|Year : 2004 | Volume
| Issue : 2 | Page : 160-163
Management of testicular tumors- SGPGIMS experience
Vishwajeet Singh, Aneesh Srivastava, Avinash Srivastava, Anant Kumar, Rakesh Kapoor, Anil Mandhani
Department of Urology & Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
Department of Urology & Renal transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow - 226 014
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives : To assess the single centre experience of multimodality treatment approaches and overall outcome in testicular tumor patients.
Methods : In a retrospective study, records of 70 patients were analysed. Seminoma was present in 21 cases, non seminomatous germ cell tumour (NSGCT) in 48 patients and Leydig cell tumor in 1 patient. The clinical staging in seminoma of the testis were stage I in 6 cases, stage IIA in 4 cases, the stage JIB in 2 cases, stage HC in 2 cases and stage III in 7 cases. In the NSGCT group stage I tumor was present in 3 cases, stage IIA in I case, stage IIB in 4 cases, stage IIC in 4 cases and stage III in 36 cases. Adjuvant radiotherapy to retroperitoneum was given in stage I and IIA of seminoma. Primary retroperitoneal lympho node dissection (RPLND) was done in 4 cases of NSGCT and biopsy of lymph nodes was positive for malignant cells in one case. Cisplatinum based chemotherapy was given in stage IIB, JIC and stage III of seminoma and NSGCT Secondary RPLND was done in 2 cases and excision of postchemotherapy residual masses in 14 cases.
Results : The patients of stage I NSGCT tumors had recurrence free mean follow-up of 9 years while 1 case of stage IIA was disease free at 1 year of follow-up. All cases of stage IIA, IIB,IIC seminoma and NSGCT patients were alive and doing well on follow-up. In advanced and metastatic tumors, 75% of seminoma and 60% of NSGCT patients were alive and disease free with mean follow-up period of 5 years and 4 years respectively.
Conclusions: Excellent prognosis was seen in early stages of testicular germ cell tumors. Advanced and metastatic seminoma showed good prognosis whereas only 60% of such NSGCT are disease free and alive on long-term follow-up.
Keywords: Germ cell, multimodality, radiotherapy, chemotherapy.
|How to cite this article:|
Singh V, Srivastava A, Srivastava A, Kumar A, Kapoor R, Mandhani A. Management of testicular tumors- SGPGIMS experience. Indian J Urol 2004;20:160-3
| Introduction|| |
Testicular tumors are the most common malignancy in the young male aged between 15-34 years.  Germ cell tumors are the most common testicular tumors. Testicular treatment cancer has improved dramatically over the last 25 years, with cure rates approaching as high as 95% in early stage germ cell tumor.  This success in treatment is the result of multimodality therapy that may include cisplatin based chemotherapy, surgery and radiotherapy  . In spite of the remarkable progress made over the last two decades using cisplatin based combination chemotherapy, approximately 20% of patients presenting with metastasis, die of their stage of the disease.  The prognosis of the patients decreases with advancement of disease.  Two groups have been distinguished on the basis of predicted treatment outcome. One group, which includes the majority of the patients and who are likely to obtain an initial complete response, is categorized as good risk germ cell tumor. The second group comprises the minority of patients who are likely to fail in achieving a durable complete response to standard programs and is categorized as poor-risk germ cell tumors.  The majority of the studies on multi model therapy of testicular tumors are from the Western world. The aim of this study is to assess our experience regarding management of testicular tumor patients and the outcome of multimodality treatment approaches in these patients, and also to see if any differences exist between the response of our patients and that of the Western world.
