BTT had different histologic types on both sides. GCTT of one histologic type were observed in respect of the first tumor: 11 seminomas, three embryonal carcinomas, in respect of the 2nd tumor: 10 seminomas, three embryonal carcinomas, in respect of the 2nd tumor: 10 seminomas, three embryonal carcinomas and one mature teratoma. GCTT of more than one histologic type were observed in respect of the first and the 2nd tumors: 6 mixed GCTT with seminoma component and 7 without seminoma component. Majority of BTT was presented in clinical stage I (in respect of the first tumor in 70.4%, in respect of the 2nd tumor in 62.9%). The median duration of the follow-up after the diagnosis of the first GCTT was 149 months (range, 13-288 months) and after the diagnosis of the contralateral GCTT was 68 months (range, 1-167 months). Twenty-five patients (92.6%) were alive with NED at their last follow-up visit. Two patients died by mean of 22.5 months (range, 21-24 months) after the 2nd orchiectomy. CONCLUSIONS: All patients with unilateral GCTT have an increased risk of developing a contralateral testicular tumor, even decades after diagnosis. Management should be individualised for each patient.
OBJECTIVE: The therapeutic procedures in the management of testicular germ cell tumors (TGCT) are determined by histological findings in the removed testis and by the extent of the disease at the time of diagnosis. However, all advanced TGCT could be treated by primary chemotherapy (CHT) regardless of histological findings. The current imaging techniques (ultrasonography of the testis, abdominal and thoracic CT examination) and laboratory tests (determination of serum tumor markers AFP and hCG) provide sufficient evidence for the presence of TGCT. In cases of acute abdominal and/or pulmonary symptoms because of life-threatening distant metastases, when the diagnosis of advanced TGCT is evident, it is possible to start the treatment without primary orchiectomy (OE). The aim of this study was to evaluate the advantages of neo-adjuvant CHT with delayed OE in the management of advanced TGCT. MATERIAL AND METHODS: During last 12 years a total of 40 patients with advanced TGCT were treated by neo-adjuvant cisplatin-based combination CHT without previous OE. Eleven patients had bulky mass in the retroperitoneum (Stage IIC), three patients had enlarged retroperitoneal lymph nodes (Stage IIB), two patients had enlarged mediastinal lymph nodes (Stage III). Another 24 patients had pulmonary metastases (Stage IV), 15 of them had also bulky mass in the retroperitoneum and 6 of them in the mediastinum. Following the completion of CHT, OE was performed alone or simultaneously with retroperitoneal lymph node dissection (RPLND) and subsequent lung metastasectomy in cases with persistent residual mass. RESULTS: Complete disappearance of metastases was observed in 13 (32.5%) patients following PVB or BEP CHT alone. The residual mass in the retroperitoneum was removed surgically in 27 patients. In three of them residual tumorous mass was removed also from the lungs without finding of viable tumor. Viable malignant tumor in the removed retroperitoneal tissue was identified in two patients (7.4%). Residual viable malignant tumor in the testis was found in 5 patients (12.5%). Overall survival was 29/40 patients--72.5% (by mean of 55.2 months since the start of the therapy). CONCLUSIONS: The benefit of this therapeutic approach in the immediate management of acute abdominal and/or pulmonary symptoms of life-threatening distant metastases. Another advantage is the like hood of surgical treatment of residual metastatic masses simultaneously with delayed OE on the same day, under one anaesthesia.
