Carcinoma in situ of the testis followed by an overt malignant teratoma of the testis within 12 months.

A case of bilateral metachronous testicular non-seminomatous germ cell tumour (NSGCT) is presented. The second tumour was preceded by carcinoma in situ, diagnosed at the time of the first orchidectomy. The patient was placed under active surveillance and 1 year later the second testis tumour developed. A second orchidectomy was performed and testosterone replacement begun. Carcinoma in situ of the testis is discussed.

Primary thyroid lymphoma: clinical features, treatment and outcome: a report of 8 cases.

AIM: To assess the clinical findings and response to treatment of patients with primary thyroid lymphoma. METHODS: Patients with primary thyroid lymphoma were identified by reviewing the diagnoses of all patients with thyroid malignancies diagnosed at Christchurch Hospital between 1980-91. The records of patients with primary thyroid lymphoma were abstracted. RESULTS: During the 12 year period eight patients (6 females, 2 males) with primary thyroid lymphoma were diagnosed and treated. The median age was 78 years (range 18-90 yr). All patients presented with recent thyroid masses and obstructive symptoms were prominent. Two patients were initially referred with endocrine dysfunction--one thyrotoxic and one hypothyroid. Six patients had nonHodgkin lymphoma and two Hodgkin's disease, with all having stage IA disease. Two patients were treated by thyroidectomy, and in the remaining six patients the thyroid lymphoma masses regressed following radiotherapy with the two youngest patients also receiving chemotherapy. At follow up all five elderly patients have since died--two of disseminated lymphoma, two of concurrent cancers and one of vascular disease, and the three younger patients remain in remission after 4.5, 6.5 and 10.5 years. CONCLUSION: Primary thyroid lymphoma usually presents with obstructive symptoms, but there may be associated thyroid dysfunction. Thyroid lymphoma masses respond well to radiotherapy.

Second malignant neoplasms in patients with Hodgkin's disease.

AIM: To determine the incidence of second malignant neoplasms in patients treated for Hodgkin's disease. METHODS: The records were reviewed of all patients receiving primary treatment for Hodgkin's disease at the Oncology Service, Christchurch Hospital from 1969 to 1992. Second malignant neoplasms presenting at least six months after the diagnosis of Hodgkin's disease were noted and the cumulative risk estimated. RESULTS: Twenty-two second malignant neoplasms developed in 20 of the 209 patients. The risk was 5.6 +/- 3.8% (CI) at five years, 11.4 +/- 6.2% at ten years, and 21.7 +/- 11.2% at 15 years and continued to increase thereafter. Thirteen patients have died of their second malignancy, including two of a third malignancy, while four have been followed for less than one year. Three leukaemias (CML, 1; acute non lymphocytic leukaemia, 2), three lymphomas and 16 solid tumours developed. The risk was greater after six or more cycles of MOPP-like chemotherapy and after radiation doses exceeding 30 Gray. The risk was less after laparotomy and splenectomy (p = 0.0205). CONCLUSIONS: In view of the significant risk of a second neoplasm in survivors of Hodgkin's disease follow up should continue beyond ten years, after which time second malignancies were more likely than recurrence. Efforts should continue to minimise the carcinogenicity of therapy while preserving efficacy.

Fasting plasma lipid measurements following cisplatin chemotherapy in patients with germ cell tumors.

PURPOSE: Elevated total serum cholesterol levels have been reported recently in a group of patients with metastatic testicular cancer after treatment with cisplatin combination chemotherapy. We have studied the lipid profile of a similar group of patients in an attempt to confirm this observation. PATIENTS AND METHODS: Fasting plasma lipid concentrations were measured in 47 patients with advanced germ cell tumors who were previously treated with a cisplatin combination chemotherapy. The values obtained for mean total cholesterol, high-density lipoprotein (HDL) cholesterol, triglyceride, apolipoprotein A1, and apolipoprotein B concentrations were compared with those obtained from a control group of 59 patients with germ cell tumors who were not treated with chemotherapy and with data from the New Zealand male population. Median time from the completion of chemotherapy to lipid measurement in the treated group was 50 months (range, 2 to 138 months). The median total dose of cisplatin given was 720 mg (range, 300 to 1,625 mg). RESULTS: Mean total plasma cholesterol concentrations in the cisplatin group (5.87 mol/L) and the control group (5.70 mmol/L) did not differ significantly (P > .4). There was no significant difference for any of the variables between the chemotherapy and control groups and those of the New Zealand male population. There was a trend toward higher mean triglyceride concentrations in the chemotherapy group, but this did not reach significance. CONCLUSIONS: We have not demonstrated an elevation in total plasma cholesterol after cisplatin chemotherapy as has been reported by previous investigators. Our results suggest that in these patients, cisplatin-containing combination chemotherapy is not associated with a significant adverse effect on plasma lipid profile.

The management of small cell lung cancer in Christchurch 1979-89.

