Lucien E. Nochomovitz

Vinblastine, bleomycin and cis-diamminedichloroplatinum in the treatment of advanced testicular carcinoma: Possible importance of longer induction and shorter maintenance schedules

Twenty-eight patients with stage III or recurrent stage I or II testicular cancer were treated with four to six cycles of vinblastine, bleomycin and cis-diamminedichloroplatinum, and then with vinblastine maintenance for one year. With a median follow-up of more than 20.5 months for all patients, complete remission has been achieved with chemotherapy and operation in 23 (82 per cent). One of these 23 patients has had a relapse, and only three are still receiving maintenance therapy. The toxicity incurred by the extra cycles of chemotherapy in patients with extensive disease was no greater than that experienced by patients receiving smaller doses of drugs. These results confirm the high response rate reported for this combination of drugs and strongly suggest that some relapses after complete remission can be prevented by longer remission induction schedules. The value of maintenance therapy is questionable and needs further study.

Serum Alpha-Fetoprotein and Human Chorionic Gonadotropin in Patients with Seminoma

We analyzed the case histories of 31 patients who initially had a diagnosis of seminoma and elevated serum levels of alpha-fetoprotein or human chorionic gonadotropin. We concluded that an elevated alpha-fetoprotein level is firm evidence of the presence of non-seminomatous germ cell tumor and that the patient should be treated accordingly. However, if the level of human chorionic gonadotropin alone is elevated the diagnosis may be either non-seminomatous tumor or seminoma. Patients with seminoma and an elevated level of human chorionic gonadotropin do respond well to radiation therapy if they have low stage disease but if metastatic seminoma is present an elevated human chorionic gonadotropin level appears to be a poor prognostic sign if conventional treatment is given. A plan of treatment is proposed for these patients.

Postirradiation mixed müllerian tumors of the uterus. A comparative clinicopathologic study

Nine patients with mixed müllerian tumors (MMT) of the uterus associated with a history of prior pelvic irradiation were compared clinically and pathologically with 8 nonirradiation‐associated MMT control patients. Patients with postirradiation tumors presented at a younger age and with symptoms indicative of extensive intraabdominal disease while the nonirradiation‐associated control patients were initially evaluated for abnormal uterine bleeding only. Two‐thirds of the postirradiation patients neoplasms were classified as heterologous MMT (mixed mesodermal tumor) whereas 62% of the control patients neoplasms were homologous MMT (carcinosarcoma). Regardless of clinical presentation or histologic composition, both groups fared equally poorly with average survival times of six and seven months, respectively. We were unable to substantiate that some histologic components of uterine MMT denote a poorer prognosis than others or that the postirradiation MMT behaves any differently, in the course of time, from the sporadic type. When uterine MMT is encountered in a patient under 55 years of age, the possibility that pelvic irradiation was administered some years before should be raised.

Tumor markers in advanced nonseminomatous testicular cancer

The serum levels of human chorionic gonadotropin (HCG), alphafetoprotein (AFP), lactic dehydrogenase (LDH), and carcinoembryonic antigen (CEA) were measured in 62 men with advanced nonseminomatous germ‐cell testicular tumors. The HCG level was elevated in 64%, the AFP level in 67%, and the LDH level in 62%, including three of the six men with normal levels of the other two markers. At least one of these three markers was elevated in 91% of patients. Sustained or rising levels of HCG or AFP always were accompanied by persistent or recurrent tumor. Carcinoembryonic antigen was found not to be a useful marker in testicular cancer. Patients whose tumors contained yolk‐sac elements always had elevated AFP levels, and patients with choriocarcinoma always had elevated levels of HCG. However, absence of these histologic types did not preclude elevations of the respective markers. Tumor markers are indispensable in the management of patients with testicular cancer, and several markers must be measured repeatedly if the greatest percentage of patients is to benefit.

Human chorionic gonadotropin and alphafetoprotein in the staging of nonseminomatous testicular cancer

Thirty patients with nonseminomatous testicular cancer and no evidence of metastases outside the retroperitoneum were evaluated for discrepancy between the clinical and pathologic stages and also for frequency of elevations of the serum levels of human chorionic gonadotropin (hCG) and alphafetoprotein (AFP). When marker‐level data were not considered in the staging, the clinical and pathologic stages differed in 47% of the patients; the inclusion of marker data reduced the staging error to 37%. Seven of ten patients with clinical Stage I, pathologic Stage II disease had normal marker levels (false‐negative results). However, there were no false‐positive results: abnormal marker levels before retroperitoneal lymphadenectomy always signalled persistent tumor unless the level could be accounted for by the metabolic decay rate of marker produced by the primary tumor. Comparison of marker‐level data from these patients with data from 48 patients with Stage III disease demonstrated increasing frequency of elevated marker levels with increasing stage (P < 0.001). Serial determinations of HCG and AFP are helpful in clinical staging and are necessary in clinical management.

Tumor classification and size in germ-cell testicular cancer. Influence on the occurrence of metastases

The influence of local tumor spread (T‐classification) and of tumor size on the occurrence of metastases was studied in 241 patients with testicular germ‐cell neoplasms. All patients underwent thorough clinical or pathologic staging, or both, and were treated at the University of Minnesota Hospitals. Spread of tumor through the tunica vaginalis (T2) was associated with abdominal lymph node or distant metastases in eight of nine patients. Local tumor extension to the spermatic cord (T4a) was associated with metastatic spread in 29 of 31 men. Tumor size did not appear to correlate with metastatic rate. These findings are an important aid in designing adjuvant therapy trials and in establishing a “no treatment” approach after orchiectomy.