INTRODUCTION: The incidence of cancers after renal transplantation is significantly higher than in population that have not undergone transplantation. It is increased by a long-term survival of functional graft requiring long-term immunosuppressive therapy. MATERIAL AND METHODS: Since 1972, 620 renal transplantations have been performed for different causes of end stage renal disease. The authors report a group of 18 renal transplant patients (2.9%) who had cancer. Patients with malignancies are reviewed according to their age, sex, type of immunosuppression, interval between transplantation and the diagnosis of cancer, method of treatment and survival. RESULTS: All patients received cadaver kidneys, and secondary transplantation was performed in two patients. Five patients received conventional immunosuppression--azathioprine with prednisone, another 13 patients received cyclosporine with prednisone and/or azathioprine. In 13 males and 5 females (mean age 46.1 years) the malignant disease developed about 62.4 months after renal transplantation. Six patients had epithelial skin cancers (four of them had squamous cell carcinomas and two basal cell carcinomas). Two patients had breast cancer, colorectal carcinoma, renal cell carcinoma and bladder cancer, respectively, one patient had gastric cancer, thyroid carcinoma, carcinoma of tonsilla, and monocytic leukaemia with blastic transformation, respectively. The average survival of patients with malignancies was 20.3 months. Of 17 patients with cancer, 13 underwent surgical treatment, four patients with advanced disease received radiotherapy, hormonal treatment or only symptomatic therapy. In one patient the malignant disease was only discovered at autopsy. Five patients died of progressive malignant disease, four of intercurrent disease. Nine (50%) patients are alive, with no evidence of disease (NED), 31.9 months in average following the diagnosis of malignancy. Three patients returned to dialysis treatment, other 6 patients live with well functioning graft. CONCLUSIONS: In patients surviving long time after kidney transplantation the possibility of development of malignant disease should be considered. Preventive evaluation should guarantee early detection of cancer. Appropriate treatment, without cessation of immunosuppressive therapy, is indicated with the intention to prolong the patients' life with a functional graft and without dialysis treatment.
BACKGROUND: Surveillance after orchiectomy alone becomes popular for the management of CS I NSGCTT. Effort to identify patients at high risk of relapse leads to searching for prognostic factors of CS I NSGCTT. OBJECTIVES: The aim of this study was to identify those patients in whom surveillance policy is less likely to be successful. METHODS AND RESULTS: 95 CS I NSGCTT patients were stratified to different risk-adapted therapeutic approaches according to histopathologic findings of primary tumor removed by inguinal orchiectomy. Twenty nine patients (group A) with vascular invasion and majority of embryonal carcinoma component in the primary tumor were treated with adjuvant BEP chemotherapy. Disease progression was experienced in one patient (3.4%) 19 months of follow-up. Other 28 patients live without evidence of disease (NED) with a mean follow-up period of 31.1 months after orchiectomy. Six patients (group B) with vascular invasion and majority of teratomatous elements in the primary tumor have been followed 52.7 months after orchiectomy in average. They were treated with primary retroperitoneal lymph node dissection (RPLND). Two of them (33.3%) had pathologic stage II after RPLND and underwent subsequent chemotherapy. The progression of disease was observed in one patient (16.7%) who died 29 months following orchiectomy, another 5 patients live with NED. Sixty patients (group C) without vascular invasion have been followed for 40.6 months in average after orchiectomy. They were kept under close surveillance, consisted of regular follow-up with tumor markers, chest x-ray and CT of the retroperitoneum. Disease progression was observed in 11 (18.3%) patients after a mean duration of 11.8 months after orchiectomy. They were treated with BEP chemotherapy. All of them live with NED (five of them need postchemotherapy RPLND) with mean duration of follow-up 24.8 months after treatment. The overall survival rate of all 95 patients was 98.9% with mean duration of 38.5 months (range, 2-83+). CONCLUSIONS: Surveillance policy is recommend only in patients without vascular invasion in the primary tumor. (Fig. 1, Ref. 32.)
OBJECTIVE: Surveillance after orchiectomy alone becomes popular for the management of clinical stage I nonseminomatous germ cell testicular tumours (CS I NSGCTT). Effort to identify patients at high risk of relapse leads to searching prognostic factors of CS I NSGCTT. The aim of this study was to identify those patients in whom a surveillance policy is less likely to be successful. PATIENTS AND RESULTS: Seventy-two CS I NSGCTT patients were stratified to different risk-adapted therapeutic approaches according to histopathologic findings of primary tumor removed by inguinal orchiectomy. Eighteen patients (group A) with vascular invasion and majority of embryonal carcinoma component in the primary tumor were treated with adjuvant BEP chemotherapy. None of them experienced disease progression after a median follow-up period of 36 months after orchiectomy. Five patients (group B) with vascular invasion and the majority of teratomatous elements in the primary tumor have been followed up 56 months after orchiectomy. They were treated with primary retroperitoneal lymph node dissection (RPLND). Two of them (40%) had pathologic stage II after RPLND and underwent subsequent chemotherapy. One of them died due to disease progression 29 months following orchiectomy. Another one lives with no evidence of disease (NED). Three patients in pathologic stage I are alive with NED. Forth-nine patients (group C) without vascular invasion have been followed up for a median duration of 37 months after orchiectomy. They were kept under close surveillance, consisted of regular follow-up with tumor markers, chest x-ray and CT of the retroperitoneum. Disease progression was observed in 7 (14.3%) patients after a median duration of 8 months after orchiectomy. They were treated with BEP chemotherapy and live with disease-free median survival of 22 months after completion of therapy. The overall survival rate of all 72 patients was 98.6%. The median survival for all patients was 37 months (range 7-73). CONCLUSIONS: The authors will continue to use surveillance policy only in patients without vascular invasion in the primary tumor.
