PET-CT para el manejo de pacientes con cáncer testicular tipo seminoma con masa residual post quimioterapia / PET-CT for the management of testicular seminoma patients with post-chemotherapy residual masses

INTRODUCCIÓN En pacientes con cáncer testicular avanzado tipo seminoma que tienen lesiones residuales post quimioterapia de más de 3 cm, el PET-CT podría seleccionar un subgrupo susceptible de ser manejado con seguimiento, evitando una resección quirúrgica innecesaria de tumor no viable. MÉTODOS Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES Identificamos tres revisiones sistemáticas que en conjunto incluyeron 11 estudios primarios, de los cuales, ninguno es un ensayo aleatorizado. Concluimos que el uso de PET-CT en la evaluación de masas residuales post quimioterapia en pacientes con cáncer testicular tipo seminoma podría evitar un porcentaje importante de cirugías innecesarias (certeza de la evidencia baja). Además, el uso de PET-CT podría presentar balances riesgo/beneficio y costo/beneficio favorables en el manejo de pacientes con cáncer testicular tipo seminoma. Sin embargo, se requieren revisiones sistemáticas y estudios primarios que evalúen directamente el impacto diagnóstico del test.

INTRODUCTION The use of PET-CT could select a subgroup of advanced testicular seminoma patients that display post-chemotherapy residual masses measuring >3 cm and could be managed with surveillance, avoiding unnecessary surgical resection of unviable tumor masses. METHODS We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS We identified three systematic reviews that included eleven primary studies; none of these were randomized trials. We concluded the assessment of postchemotherapy residual masses by PET-CT in testicular seminoma patients may prevent unnecessary surgeries, but the certainty of the evidence is low. Furthermore, PET-CT could also offer a favorable risk/benefit and cost/benefit ratio for the management of testicular seminoma patients. However, systematic reviews and primary studies assessing the direct diagnostic impact of PET-CT are required.

On thin ice: barriers to adoption of surveillance for patients with stage I testicular seminoma. Survey of US radiation oncologists

ABSTRACT Purpose: Most men with stage I testicular seminoma are cured with surgery alone, which is a preferred strategy per national guidelines. The current pattern of practice among US radiation oncologists (ROs) is unknown. Materials and Methods: We surveyed practicing US ROs via an online questionnaire. Respondent's characteristics, self-rated knowledge, perceived patient compliance rates with observation were analyzed for association with treatment recommendations. Results: We received 353 responses from ROs, of whom 23% considered themselves experts. A vast majority (84%) recommend observation as a default strategy, however this rate drops to 3% if the patient is believed to be noncompliant. 33% of respondents believe that survival is jeopardized in case of disease recurrence, and among these respondents only 5% support observation. 22% of respondents over-estimate the likelihood of noncompliance with observation to be in the 50-80% range. Responders with a higher perceived noncompliance rate are more likely to recommend adjuvant therapy (Fisher's exact p<0.01). Only 7% of respondents recommend observation for stage IS seminoma and 45% administer adjuvant RT in patients with elevated pre-orchiectomy alpha-fetal protein levels. Conclusions: Many US ROs over-estimate the likelihood that stage I testicular seminoma patients will be noncompliant with surveillance and incorrectly believe that overall survival is jeopardized if disease recurs on surveillance. Observation is quickly dismissed for patients who are not deemed to be compliant with observation, and is generally not accepted for patients with stage IS disease. There is clearly an opportunity for improved physician education on evidence-based management of stage I testicular seminoma.

[ case report of typhlitis immediately after chemotherapy for seminoma of testes]

Typhlitis is a complication in GI tract specially in ileum and cecum due to severe prolonged neutropenia. The syndrome usually occurs in patients with leukaemia who take aggressive chemotherapy or in solid tumor treated with taxane base regimen. The syndrome is accompanied with neutropenia, fever, generalized abdominal pain specially in right lower quadrant and probably a mass in this area. Case: The patient is a 44 year old man which was presented with enlargement of right testes since two months ago. In sonographic evaluation of testes a mass was defined and surgery was done for him, which pathologic result was seminoma. Staging workup was done and in CT Scan a lymph node with size of 35 mm was detected in paracaval area. According to this result the patient received chemotherapy with Cisplatin and Etoposide. One day after completion of chemotherapy he developed abdominal pain, fever and bloody diarrhea and referred to hospital and admitted with diagnosis of typhlitis. Typhlitis is not restricted to a complication of leukaemia treatment or taxane base chemotherapy and other cytotoxic drugs can induce this problem. On the other hand, neutropenia and typhlitis can occur immediately after chemotherapy in sensitive patient and so the time of nadir value of white blood cell is too short

Extensäo cardíaca de seminoma primário do mediastino, comprimindo a via do ventrículo direito / Cardiac extension of primary mediastinal seminoma compressing the right ventricular outflow tract

We report the case of a 33-year-old male with primary seminoma of the anterior mediastinum with initial clinical manifestations suggestive of heart disease

Management consideration in nonpulmonary visceral metastatic seminoma of testis

To develop a more appropriate therapeutic strategy for treatment of nonpulmonary visceral metastatic testicular seminoma based on the International Germ Cell Consensus Classification, we reviewed the medical records of patients with nonpulmonary visceral metastatic testicular seminoma who were treated over a 20-year period. Only 15 (2.2%) of the 686 cases of testicular seminoma were nonpulmonary visceral metastatic seminoma. The median age of patients was 38 years (range, 22-53 years). Ten (67%) of the patients had an initial diagnosis of supradiaphragmatic or visceral metastatic disease. In addition to nonpulmonary visceral metastasis, all patients had lymph node metastasis as well, the majority of which involved the retroperitoneal lymph nodes. The median and mean progression-free survival durations after chemotherapy for advanced disease were 19 months and 63.7 months, respectively. Six patients (40%) survived, five relapsed after radiation therapy and four died of chemorefractory disease not dependent on the specific regimen. Although the number of cases reviewed in this study was small, we conclude that the choice of chemotherapeutic regimen among the current treatments for nonpulmonary visceral metastatic seminoma of testis primary does not present a different outcome. Therefore, multimodality therapies using new strategies or new agents are well indicated.

