Late toxicities and recurrences in patients with clinical stage I non-seminomatous germ cell tumours after 1 cycle of adjuvant bleomycin, etoposide and cisplatin versus primary retroperitoneal lymph node dissection - A 13-year follow-up analysis of a phase III trial cohort.

BACKGROUND: One cycle of adjuvant chemotherapy with bleomycin, etoposide and cisplatin (BEP) has shown superiority in recurrence-free survival over retroperitoneal lymph node dissection (RPLND) in patients with clinical stage (CS) I non-seminomatous germ cell tumours (NSGCTs) of the testis in the setting of a phase III trial. We report the recurrences and late toxicities of this study after 13 years of follow-up. METHODS: Questionnaires from 382 patients with CS I NSGCT treated with 1 cycle of adjuvant BEP (arm A) or RPLND + two cycles of adjuvant BEP in cases of pathological stage II disease (arm B) were evaluated regarding recurrences and late toxicity. Overall, information on recurrence status was available in 337 patients, and 170 questionnaires were evaluable for toxicity (arm A: 95; arm B: 75). RESULTS: With a median follow-up of 13.8 years (0-22), 3 patients (1.6%) in arm A and 16 patients (8.4%) in arm B experienced recurrence. The 15-year PFS in arm A/B was 99% (CI 96-100%)/92% (CI 89-99%) (p = 0.0049). The 15-year OS in arm A/B was 93% (CI 87-97%)/93% (CI 86-97%) (p = 0.83). Eight patients (4.2%) in arm A and four patients (2.1%) in arm B showed metachronous secondary testicular cancer (p = 0.26). Five patients (2.6%) in arm A and four patients (2.1%) in arm B developed other malignancies. Toxicities were not significantly different apart from retrograde ejaculation, which occurred more frequently after RPLND (10% versus 24%, p = 0.01). CONCLUSIONS: With long-term observation, one cycle of BEP remains superior to RPLND in preventing recurrence and was tolerated without any clinically relevant long-term toxicities.

Chemotherapy is of limited efficacy in the control of contralateral testicular intraepithelial neoplasia in patients with testicular germ cell cancer.

INTRODUCTION: Testicular intraepithelial neoplasia (TIN, also called carcinoma in situ of the testis), the precursor of testicular germ cell tumors, will progress to invasive cancer unless appropriate treatment is instituted. Orchiectomy and local radiotherapy have been shown to eradicate TIN safely. The efficacy of chemotherapy is equivocal to date. PATIENTS AND METHODS: Eleven patients with unilateral testicular cancer (5 pure seminoma, 6 nonseminoma) and biopsy-proven contralateral TIN underwent chemotherapy. Four patients received 2 courses of carboplatin single agent, 4 had 2 courses of platin, etoposide, bleomycin (PEB) treatment and 3 had a full 3-cycle treatment with PEB. Rebiopsy to look for persistent TIN was performed after a mean interval of 8.8 months (range 2-31). The patients were then followed clinically. RESULTS: Five patients had persistent TIN upon rebiopsy. Each of the patients failing to chemotherapy had undergone 2 or 3 cycles of the PEB regimen, while 3 had received carboplatin treatment. Two of the patients with no TIN upon rebiopsy developed invasive testis cancer subsequently. In summary, 7 of 11 patients thus failed to chemotherapy (64%; exact 95% confidence interval 30.8-89.1%). Three of the patients had complete absence of spermatogenesis upon rebiopsy histologically, while the remaining cases showed various forms of spermatogenetic arrest. Three of the failing patients were rescued by local radiotherapy, 4 patients underwent partial orchidectomy followed by local radiotherapy. No relapse occurred thereafter. CONCLUSIONS: Chemotherapy was shown to be of only littleeffect in eradicating TIN. The failure rate of 64% is much higher than reported previously. As the majority of failing cases had received carboplatin single-agent therapy or adjuvant PEB therapy with 2 cycles, it may be speculated that the efficacy of chemotherapy regarding TIN clearance is dose dependent. Multidrug regimens appear to be more efficacious than single-agent therapy. As spermatogenesis is only incompletely eliminated by chemotherapy, it is postulated that chemotherapy does no more than temporarily suppress TIN, while only selected cases are cleared of the lesion. Practically, rebiopsy to look for retained TIN about 2 years after completion of chemotherapy is valuable.