BACKGROUND: The increasing use of progressive noninvasive diagnostic imaging techniques, has substantially increased the detection of incidentally detected renal cell carcinoma (RCC). OBJECTIVES: To determine the manner of presentation of RCC and the frequency of incidentally detected RCC. The natural history of RCC of incidentally discovered RCC was compared with that of symptomatic RCC, the reasons for examination and the methods of diagnosis in patients with incidental tumours were analysed. PATIENTS AND METHODS: In a retrospective study, 463 patients with RCC treated between 1981 and 1995 were reviewed. The patients were divided into four groups according to the fact as to whether the tumours were diagnosed on the basis of urologic symptoms, with paraneoplastic syndromes, with symptoms of metastatic disease, or whether they were detected incidentally. The records of 180 patients with RCC treated between 1991 and 1995 were grouped according to the fact as to whether the tumour was detected incidentally (n = 85), or whether it was discovered with symptoms related to the neoplastic renal disease (n = 95). The groups were compared regarding patient's age, sex, tumour size, grade of malignancy, stage and survival using univariate analyses. RESULTS: The number of RCC detected incidentally has increased from 9.3% (1981-1985) to 47.2% (1991-1995). There were significant differences between groups in the distribution of clinical stages, T1 + T2 stages were more frequently detected in incidental tumours (p < or = 0.005). No significant difference was observed between the survival of incidental and symptomatic patients. Abdominal ultrasonography was the most useful method for the detection of incidental RCC (88.2%). CONCLUSIONS: The results of this study suggest that the incidentally detected RCC occur in lower stages than the symptomatic tumours.
Familial occurrence belongs to factors followed in etiology and pathogenesis of testicular germ-cell tumors. Association with abnormal testicular development, or with other risk factors is relatively frequent. In our material 650 patients had been treated for testicular cancer in the period of 1981-1995. Familial occurrence was observed 7-times (1.08%), most frequently in combination with cryptorchidism. Individual families were analyzed in details, including HLA typing. On basis of the observations the supplementation of initial examination of each patient with suspicious testicular cancer with detailed familial history aimed also at the occurrence of urogenital developmental anomalies and tumors has been recommended. The knowledge about familial tumor occurrence in the first-degree relatives in combination with thorough testicular self-examination is being considered of great importance in the secondary prevention.
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BACKGROUND: Family occurrence ranks belong the factors followed in etiology and pathogenesis of germ-cell tumours of the testis. Its association with abnormal testicular development, respectively with other risk factors is relatively frequent. OBJECTIVES: The aim of this study was to indicate this coherence by means of case histories of author's patients and to propose further procedures. METHODS AND RESULTS: There were 535 patients treated for testicular cancer in the period of 1982-1994. Family occurrence was observed in 6 cases (1.12%), most frequently incombination with maldescensus testis. Individual families were analysed in detail, including HLA typization. Bilaterality of testicular cancer was observed in two brothers who were HLA identical. Other two brothers had the history of bilateral maldescensus testis, one of whom was subdued to bilateral orchiectomy in childhood, the other at the age of 16, a tumour in one testicle following orchidopexy performed in childhood. The history of maldesensus testis was observed in four members of another family, two of whom developed tumours. CONCLUSIONS AND MEANING FOR PRACTICE: Authors recommend supplementation of the initial examination of each patient with suspective testicular cancer with detailed family history aim at the occurrence of urogenital anomalies and tumours. General knowledge of the first-degree relatives about the possibility of family occurrence of tumours, and instructions for testicular self-examination are considered as the most suitable method from the stand point of secondary prevention. (Ref. 21.)
