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Journal of Clinical Oncology, Vol 22, No 9 (May 1), 2004: pp. 1755-1756 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.08.005
Germ Cell TumorsCASE 2. Unusual Course of Pure Testicular SeminomaDepartment of Medical Oncology, Institut Gustave Roussy, Villejuif; Department of Medical Oncology, Hopital Tenon, Paris, France A 33-year-old white man sought medical advice concerning abdominal pain that had lasted a month. He had no significant other medical history. Physical and laboratory evaluation was unremarkable. Ultrasound evaluation showed an enlarged abdominal lymph node. Computed tomography (CT) scan confirmed a 10-mm interaortocaval lymph node without any other abnormal image. Symptoms resolved within hours of treatment with analgesics. The patient was seen 1 month later with recurrent abdominal pain. His new CT scan showed an enlargement of the lymph node to 25 mm. Testicular ultrasound depicted a heterogeneous right testicle, consistent with a testicular tumor. Alpha-fetoprotein, human chorionic gonadotrophin (HCG), free beta-HCG, and lactate dehydrogenase (LDH) levels were normal. A right orchidectomy was performed. The histopathologic diagnosis was a typical pure seminoma. He was then treated with four cycles of chemotherapy with etoposide 100 mg/m2 and cisplatin 20 mg/m2, days 1 to 5, because of the unusual growth pattern of the involved lymph node. A partial remission was attained, with shrinkage of the lymph node to 12.5 mm. Close clinical and radiologic follow-up was initiated. Six months later, the lymph node image had enlarged to 30 mm. Excision of the involved retroperitoneal lymph node was performed and pathologic results revealed only necrosis with no viable tumor. The patient missed follow-up appointments and presented 7 months later with painful abdominal swelling, anorexia, and fatigue. Physical examination revealed massive hepatomegaly. The alkaline phosphatase level was 363 U/L (normal < 135 U/L), gamma-glutamyltransferase level was 361 U/L (normal < 64 U/L), AST level was 223 U/L (normal < 42 U/L), and total bilirubin was 31 µmol/L (normal < 17 µmol/L). The serum LDH level was 10,000 U/L (normal < 600 U/L). Alpha-fetoprotein as well as HCG and free beta-HCG levels were normal. An abdominal CT scan (Fig 1) showed numerous liver metastases as well as portal and celiac lymph node involvement. Thoracic and cerebral CT scans were normal. Ultrasound-guided liver biopsy revealed a typical pure seminoma. Salvage chemotherapy consisting of three cycles of vinblastine, ifosfamide, and cisplatin1 led to the normalization of serum LDH, but only a partial response was obtained on the liver and the lymph node metastases. The patient then was treated with two consecutive cycles of high-dose chemotherapy according to the regimen with ifosfamide 12 g/m2, carboplatin 1,500 mg/m2, and etoposide 1,500 mg/m2,2 followed by autologous stem-cell transplantation. Consecutive abdominal CT scans showed progressive shrinkage of the liver and lymph node metastases. Additional surgery, including retroperitoneal lymph node dissection and partial hepatectomy, were discussed but not performed because the positron emission tomography scan was normal. At present, the patient is well, with no evidence of disease on CT scan (Fig 2), 24 months after the end of salvage chemotherapy.
Poor-prognosis early-stage seminoma is unusual. Radiotherapy remains the standard treatment for early-stage (stage I and IIA-B, American Joint Committee on Cancer and International Union Against Cancer 1997 classification3) pure seminoma. However, this patient's management with chemotherapy according to the advanced seminoma reference protocol4 was a result of the rapid tumor growth pattern. Retroperitoneal lymph node dissection was not performed after initial chemotherapy in accordance with guidelines regarding the treatment of advanced seminoma.5 Unlike nonseminomatous germ cell tumors, seminomas remain a highly chemotherapy-sensitive malignancy, even at relapse. Although the indications for intensive chemotherapy are not defined clearly in germ cell tumors in general,6,7 seminoma presenting with an unusually aggressive clinical course may be an indication. Indeed, few malignant tumors with such extensive hepatic metastases are amenable to long-term complete remission with chemotherapy alone. This case report emphasizes the importance of avoiding large-field radiotherapy as initial treatment for rapidly growing seminoma to preserve the bone marrow potential. It also raises the question of initial treatment with a different chemotherapy protocol other than etoposide and cisplatin in these patients. Moreover, because the morphologic pathologic appearance of this tumor was unremarkable, it stresses the importance of research on the biologic characteristics of aggressiveness in seminoma. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
REFERENCES 1. Miller KD, Loehrer PJ, Gonin R, et al: Salvage chemotherapy with vinblastine, ifosfamide and cisplatin in recurrent seminoma. J Clin Oncol 15:1427–1431, 1997[Abstract] 2. Lotz JP, Andre T, Bouleuc C, et al: The ICE regimen (ifosfamide, carboplatin, etoposide) for the treatment of germ-cell tumors and metastatic trophoblastic disease. Bone Marrow Transplant 18:S55–S59, 1996 (suppl 1)
3. International Germ Cell Consensus Classification: A prognostic factor-based staging system for metastatic germ cell cancers. J Clin Oncol 15:594–603, 1997 4. Mencel PJ, Motzer RJ, Mazumdar M, et al: Advanced seminoma: Treatment results, survival, and prognostic factors in 142 patients. J Clin Oncol 12:120–126, 1994[Abstract]
5. Puc HS, Heelan R, Mazumdar M, et al: Management of residual mass in advanced seminoma: Results and recommendations from the Memorial Sloan-Kettering Cancer Center. J Clin Oncol 14:454–460, 1996 6. Rosti G, Pico JL, Wandt H, et al: High-dose therapy in the salvage treatment of patients failing first-line platinum chemotherapy for advanced germ cell tumors: First results of a prospective randomized trial of the European Group for Blood and Marrow Transplantation—T-94 Study. Proc Am Soc Clin Oncol 21: 2002 (abstr 716)
7. Vuky J, Tickoo SK, Sheinfeld J, et al: Salvage chemotherapy for patients with advanced pure seminoma. J Clin Oncol 20:297–301, 2002
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Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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