Preoperative short-course radiotherapy versus combined radiochemotherapy in locally advanced rectal cancer: a multi-centre prospectively randomised study of the Berlin Cancer Society.

BACKGROUND: The additional use of radiotherapy has changed the treatment of locally advanced rectal cancer (LARC) dramatically. But a major achievement has been the development of total mesorectal excision (TME) as a surgical standard and the recognition that the surgeon is the predominant prognostic factor. The benefit of preoperative hypofractionated radiotherapy (SCRT; five fractions each of 5 Gy), initially established by the Swedish Rectal Cancer Trial, has been demonstrated in conjunction with TME by the Dutch Colorectal Cancer Group. The concept of combined neoadjuvant radiochemotherapy (conventional radiation of about 50 Gy with chemotherapy) has not been compared over surgery alone with TME. However, the German Rectal Cancer Study Group recently demonstrated that preoperative radiochemotherapy (RCT) was better than postoperative radiochemotherapy in terms of local control. METHODS AND DESIGN: Patients with histological proven rectal cancer staged T2N+ or T3 are randomized to receive either SCRT (25 Gy in five fractions of 5 Gy) plus TME-surgery within 5 days or RCT (50.4 Gy in 28 fractions of 1.8 Gy, continuous infusion 5-fluorouracil) plus TME-surgery 4-6 weeks later. All patients receive adjuvant chemotherapy (12 weeks continuous infusional 5-FU) and are followed up for 5 years. TME-quality is independently documented by the surgeon and the pathologist. Hypothesis of the study is that RCT is superior to SCRT in terms of local recurrence after five years. Secondary endpoints are overall survival, disease-free survival, complete resection rate (R0 resection), rate of sphincter saving resection, acute and late toxicity (radiation related side effects), and quality of life (including long term bowel function). DISCUSSION: Similar long-term survival, local control and late morbidity have been reported for both concepts of preoperative therapy in non-comparative studies. In addition to other ongoing (and recently published) comparative trials we include a larger number of patients for adequate power, apply quality-controlled TME and try to avoid the adjuvant treatment bias by mandatory adjuvant chemotherapy in both groups. Further more, stratification of the initially planned surgical procedure and sphincter-preservation will generate valid evidence whether RCT will allow a less aggressive (sphincter saving) surgical approach.

Randomized phase III trial comparing retroperitoneal lymph node dissection with one course of bleomycin and etoposide plus cisplatin chemotherapy in the adjuvant treatment of clinical stage I Nonseminomatous testicular germ cell tumors: AUO trial AH 01/94 by the German Testicular Cancer Study Group.

PURPOSE: Retroperitoneal lymph node dissection (RPLND) and adjuvant chemotherapy are two adjuvant treatment options for patients with clinical stage I nonseminomatous germ cell tumors of the testis (NSGCT). Aim of this trial was to prove the advantage of one cycle of bleomycin, etoposide, and cisplatin (BEP) chemotherapy compared with RPLND in terms of recurrence. PATIENTS AND METHODS: Between 1996 and 2005, 382 patients were randomly assigned to receive either RPLND (n = 191) or one course of BEP (n = 191) after orchidectomy. The primary study end point was the rate of recurrence. The trial was powered to detect a 7% reduction (from 10% to 3%) of recurrence with chemotherapy compared with surgery. RESULTS: After a median follow-up of 4.7 years, two and 15 recurrences were observed in the intention-to-treat population with chemotherapy and surgery, respectively (P = .0011). The difference in the 2-year recurrence-free survival rate between chemotherapy (99.46%; 95% CI, 96.20% to 99.92%) and surgery (91.87%; 95% CI, 86.87% to 95.02%) was 7.59% (95% CI, 3.13% to 12.05%). The hazard ratio to experience a tumor recurrence with surgery as opposed to chemotherapy was 7.937 (95% CI, 1.808 to 34.48). CONCLUSION: To our knowledge, this is the largest randomized trial investigating adjuvant treatment strategies in clinical stage I NSGCT, which showed the superiority of one course BEP over RPLND performed according to community standards to prevent recurrence. Although not standard treatment, one course of BEP is active in an unselected group of patients with clinical stage I disease and merits further investigation.