The authors analyse 34 cases of surgeries performed due to residual pulmonary metastases with germinative testicular tumours. Good results in the length of survival are ascribed to thoracotomy, or sternotomy with the resection of metastatic foci, i.e. the only method which reliably ascertains the biological nature of residual pulmonary lesion after chemotherapy. (Tab. 1, Fig. 2, Ref. 17.)
Two hundred and twenty patients with metastatic nonseminomatous germ cell testicular tumors received primary chemotherapy including cisplatin, vinblastine and bleomycin (PVB). Complete response was achieved with chemotherapy alone in 108 (49.1%) patients. Postchemotherapy surgery of the residual mass was done in 85 (38.6%) patients with normalized serum tumor markers. Laparotomy was done in 62 patients, 19 patients underwent thoracic surgery, and 4 patients had both postchemotherapy treatments. Thirteen (5.9%) patients had persistently elevated serum tumor markers, they died despite salvage second-line chemotherapy. Fourteen (6.4%) patients died during primary PVB chemotherapy. The masses removed at laparotomy consisted of necrotic and/or fibrotic tissue in 25.8%, mature teratoma in 61.3% and viable cancer was detected in 12.9% of cases. In contrast, resected pulmonary masses consisted of necrotic and/or fibrotic tissue in 42.1%, mature teratoma in 26.3% and viable cancer in 31.6%. The total therapeutic outcome in 220 patients was as follows: 159 (72.3%) patients are alive and free of disease; 4 (1.8%) patients live with disease, and 57 (25.9%) died of the disease.
The prospective study, carried out from February 1992 to January 1996, included 49 patients in clinical Stage I nonseminomatous germ cell testicular tumors (NSGCTT). They were aged 16-40 years (mean, 25 years). Patients were stratified to different risk-adapted therapeutic approaches according to histopathologic findings of primary tumor removed by inguinal orchiectomy. Eleven patients of the 1st group with vascular invasion and majority of embryonal carcinoma components in the primary tumor were treated with adjuvant chemotherapy (2 cycles of BEP). None of them had disease progression after the follow-up of 4-43+ months (mean, 20.9 months) after orchiectomy. Five patients of the 2nd group with vascular invasion and majority of teratoma elements in the primary tumor were treated with primary retroperitoneal lymph node dissection (RPLND). They were followed-up 29-45+ months (mean, 33.4 months) after orchiectomy. Two of them (40%) had pathologic Stage II after RPLND and underwent subsequent BEP chemotherapy. One of them died due to disease progression in disseminated stage 29 months after orchiectomy. The second one lives with no evidence of the disease (NED). Thirty three patients in the 3rd group without vascular invasion were kept under surveillance. They were followed-up 3-48+ months (mean, 22.3 months) after orchiectomy. Disease progression was observed in 5 of them (15.1%), 7-10 months (mean, 8.8 months) following orchiectomy. These patients were treated with BEP chemotherapy and live with NED 1-16+ months (mean, 9.2 months) after completion of the therapy. The overall survival rate in clinical Stage 1 patients was 97.9%. The authors recommend the surveillance policy only in clinical Stage I NSGCTT patients without vascular invasion in the primary tumor.
Twenty eight patients with germ cell testicular cancer pulmonary metastases received primary chemotherapy including bleomycin, etoposide, and cisplatin (BEP). Complete response was achieved in 21 (75%) patients, in 11 of them CR was achieved following chemotherapy alone. Postchemotherapy surgery of residual mass was performed in 12 (42.9%) patients with normalized serum tumor markers. Retroperitoneal lymph node dissection was performed in one patient, pulmonary surgery in four, and both postchemotherapy treatments in 7 patients. Overall cure rate was 89.3%, 26 (92.9%) patients are still alive at a mean follow-up of 19.7+ months (range, 3-34+ months) after the treatment start. Two (7.1%) patients died: one of them due to disease progression during chemotherapy, and the second one due to postoperative complication (acute respiratory failure). Relapse of disease was observed in one patient 21 months following CR achievement, and sequential chemotherapy was introduced. Authors recommend surgical remove of all radiologically detected residual deposits, because the available imaging methods are not adequate for determining the histologic composition of residual mass, which is decisive for further therapy and has prognostic value.