| Patients and Methods|| |
In this retrospective study the records of all 70 treated patients between 1991-2002, were analysed. Mean patient age was 34 years. Right side tumor was present in 35 patients of whom 2, patients had tumor in the cryptorchid testis and left side tumor was seen in 33 cases. Two patients presented with tumors in bilateral undescended testes (synchronous tumors). Apart from routine investigations, the tumor markers α feto-protein and β-hcg were done in all the cases. All the patients had chest X-ray and contrast enhanced computed tomography (CT) scan of the abdomen. CT scans of the head was done in one case who had suspected brain metastasis. MRI of the spine was done in two cases who had backache and paraperesis. The histopathological diagnosis was obtained from the primary tumor mass by inguinal orchiectomy in 66 cases, fine needle aspiration cytology of the tumor in intra-abdominal cryptorchid testes in 2 cases and by abdominal exploration and orchiectomy in 2 cases.The staging system used was based primarily on the Boden and Gibb staging system and with modification of the Memorial Sloan Kettering Cancer Center and AJCC 1997. The clinical stage among seminoma testis were stage I in 6, stage IIA in 4,stage JIB in 2, stage IIC in 2 and stage III in 7 cases. The clinical stage in non-seminomatous germ cell tumor (NSGCT) were stage I in 3. stage IIA in one, stage IIB in 4, stage IIC in 4 and stage III in 36 cases. Stage I and IIA seminomas were given adjuvant radiotherapy. The dose of radiotherapy was 25 Gy to both the paraaortic lymph nodes and the ipsilateral iliac lymph nodes. Primary retroperitoneal lymph node dessection (RPLND) was done in 4 cases of NSGCT. The cases of stage IIB, IIC and III seminoma and NSGCT were initially treated by primary chemotherapy. We used the primary BEP(Bleomycin,Etoposide and Cisplatinum) chemotherapy regimen in 11 cases of seminoma and 44 cases of NSGCT. One case of stage IIA NSGCT received 2 cycles of BEP adjuvant chemotherapy following primary RPLND. The dose of BEP regimen was at cisplatinum-20mg/m 2 on day 1-5, etoposide- 100 mg/ m 2 on day 1-5 and bleomycin 30 units on day 2, 9 16. The cycles repeated at every 21 days. These patients were given 3 to 4 cycles primary chemotherapy based on the prognosis group they fell in. The poor prognosis group (non pulmonary visceral metastasis, AFP >10,000 ng/ml, hCG > 50,000 IU/L, LDH>l0times upper limit of normal) was given 4 cycles of chemotherapy while the good prognosis group was given 3 cycles. In the present study 5 cases of seminoma and 19 cases of NSGCT were given 4 cycles of chemotherapy. The follow-up protocols used for seminoma was physical examination, chest X- ray monthly and abdominal CT scan 3 monthly for the first 2 years and physical examination, and chest X-ray 3 monthly for the next 3 to 5 years and CT scan of the abdomen 6 monthly from the 3 rd to 5 th year. Thereafter physical examination, chest X-ray and CT scan yearly was carried out till 10 years. In NSGCT at each visit apart from the above protocol, AFP and β hcg were also done. Secondary RPLND was done in 2 cases and excision of postchemotherapy residual masses in 14 cases. The criteria for secondary RPLND were raised tumor markers with normal hetroperitoneal lymph nodes. The criteria for the excision of post chemotherapy mass were a mass more than 3 cm in the case of a seminoma and a mass more than 1.5 cm in the case of NSGCT with or without raised tumor markers in NSGCT. The excision of residual masses was accomplished with unilateral nephrectomy in 5 cases. The residual masses was very densely adherent to the aorta in one case in which a partial aortic wall excision and reconstruction was done. In one more patient the residual mass was adherant to the vena caval wall which was managed by partial vena caval wall excision and reconstruction. The patients who lost to follow-up were sent a letter. They were taken as dead if there was no response or after confirmation from the relatives. The mean survival for stage I, II and II seminoma and NSGCT were calculated.
| Results|| |
The primary histopathology was seminoma in 21 cases and NSGCT in 48 cases. All cases of NSGCT were of mixed histology. No correlation could be drawn between histopathology and the level of preoperative tumor markers. The tumor markers showed downward trend following inguinal orchiectomy and it was more marked in the advanced stage NSGCT. The stage I and IIA seminomas had a mean survival of 8 years [Table - 1]. All the 3 patients of stage I NSGCT were disease free in a mean follow-up 9 years and 1 patient of stage IIA NSGCT had 1 year of follow-up [Table - 2].The patient of benign leydig cell tumor is disease free at 4 years of follow-up.The patients of stage JIB and IIC seminoma have disease free mean follow-up of 6 years [Table - 1]. The stage JIB and IIC NSGCT patients are disease free in mean follow-up of 5 years [Table - 2]. The poor risk group comprised of 5 cases of stage III seminoma and out of that 2 died in the follow-up. The other 3 patients are doing well on follow-up. In stage III NSGCT the poor risk group comprised of 19 cases and out of these 2 patients refused salvage chemotherapy following secondary RPLND. They were taken as dead when the failed to respond to letters and 9 more cases died following chemotherapy because of the extensive recurrences. All the above poor risk patients of seminoma and NSGCT were given 4 cycles of chemotherapy. None of the patients dropped out of primary chemotherapy or radiotherapy. Overall 75% patients of stage III seminoma and 60% of stage III NSGCT were alive and disease free in the mean follow-up periods of 5 years and 4 years respectively [Table - 1],[Table - 2]. The poor prognosis in stage III NSGCT may be related to the presence of 19 cases (53%) of poor risk group of whom 11 died. The excision of postchemotherapy residual mass was done in 14 cases. The histopathological examination of the excised of postchemotherapy residual masses showed only fibrotic and necrotic tissues and there was no evidence of malignant cells. These patients are doing well in the subsequent follow-up.