Ki67 staining index and neuroendocrine differentiation aggravate adverse prognostic parameters in prostate cancer and are characterized by negligible inter-observer variability.

INTRODUCTION: This study aims to clarify whether neuroendocrine differentiation (NED) and/or proliferation activity assessed by means of Ki67 staining index (Ki67SI) might aggravate other established adverse prognostic parameters commonly used for predicting outcome in surgically treated prostate cancer, and to assess inter-observer variability in assigning NED and Ki67 SI. MATERIAL AND METHODS: A total of 528 patients surgically treated due to prostate cancer were evaluated in this study. Relevant data were retrospectively obtained by chart review. Immunostaining with antibodies directed against Chromogranin A and Ki67 was performed on archived surgical material, and was evaluated by two independent histopathologists blinded to the specimens. Surveying a median postsurgical follow-up of 46.4 months, postsurgical serum PSA-levels were regularly documented for identifying biochemical progress. Multivariate analysis was performed by means of the Cox regression hazards regression method to evaluate possible aggravations of established adverse prognostic parameters (nodal status, tumour stage, pretherapeutic PSA-level, and Gleason score) by NED and/or Ki67SI. Ki67 SI and NED were shown to significantly aggravate these established adverse prognostic parameters, and were found to be characterized by negligible inter-observer variability. CONCLUSION: Ki67 SI and NED should be advocated to be rendered by the histopathologist because both parameters can be immunohistochemically determined without much additional expense in time and cost involved. This concept is rewarded by an additional gain of prognostic accuracy in evaluating individual risk profile after surgery.

Prognostic significance of proliferation activity and neuroendocrine differentiation to predict treatment failure after radical prostatectomy.

OBJECTIVES: Neuroendocrine (NE) cells in prostate cancer may influence tumor cell proliferation in a paracrine fashion. The aims of this study were to clarify the prognostic value of tumor cell proliferation and NE tumor cell differentiation in prostate cancer after radical prostatectomy, and to compare these parameters with each other. MATERIAL AND METHODS: Specimens were pooled from a total of 528 patients treated with radical prostatectomy without neoadjuvant hormonal therapy between 1996 and 2003. NE differentiation (NED) was determined by immunohistochemistry using antibodies directed against chromogranin A (CgA), and was scored as either NE-negative (0-1+) or -positive (2-3+). Tumor cell proliferation was assessed by means of the Ki-67 labeling index (Ki-67 LI). The mean post-surgical follow-up period was 49 months (range 10-116 months). Any subsequent rise in prostate-specific antigen (PSA) level was regarded as reflecting disease progression. The prognostic values of Ki-67 and CgA were comparatively analyzed using multivariate Cox regression. RESULTS: NED was present in 6.1% of tumors. The mean Ki-67 LI was significantly higher in the CgA-positive group in comparison with CgA-negative specimens (6.6% vs 5.0%; p=0.029). The Ki-67 LI showed the highest correlations with Gleason score and pathological tumor stage (r=0.31 and r=0.3, respectively). NED was found to have the strongest association with pathological tumor stage (r=0.2). Multivariate analysis determined Gleason score > or =7 (4+3) [hazard ratio (HR) 3.04], NED (HR 1.89), lymph node metastases (HR 1.84), preoperative PSA level>20 ng/ml (HR 1.66), and Ki-67 LI > or = 5% (HR 1.62) to be significant predictors of biochemical progression. CONCLUSION: Our results identify Ki-67 LI and NED as additional prognostic markers after radical prostatectomy.

Spermatogenesis in the contralateral testis of patients with testicular germ cell cancer: histological evaluation of testicular biopsies and a comparison with healthy males.

