Five Years Experience with Orchiectomy Alone (Surveillance) for Clinical Stage I Nonseminomatous Germ Cell Testicular Tumors

Five Years Experience with Orchiectomy Alone (Surveillance) for Clinical Stage I Nonseminomatous Germ Cell Testicular Tumors

429 430 VINCRISTINE, CISPLATIN AND CYTOXAN IN THE MANAGEMENT OF ADVANCED METASTATIC SEMINOMA, John N. Wettlaufer and *Alan S. Feiner~ Denver, CO (Pr...

72KB Sizes 2 Downloads 27 Views

429

430

VINCRISTINE, CISPLATIN AND CYTOXAN IN THE MANAGEMENT OF ADVANCED METASTATIC SEMINOMA, John N. Wettlaufer and *Alan S. Feiner~ Denver, CO (Presentation to be made by Dr~ Wettlaufer) The results of primary radiotherapy for advanced stages

FIVE YEARS EXPERIENCE WITH ORC!IIECTOMY ALONE (SURVEILLANCE) FDR CLINICAL ST]l[;E I NONSEMINCMATOUS GERM CELL TESTICULAR TUMORS. D Swanson, D Johnson, A von Eschenbach, R Babaian, and K Wishnow, Houston TX (Presentation by Dr. Swanson)

(B 1 -c) seminoma have been disappointing with significant side effects and compromise full dose chemotherapy when needed~ Many have endorsed standard nonseminoma PVB chemo-

From 10/1/81 through 9/30/86 102 patients with clinical stage I NSGCTT entered our Surveillance Protocol. We required that chest x-ray, CT scan, and lymphangio:;ram show no definite metastases, and that AFP and 13-HCG be normal. Eighty-two patients have at least 12 months minimum followup postorchiectomy. Embryonal carcinana was present in 29 patients, embryonal ca plus teratana in 48, and teratoma alone in 5. Relapses were diagnosed in 24 patients (29,3%) from 2 to 25 months postorchiectany (median 4¼), all but 3 by 9 rronths or earlier. Ten relapses among 29 patients with embryonal ca (34.5%) and 14 arrong 48 with teratocarcinana (29.2%) were similar, but none of 5 patients with teratana failed. Tumor WaB identified in only the retroperitoneum in 9, lung in 4, and both in 4; 7 patients had marker elevation only without disease shown by x-ray. All bit one relapsed patient (who died after a second relapse in the lw1gs) is disease-free off all therapy. Twenty-two patients received chemotherapy when they relapsed and 2 underwent RLND. Vascular and/or lyrrq:,hatic invasion in the primary tumor was assessed in 20 patients and positive in 7. Five have relapsed in the retroperitonewn (1), lung (1), both (2), and marker elevation (1), Two patients with vascular invasion are still clinically disease-free at 12 and 24 months. We conclude that orchiectomy alone is safe and effective under proper conditions: only 1 of 82 patients has died of disease, and 58 patients (70.7%) have been continucusly disease-free postorchiectomy without additional therapy. Among 24 patients who required rrore than orchiectomy, 23 have corrpleted all therapy and are disease-free, Further experience should tetter define risk factors such as vascular invasion in the primary tumor that will allow us to select patients most likely to benefit from this approach.

therapy programs for advanced seminoma with improved survival versus primary radiotherapy~ Since 1979 we have treated 17 patients, 8 with stage B ~ 7 with stage C~ and 2 with extra

gonadal seminoma with 1-; eight day courses (average 2~7) of multi-drug combination chemotherapy consist1:z1g of IV Vincris-

tine 2 mgs, days 1 and s Cytoxan 600 mg/m, days 1,3, and 8; and Cisplatin 20 mg/m , days l through 5 with a 2 week interval between each course of chemotherapy~ The average and median patient age was 26 years. Nine patients had anaplastic seminoma, 6 elevations in B-HCG (22-286MIU) and 12

2

elevations of LDH~ Fifteen had maximal tumor burdenG Eleven of 15 with evaluable primary tumors had either vascular invasion within the testis and/or local tumor spread (T , T3 , T 4 , T 4 ) o A complete response was achieved in all !7 patieni\ an8 16/17 (94%)have no evidence of tumor at 2-84 months with a median and mean follow-up of 50 months (7)50 months, 11)36 months, and 15)12 months)~ The one recurrence (4 months) and death (10 months) was in a patient with massive abdominal, medias tinal, liver and central nervous system metastases Toxicity was minimal (myelo suppression) o Now we routinely use two courses of chemotherapy with a 3rd course only for residual bulk 11 disease 11 These results are superior to standard PVB chemotherapy regimens o Optimal seminoma chemotherapy should include Cisplatin and Cytoxan drug combinations~ &

5

431

432

DIFFICULTIES OF A SURVEILLANCE STUDY IN CLINICAL STAGE I NON-SEMINOMATOUS TESTICULAR CANCER. *G. Pizzocaro and *F.

LIMITATIONS OF PRIMARY RETROPERITONEAL LYMPHADENECTOMY IN CLINICAL STAGE II NON-SEMINOMATOUS TESTICULl',R CANCER. *G. Pizzocaro, Milano, Italy (Presentation to be made by Dr. G. Pizzocaro)

Zanoni,Milanoritaly (Presentation to be made by Dr. Zanoni) From August 1981 to December 1984,90 consecutive patients with clinical stage I nonseminomatous testicular cancer were entered into a prospective study to receive no treatment aftGr orchiectomy until clinical evidence of relapse.Visits were scheduled monthly during the first year I bimonthly for the 2nd year and every 3 months thereafter. Computed tomography of the abdomen was scheduled every 2 visits. The first difficulty was to keep patients to so close and steady a follow-up. Four cases had to be excluded for severe protocol violations. O.f the 86 evaluable patients, 63(73%) remained continously disease-free for a median duration of 40 months (range, 21 to 61 months) ,and evidence of metastases developed in 23 cases (27%)" The median disease-free i~ terval for relapsing patients was 6 months. Distant meta st.'.:'.:_ ses developed in 10 patients (12%) 2-10 months after orchiectomy, and 13 patients (15%) developed retroperitoneal metastases at 3-36 months, While lung metastases were diagnosed early, retroperitoneal metastases were detected when >5cm in 6 cases (46%) .Furthermore, one patient with lung m~ tastases had a second relapse in the retroperitoneal nodes. Twenty-two(95%) of 23 patients with relapse are presently alive disease-free, but 3 patients needed repeated salvage therapies. In spite of excellent results (99% of patients are presently alive disease-free)we consider surveillance a very difficult study, which is justified only in well trained medical centers with poor surgical facilities. Modified retroperitoneal lymphadenectomy makes things much easier:o~ ly markers and the chest must be followed and ejaculation is preserved.

Nonbulky stage II nonseminomatous testicular cancer can be cured in over 95% of cases with either primary surgery or primary chemotherapy. The goal is to achieve the maximun cure rate with minimal treatmento From 1980 to 1984 inclusi ve, 91 consecutive patients with nonserninomatous testicular cancer and radiographic evidence of retroperitoneal metast~ ses
211A