| Discussion|| |
The cure rate in early stage germ cell tumors is approximately 95%.  Nearly 50% of these tumors are pure seminomas. , In our study only 30% had seminoma. The reason for this observation may be related to our small patient population. The serum tumor markers such as α-feto protein , β-hcg and CT scan of the abdomen remains the most widely accepted modalities for staging. ,, Primary RPLND remains the standard treatment in high risk patients with clinical stage I NSGCT. ,,,, The established poor risk factors for NSGCT include vascular or lymphatic invasion, predominance of embryonal cell carcinoma and advanced T stage. ,,, The improvement in the RPLND techniques have decreased the morbidity of the procedure as well as the incidence of retrograde ejaculation.  In our study primary RPLND was done in 4 patients and only 1 patient has preserved antegrade ejacualtion. Surveillance is not suitable in all stage I NSGCT and 30% of patients have recurrence of disease. ,, In our patients none of the patients of stage I NSGCT was kept on the surveillance protocol. Primary RPLND has the advantage that it accurately stages the disease and if the lymph node shows malignant cells, the patients should be given 2 cycles of cisplatinum based chemotherapy.  We gave 2 cycles of BEP chemotherapy in l patient who had positive lymph nodes on primary RPLND and he is doing well on followup. In patients with clinical stage I seminoma, adjuvant radiotherapy and surveillance are current treatments of choice.  Adjuvant radiotherapy to the retroperitoneum was given in 6 patients of stage I and 4 patients of stage IIA seminoma and all are disease free in mean a follow-up period of 8 years. In clinical stage JIB, IIC and III seminoma and NSGCT, 3-4 cycles of cisplatin based chemotherapy is advocated ,,,,, The cure rate of adjuvant chemotherapy in stage IIB, IIC seminoma and NSGCT are 70% to 80%. ,, Our study shows comparable results [Table - 1],[Table - 2]. At the end of 3 cycles of chemotherapy a CT scan of the abdomen and tumor markers in NSGCT should be done. If there is residual mass greater than 3 cm with or without raised tumor markers then 1 more cycle should be given. ,,,, The response to chemotherapy in advanced and metastatic germ cell tumor is 65% to 70% and they can be disease free long term follow-up.  These patients should be considered potentially curable, and aggressive multimodality treatment should be employed.  The combined modality approach has resulted in cure rates of 70% to 80%.  For advanced and metastatic germ cell tumors and advanced germ cell tumor in bilaterally undescended testes the management of post chemotherapy residual mass remains an integral part of patient management. ,, The published variables where surgery can be omitted safely are normal postchemotherapy CT scans, residual abdominal masses of less than 1.5 cm or 20 cc in volume, greater than 90% reduction of prechemotherapy mass and no teratomatous elements in the orchiectomy specimen for NSGCT and less than 3 cm for seminoma. , The patients who have viable cells in the specimen should be given second line salvage chemotherapy regimen consisting of ifosfamide, vinblastine and cisplatinum. ,, In the present study, viable malignant cells were present in both cases of secondary RPLND. They were advised for second line of chemotherapy but they were lost to follow-up. In the present series 75% cases of advanced and metastatic seminoma and 60% of cases of advanced and metastatic NSGCT are alive and disease free in the mean follow-up period of 5 and 4 years respectively.
| Conclusions|| |
Based on the multimodality treatment approaches, our experience also shows the excellent prognosis in early stage germ cell tumor. The prognosis for the advanced and metastatic seminoma is comparable to western literature. The majorities of our advanced and metastatic NSGCT were of poor risk group which ultimately led to the poor prognosis in this group.
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[Table - 1], [Table - 2]