Risk of systemic metastases in clinical stage I nonseminoma germ cell testis tumor managed by retroperitoneal lymph node dissection.

PURPOSE: We assess the risk of systemic recurrence after retroperitoneal lymph node dissection for clinical stage I nonseminoma germ cell testis tumor based on predominance of embryonal carcinoma and/or vascular invasion in the orchiectomy specimen. MATERIALS AND METHODS: A total of 292 cases of clinical stage I nonseminoma germ cell testis tumor treated with retroperitoneal lymph node dissection from 1990 to 1995 were identified from the Indiana University database. A minimum of 2 years of followup was required for study entry. Review of the written pathological reports classified tumors as embryonal carcinoma predominant, when it was present at a level greater than any other histology, nonpredominant, when it was present but not as the main histological subtype, and absent. Vascular invasion was categorized as present or absent. RESULTS: Of the 292 cases 226 (77. 4%) were pathological stage I and relapse rate after retroperitoneal lymph node dissection was 10.2%. Vascular invasion and embryonal carcinoma predominance in the orchiectomy specimen were predictors of relapse in this group. None of the 35 pathological stage II cases treated with adjuvant chemotherapy had relapse, whereas relapse occurred in 7 of 31 pathological stage II cases (22.6%) not treated with adjuvant chemotherapy. CONCLUSIONS: Pathological stage I cases with predominant embryonal carcinoma and/or vascular invasion in the orchiectomy specimen have a higher probability of systemic recurrence after retroperitoneal lymph node dissection. Dissection alone still has a major therapeutic impact (77%) in patients with clinical stage I, pathological stage II nonseminoma germ cell testis tumor.

A phase II trial of high dose epirubicin in patients with advanced breast carcinoma.

BACKGROUND: Anthracyclines are among the most active drugs in the treatment of breast carcinoma and exhibit a steep dose-response curve in vitro. This trial was performed to determine the efficacy and toxicity of epirubicin in the treatment of patients with advanced breast carcinoma when administered as a single agent in maximal doses. METHODS: Patients with chemotherapy-naïve American Joint Committee on Cancer/International Union Against Cancer Stage IIIB or IV breast carcinoma received epirubicin, 180 mg/m(2), intravenously every 3 weeks for a maximum of 8 cycles of therapy. Hematopoietic growth factors and cardioprotective agents were not used routinely. RESULTS: Twenty-seven patients were entered in the study. Although NCI/CTC criteria Grade 4 neutropenia occurred in 96% of patients, epirubicin was administered at 83.1% of the planned dose intensity. The median fall in left ventricular ejection fraction was 10%; clinical cardiac toxicity was observed in 3 patients. Objective responses were observed in 21 patients, including 6 complete responses. CONCLUSIONS: High dose epirubicin was found to result in substantial hematologic toxicity but was highly active in the treatment of patients with advanced breast carcinoma.

Biology of metastases and its clinical implications: testicular germ-cell tumors.

This article deals with observations of the clinical behavior of metastatic germ cell cancers of testicular origin. Therefore, when we speak of biology of metastases, we refer to that seen by the clinician as opposed to the laboratory scientist. First, we will review our experience with chemotherapy for metastatic disease. From this we can gain insight into risk factors for relapse and survival. Furthermore, we can infer there are fundamental differences in the biology of germ cell cancers of testicular origin as opposed to primary mediastinal or primary retroperitoneal origin. Some of these differences are further discussed. We also identify "good risk" parameters and suggest criteria for expectant or conservative management postchemotherapy instead of postchemotherapy surgical management. Second, the diversity of metastases as evidenced by a wide histologic spectrum, is discussed in clinical terms. Among topics discussed are non-germ-cell malignant elements found within metastatic germ cell tumors, and possible mechanisms for their emergence. Third, the increasing awareness of long delayed, late relapse and its relative refractoriness to chemotherapy gives further insight into the clinical biology of metastatic germ cell cancer. The multipotential nature of the germ cell results in a wide variety of metastatic subtypes, each with its own clinical behavior. Therefore, a variety of clinical management strategies may be required based upon these different clinical behaviors.