OBJECTIVE: To assess histologically signs of testicular dysgenesis (TD) in the contralateral testes of patients with testicular germ cell tumours (GCTs) and to compare these findings with the spermatogenetic quality in healthy men, as the contralateral testis is considered to be involved with dysgenetic features such as poor sperm production, and accordingly, GCTs are hypothesized to be part of the 'TD syndrome' (TDS). One testicular biopsy is thought to represent spermatogenesis in the entire testis. We evaluated this view by using testicular two-site biopsies. PATIENTS AND METHODS: 2318 patients with testicular GCT had a contralateral testicular two-site biopsy. Testicular biopsies taken on forensic autopsy from 1388 presumably healthy men served as controls. Spermatogenesis was rated histologically according to a modified Johnsen score. Clinical factors were recorded to explore associations with reduced spermatogenesis. Differences in spermatogenesis scoring results among two-site biopsies were noted. Statistical analysis involved Wilcoxon-Mann-Whitney and Jonckheere-Terpstra tests for comparing patients and controls, and for studying associations with clinical factors. Classification and regression-tree analysis was used to explore multivariate associations. RESULTS: Histologically, patients had significantly poorer spermatogenesis than healthy men. Clinically, hypospermatogenesis was significantly associated with testicular atrophy, undescended testes, male infertility, and advanced clinical stage; 5.4% of cases (95% confidence interval 4.43-6.27) had discordant findings of >2 points on double biopsy and 9.8% had differences of 1 point. Discordance was significantly associated with poor spermatogenesis and testicular atrophy. CONCLUSIONS: We confirmed histologically that there is markedly reduced spermatogenesis in the contralateral testes of patients with GCT. This result lends credence to the view that GCT is part of the so-called TDS. But as hypospermatogenesis is associated with advanced clinical stage, impairment of sperm production might at least partly be acquired secondary to the endocrine activity of GCT. There were clinically relevant discordant results on double biopsy in 5.4%, predominantly in infertile patients and in atrophic testes. Thus the histological evaluation of male infertility is best done by multiple biopsies.

Diagnosis of contralateral testicular intraepithelial neoplasia (TIN) in patients with testicular germ cell cancer: systematic two-site biopsies are more sensitive than a single random biopsy.

OBJECTIVES: Searching for testicular intraepithelial neoplasia (TIN; carcinoma in situ) in the contralateral testis of patients with germ cell tumour (GCT) may early disclose contralateral GCT. A single biopsy of the testis is thought to accurately detect TIN. Reports on false-negative biopsies have challenged this view. We investigated whether systematic two-site biopsies are more sensitive than single biopsies. We also studied the prevalence of contralateral TIN in a large patient sample. METHODS: A total of 2318 patients with testicular GCT underwent contralateral double biopsy. All of the biopsy pairs were examined histologically for spermatogenesis and for presence of TIN. Statistical analysis involved first, overall prevalence of contralateral TIN; second, associations of clinical factors with TIN; third, frequency of discordant findings regarding TIN among biopsy pairs; and finally, associations of discordance with clinical factors. RESULTS: A total of 119 patients (5.13%; 95% confidence interval [CI], 4.27-6.11) had contralateral TIN. TIN is associated with poor spermatogenesis (relative risk [RR] 15.74; 95%CI, 10.38-23.86) and with testicular atrophy (RR 3.78). According to TIN, 31.1% of biopsy pairs were discordant. Discordance was significantly less frequent in atrophic testes and in patients with poor spermatogenesis. CONCLUSIONS: We confirmed the prevalence of contralateral TIN to be about 5%. TIN is significantly associated with poor spermatogenesis and with testicular atrophy. The diagnostic extra yield imparted by double biopsies is 18%. Discordant results regarding TIN are predominantly encountered in normal-sized testicles. The new standard in diagnosing TIN is two-site biopsy.

Prognostic impact of lymphovascular invasion in radical prostatectomy specimens.

OBJECTIVE: To estimate the prognostic value of lymphovascular invasion (LVI) in patients with node-negative prostate cancer treated by radical prostatectomy (RP). PATIENTS AND METHODS: In all, 412 patients with prostatic adenocarcinoma who had RP and pN0 status were analysed for all established standard pathological factors and LVI. The influence of these pathological findings on biochemical failure was evaluated by multivariate analysis with the Cox model. The mean (range) follow-up was 52.5 (10-116) months. RESULTS: LVI was identified in 42 patients (10.2%) and significantly associated with a high preoperative prostate-specific antigen (PSA) level, a high PSA density, high percentage of positive biopsy cores, high Gleason score, and seminal vesicle invasion. Of the 42 patients with LVI, 33 (79%) had a Gleason score of > or = 7 and 27 (64%) had pathological stage pT3. The 5-year biochemical-free survival was 87.3% for patients with no LVI and 38.3% with LVI on the RP specimen (P < 0.001). By multivariate analysis, LVI and Gleason score were independent predictors of biochemical failure. CONCLUSION: These results show that in addition to the Gleason score, only LVI is strongly correlated with biochemical failure after RP. These findings support the routine evaluation of LVI status in RP specimens and provide the option for its incorporation into nomograms predictive of oncological outcome.