Testicular seminoma: an experience from NCI, Cairo with a protocol for the treatment of stage I seminoma

This study was a retrospective analysis of 60 patients with pathologically documented testicular seminoma. The group comprised 21 patients with stage I disease, 17 stage IIa, 17 stage IIb and IIc and five stage III. Cryptorchidism was reported in nine patients and elevated beta subunit of human chorionic gonadotrophin [BHCG] in six. All stage I and IIa patients were treated with radiotherapy alone and reported a five year relapse free actuarial survival rate [RFS] of 93%. Six of stage IIb and IIc patients received radiotherapy and chemotherapy, seven received radiotherapy alone and four received chemotherapy alone. The five-year RFS was 53%. Cryptorchidism did not adversely affect the survival of the patients. High level beta HCG was more commonly encountered in patients with an advanced disease 5/22 in stages IIb, IIc and III compared with 1/38 in stages I and IIa

Seminoma testicular: enfoques terapéuticos de la enfermedad voluminosa / Testicular seminoma: therapeutic focus of bulky disease

De junio de 1986 a junio de 1989, 47 pacientes con diagnóstico de seminoma testicular fueron tratados en los Departamentos de Oncología Médica y Radioterapia del Hospital de Oncología del Centro Médico Nacional. En la etapificación post orquiectomía radical inguinal se encontró que el 59.5 por ciento de los casos fueron etapas II, el 25.5 por ciento recurrencias de etapas IA, mantenidos en vigilancia después de la cirugía y el resto correspondió a etapas IA (6.3 por ciento), III y IV (8.5 por ciento). La enfermedad voluminosa a nivel retroperitoneal fue el problema médico dominante en el 89 por ciento de los casos en etapa II y en el 66.6 por ciento de los casos recurrentes. El tratamiento inicial en todos los casos fue con quimioterapia a base de esquemas con Cis-platino (VBP o EP), el número de cilos varió de 2 a 6. posterior a la quimioterapia 27 pacientes recibieron manejo con radioterapia, 10 de ellos de manera electiva tras una respuesta completa con la quimioterapia, 12 recibieron radioterapia después de respuesta parcial a la quimioterapia con residual tumoral retroperitoneal, y el resto de los pacientes recibieron tratamiento paliativo además de quimioterapia se segunda línea por falla o recurrencia a quimioterapia. La sobrevida actuarial a 5 años fue de 46 por ciento con una media de seguimiento de 42 meses (rango 24 a 98 meses). Comparativamente la sobrevida fue estadísticamente significativa (p= 0.03) mayor para el grupo de manejo combinado, 62 por ciento a 5 años, que para el grupo tratado sólo con quimioterapia, 20 por ciento a 5 años

Tratamiento quimioterápico del seminoma puro / Chemotherapy treatment of pure seminoma

Hemos efectuado quimioterapia complementaria en 9 pacientes orquiectomizados por Seminoma puro. 4 pacientes clasificados clínicamente en estadío IIa y 5 pacientes en estadío IIb. Con un promedio de seguimiento de 18 meses (rango 6-38 meses) la sobrevida es de 100 por ciento y no hemos detectado actividad tumoral recurrente. Concluímos que la quimioterapia es un tratamiento válido para el Seminoma puro

Manejo del cáncer testicular avanzado / Management of the testicular cancer stage B-3 y C

Se presenta la experiencia obtenida, entre 1982-1987, en el tratamiento de 20 pacientes de un cáncer testicular en etapas B-3 y C, 5 tenían un seminoma y 15 un tumor no seminomatoso. Los pacientes en etapa C se dividieron en 2 grupos: C de bajo riesgo (4 pacientes) y C de alto riesgo (8 pacientes), estos últimos tenían metástasis pulmonar múltiples y/o enfermedad visceral diseminada. Todos los pacientes fueron tratados con un esquema de quimioterapia con cistoplatino, bleomicina y vinblastina y 13 de ellos sometidos posteriormente a una linfadenoctompia lumboaórtica y 2 además, a una resección de masa tumoral pulmonar residual. El 37,5 por ciento de los pacientes tenían enfermedad residual post-quimioterapia y de éstos, sólo el 60 por ciento tenían marcadores positivos previo a la intervención. Cuatro pacientes recibieron una quimioterapia de salvataje con cistoplatino, vinblastina y etopósido. La sobrevida libre de enfermedad a 3 años es de 88 por ciento en la etapa B-3, 75 por ciento en la etapa C de bajo riesgo y de 25 por ciento en la etapa C de alto riesgo. Los factores que afectan adversamente el pronóstico son: 1) la presencia de metástasis múltiples pulmonar y 2) la existencia de tumor residual. Estos datos apoyan el uso de una quimioterapia de salvataje, de una cirugía agresiva sobre masas residuales y destacan la importancia que juega lalinfadenectomía lumboaórtica en la detección de tumor residual