Prognostic factors in unselected patients with nonseminomatous metastatic testicular cancer: a multicenter experience.

Abstract

Between 1981 and 1986, 200 consecutive patients with metastatic nonseminomatous testicular cancer were entered into the Swedish Norwegian Testicular Cancer (SWENOTECA) project from 14 hospitals. The treatment plan was four chemotherapy cycles (cisplatin, vinblastine, and bleomycin) followed by surgical resection of residual tumor masses. After a median observation time of 75 months, the overall 5-year survival rate was 82%. In a univariate analysis, the following parameters influenced the prognosis significantly: the extent of the disease (Medical Research Council [MRC] grouping); the prechemotherapy levels of serum alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and lactate dehydrogenase (LDH); the patients' age; the presence of extrapulmonary hematogeneous metastases; and/or particularly large lymph node metastases. Patients fared better when more than 3 weeks elapsed between orchiectomy and start of chemotherapy as compared with those who were treated within this interval. The place of treatment (a large oncology unit v smaller units) also represented a significant prognostic factor for patients with large-volume (LV) and very-large-volume (VLV) disease combined. Multivariate analysis (Cox regression proportional hazards model) performed in all 193 assessable patients showed the following adverse prognostic factors: high-volume metastatic burden, age older than 35 years, prechemotherapy AFP greater than 500 micrograms/L and/or HCG greater than 1,000 U/L, and an interval between orchiectomy and start of chemotherapy of less than 3 weeks. The place of treatment also significantly influenced the final outcome. If patients with LV and VLV disease were combined, the presence of two of the following risk factors represented an additional prognostic factor: AFP greater than 1,000 micrograms/L, HCG greater than 10,000 U/L, liver metastases, brain metastases, bone metastases, retroperitoneal tumor greater than or equal to 10 cm, and mediastinal tumor greater than or equal to 5 cm.

Late recurrences of germ cell malignancies: a population-based experience over three decades

“…Our incidence rate of 1.3% is considerably lower than figures from the literature (2.9% (Baniel et al, 1995), 4.3% (Gerl et al, 1997), 5.9% (Shahidi et al, 2002)). These discrepancies may be due to referral and publication bias in that patients with poor prognosis, and thus, at high risk of late relapses, may preferably have been referred to experienced centers (Aass et al, 1991;Collette et al, 1999), which regularly publish their results. A referral-bias may also explain the finding of 40% initial seminoma in late relapses compared to 2 -4% in the series from the Indiana group (Baniel et al, 1995;George et al, 2003), 4% in a German series (Gerl et al, 1997), or to 28% in a series from the Royal Marsden Hospital (Shahidi et al, 2002).…”

Centralised treatment, entry to trials and survival

“…In the United States, no difference was found in survival rates between major centres and local community hospitals for any of the nine cancer sites included in tnals sponsored by the Eastern Cooperative Oncology Group during 1976-81 (Begg et al, 1982), or for five studies of the Radiation Therapy Oncology Group (Gillespie et al, 1986 (Meadows et al, 1983;Stiller & Draper, 1989); an unusually high survival rate was achieved at one centre in Britain during the 1970s which had only a moderate number of patients, but where there was believed to be an unusually strong emphasis for that period on strict adherence to the treatment protocol (Eden et al, 1988). Two studies of testicular cancer found that, among men receiving protocol treatment, survival rates were higher at a single centre treating very large numbers of patients (Aass et al, 1991;Harding et al, 1993) (Matthews et al, 1986;Allum et al, 1989). Two studies of colorectal cancer have shown wide variability in mortality between surgeons (Phillips et al, 1984;McArdle & Hole, 1991), but this appeared to be unrelated to the number of operations performed.…”

Long-term follow-up of residual masses after chemotherapy in patients with non-seminomatous germ cell tumours

“…However, there is no clear consensus as to the management of patients with serological CR. Treatment strategies have included surgery (usually retroperitoneal lymph node dissection (RPLND)) in all patients including those with radiological CR (Gelderman et al, 1986;Fossa et al, 1989;Aass et al, 1991), surgical intervention in those with residual masses only (Donohue and Rowland, 1984;Steyerberg et al, 1993) or resection in a selected group of patients with residual masses (Levitt et al, 1985;Hendry et al, 1993;Debono et al, 1997). Criteria proposed and used for selection of these patients have included the size of the mass, the degree of shrinkage of the mass with chemotherapy, degree of further shrinkage after chemotherapy and the histology of the primary tumour (Levitt et al, 1985, Donohue et al, 1987, Fossa et al, 1992, Hendry et al, 1993, Jaeger et al, 1994, Debono et al, 1997.…”