Contralateral testicular cancer in spite of TIN-negative double biopsies and interval cisplatin chemotherapy.

BACKGROUND: Current models of tumorigenesis postulate that testicular germ cell cancer uniformly develops through a preinvasive lesion termed testicular intraepithelial neoplasia (TIN). An open testicular biopsy is a simple and highly sensitive method to diagnose TIN, and this procedure constitutes the basis for curative treatment of TIN. Patients with testis cancer carry a significantly increased risk of developing contralateral testicular tumors. Therefore, a contralateral biopsy has been recommended in these patients. A negative biopsy was assumed to exclude the risk of a subsequent germ cell cancer in the testis due to the high sensitivity of the method. Reports on false-negative biopsies gave rise to the idea that TIN is not uniformly distributed throughout the testis. Consequently, double biopsies are thought to increase the diagnostic sensitivity. CASE REPORT: A 24-year-old patient with nonseminomatous testis cancer is reported. The patient had TIN-negative double biopsies in the contralateral testis. He received three cycles of standard PEB (cisplatin, etoposide, bleomycin) chemotherapy for visceral metastasis. 1 year after treatment the patient developed a nonseminomatous contralateral testis cancer which was treated by partial orchiectomy and subsequent local radiotherapy with 20 Gy. CONCLUSION: The case presented here highlights some clinically important aspects: a) even double biopsies of the testis may fail to detect TIN. b) Systemic cisplatin-based chemotherapy may fail to prevent contralateral testicular germ cell cancer. c) A metachronous contralateral testis cancer may-in contrast to common clinical perception-develop even soon after the diagnosis of the first testis tumor. Furthermore, the case could foster the hypothesis that testicular germ cell tumors may in some cases develop without a preceding stage of TIN.

Prevalence of testicular intraepithelial neoplasia in healthy males.

PURPOSE: Testicular intraepithelial neoplasia (TIN), also called intratubular germ cell neoplasia, is thought to be the precursor of testicular germ cell tumors (GCTs). Evidence for this theory stems from clinicopathological studies because to our knowledge experimental models are lacking. While GCT clinical risk groups have been studied extensively for TIN, only 1 small study to date has assessed the presence of TIN in the general population. In the current study we analyzed the prevalence of TIN in a large group of healthy men. MATERIALS AND METHODS: Bilateral testicular specimens were obtained from 1,388 presumably healthy men who died unexpectedly and underwent autopsy at forensic institutes in Germany. Median age in this patient sample was 33 years. Specimens were fixed in Stieve's solution and all specimens were examined immunohistologically with placental alkaline phosphatase staining. RESULTS: TIN was found in 6 cases (0.43%, 95% CI 0.16 to 0.94). Two cases also showed microinvasive seminoma. TIN was bilateral in 1 case. The right testicle was afflicted in 4 cases and the left was affected in 1. Median age of the individuals with TIN was 33 years. CONCLUSIONS: As found in the current study, the prevalence of TIN is consistent with the lifetime risk of GCT in Germany. Data in the current study are in accordance with those in a previous study from Denmark. In all these data represent fundamental support of the role of TIN as the precursor of GCT.

Diagnosis and management of testicular intraepithelial neoplasia (carcinoma in situ)--surgical aspects.

Germ cell tumours (CT) are no true carcinomas; therefore the term testicular intraepithelial neoplasia (IN) is probably more appropriate than "CIS". The diagnostic accuracy of a single-site biopsy is an open question. We experienced 9 false-negative biopsies among 1859 cases. Thus, the proportion of a failed diagnosis is 0.5%. The main reason for diagnostic failure is the non-random distribution of TIN within the testicle. Currently we are investigating whether a two-site biopsy is more accurate than a single biopsy. In the ongoing trial, the over-all prevalence of TIN is around 5.3%, so far. In one quarter of the positive cases the lesion was found in only one of the two specimens. Thus, a double biopsy appears to be more favourable than the traditional single biopsy. Surgical complications amount to 2.5% in that double biopsy study. Only one surgical re-intervention was required among 983 patients. Serial imaging studies with scrotal sonography and magnetic resonance imaging (MRI) disclosed a transient intratesticular haematoma/oedema postoperatively. So, testicular biopsy, even when performed at two sites is in fact a low-complication procedure. Low dose radiotherapy to the testis is the treatment of choice for TIN. However, more than one quarter of patients require testosterone supplementation secondary to androgen-deficiency. Two dose-reduction studies (Denmark and Germany) had to be terminated prematurely because unexpected relapse of TIN was encountered at 14 Gy and 16 Gy. Possibly, hyperfragmentation schedules can overcome the antagonism of androgenic compromise and oncological safety. In a nation-wide survey, it was shown that contralateral biopsies were routinely performed in 66% of the urological departments in Germany. Another 19% offered the biopsy to particular "risk-cases"; only 15% never did a biopsy. Among those refusing biopsies, there was a higher proportion of small hospitals and a significantly lower annual case-number of GCT, when compared to those doing the biopsy. Thus, the contralateral biopsy is a well-established procedure among German urologists; those with a high caseload of GCT particularly appreciate it.

Risk factors for relapse in clinical stage I nonseminomatous testicular germ cell tumors: results of the German Testicular Cancer Study Group Trial.

PURPOSE: To prospectively assess potential risk factors for relapse in clinical stage I nonseminomatous germ cell tumors of the testis (CS I NSGCT). PATIENTS AND METHODS: From September 1996 to May 2002, 200 patients with CS I NSGCT were prospectively assigned to retroperitoneal lymph node dissection (RPLND), and risk factor assessment was performed within a multicenter protocol. One hundred sixty-five patients had an adequate minimum follow-up of 12 months (mean, 34.5 months) or had pathologic stage II. RESULTS: Pathologic stage II disease was found in 27.9% of patients. Only 0.6% of patients relapsed in the retroperitoneum after confirmation of pathologic stage I disease. With reference pathology, vascular invasion (VI) was most predictive of stage in multifactorial analysis (accuracy, 65.1%). However, the positive predictive value (PPV) of VI to predict patients who have metastatic disease or relapse during follow-up was only 52.7%. With absent VI, low-risk patients had a negative predictive value (NPV) of 76.9%. With a combination of several risk factors, the PPV increased to 63.6% and the negative predictive value increased to 86.5%. CONCLUSION: Even with an optimal combination of prognostic factors and reference pathology, more than one third of patients predicted to have pathologic stage II or relapse during follow-up will not harbor metastatic disease and, therefore, would be overtreated with adjuvant therapy. However, patients at low risk may be predicted at an 86.5% level, and thus, surveillance in highly compliant patients would be a valuable option. For high-risk patients, further reduction of adjuvant treatment is necessary.

ALCAM/CD166 is up-regulated in low-grade prostate cancer and progressively lost in high-grade lesions.

BACKGROUND: Activated leukocyte cell adhesion molecule (ALCAM, CD166) is expressed in various tissues, including malignant melanoma, prostate cancer cell lines, and prostate cancer. We aimed to clarify the expression patterns of ALCAM in normal and malignant prostate tissue. METHODS: RNA from 54 matched pairs of microdissected prostate tissue (tumor and normal) was hybridized to a custom built 4K GeneChip. Frozen section immunohistochemistry was used to confirm the ALCAM expression. RESULTS: Chip-based transcript analysis revealed an up-regulation of ALCAM in prostate cancer in 22% of cases. Immunohistochemistry showed a focally raised ALCAM expression in 81% and a decreased expression in 19% of cases. These expression patterns correlated significantly with Gleason tumor grade: ALCAM up-regulation was found in most low-grade tumors (Gleason grade 1-3), whereas down-regulation occurred preferentially in high-grade tumors (Gleason grade 4 and 5), although up-regulation of ALCAM expression was preserved in two Gleason grade 5 tumors. CONCLUSION: ALCAM expression is commonly disturbed in prostate cancer, which might indicate a role of ALCAM in the progression of this disease.