The management of 215 consecutive patients with small cell lung cancer referred to the oncology service at Christchurch Hospital, 1979-89, was reviewed. After staging, 118 patients were treated with combination chemotherapy (cyclophosphamide, vincristine and doxorubicin), with (87) or without (31) thoracic irradiation. Patients with other medical problems were treated with alternative chemotherapy (34) or irradiation alone (54). Nine received symptomatic care alone. Eighty-five (40%) had limited disease, with no extrathoracic metastases beyond supraclavicular nodes. The response rate to treatment was 66%. Median survival for the whole group was 33 weeks, 51 weeks for those with limited and 26 weeks for extensive disease. The cumulative risk of developing cerebral metastases was 40% at one year. Patients surviving 26 weeks spent one third of their time as hospital inpatients or outpatients. Twenty-two patients survive, five progression free for 4-8 years, including two who had initial surgical resection. The study supports the policy of reserving intensive staging for fit patients who appear to have limited disease and for those entered into clinical trials. Fit patients with limited disease warrant treatment with combination chemotherapy and thoracic irradiation.

Comparison of methods of assessment of renal function in patients with cancer treated with cisplatin, carboplatin or methotrexate.

In patients with cancer treated with cisplatin, carboplatin or methotrexate creatinine clearance calculated using the Cockcroft-Gault formula was compared with measured clearance and with the glomerular filtration rate. In 106 patients the average squared difference for calculated and 24 hour urine creatinine clearance was 0.288, n = 606; and for calculated creatinine clearance and glomerular filtration rate (measured using diethylenetriaminepenta-acetic acid, DTPA), 0.212, n = 34. On 35 of 606 occasions (6%) in 18 patients (17%), the calculated clearance overestimated the 24-hour urine creatinine clearance when it was less than 1 mL/s. In all but one patient, this was explained by factors leading to renal impairment (seven patients) or overestimation of clearance (ascites in two patients) or by an isolated low value of 24-hour urine creatinine clearance (eight patients). Declining renal function with increasing total dose of cisplatin was detected by both calculated and 24-hour urine creatinine clearance in patients with germ cell tumours. Derivation of an equation to predict creatinine clearance showed a linear association with plasma creatinine concentration, patient age, weight and gender. Variability in cancer patients was similar to that in the original Cockcroft-Gault study. Calculation of creatinine clearance can be used in cancer patients to monitor treatment with renally-eliminated chemotherapy agents.

Carboplatin is ototoxic.

For assessment of the ototoxic potential of carboplatin [cis-diammine-1,1-cyclobutane dicarboxylate platinum(II); CBDCA], pure-tone audiograms were evaluated in 27 patients receiving a total of 119 doses of carboplatin in the range of 300-400 mg/m2. Pure-tone audiometry (PTA) was done immediately prior to and 4 weeks after the administration of 80 doses (67%). Defining carboplatin ototoxicity as an increase of greater than or equal to 30 dB in auditory thresholds that was unexplainable by other causes, we identified 5 examples (19%). Hearing loss tended to be cumulative with increasing dose and was always maximal at 8,000 Hz. Two patients had an increase in auditory thresholds at 1,000 Hz, but this only amounted to 10 dB in each case. Patients developing ototoxicity tended to be older. Sex, the pre-treatment creatinine clearance, the pretreatment audiogram, the number of doses, and the cumulative dose did not emerge as being reliable predictors of subsequent ototoxicity. We conclude that although carboplatin is ototoxic, clinically significant deafness does not occur with conventional dosing and routine audiometric monitoring is therefore unnecessary. However, we suggest that caution should be exercised when carboplatin is given either at higher doses or for longer periods when there is concomitant use of other potentially ototoxic agents or when there is significant pre-existing auditory impairment.

A risk factor for relapse in Hodgkin's disease: female gender?

A retrospective study of 163 patients with Hodgkin's disease treated between 1969 and 1987 was performed to identify adverse prognostic factors. One hundred and thirty-five patients (83 per cent) attained a complete remission and 42 (31 per cent) of these have relapsed (median follow-up--43 months). Using multivariate analysis, no independent factors predicted for the event of relapse. However, analysis of disease-free survival revealed that females fared significantly worse than males (p less than 0.05) and this was independent of other prognostic variables. Female sex has not been recognized as an independent prognostic factor predictive of inferior survival and inferior disease-free survival.

High grade nonHodgkin's lymphoma: management with moderate dose combination chemotherapy.

We have reviewed the management of high grade nonHodgkin's lymphoma in a regional cancer centre over an eight year period. Forty-seven patients were referred with diffuse histiocytic, diffuse undifferentiated and lymphoblastic lymphomas or true histiocytic neoplasms. Twenty-six were treated with doxorubicin, cyclophosphamide, vincristine and prednisone (ACOP). The overall complete remission rate was 73%, 83% for stage I and II disease and 62% for stages III and IV. Kaplan-Meier analysis shows 49% surviving at a median follow up time of 23 months (range 1-108 months) with 11 of the 13 survivors continuously disease free. Toxicity was not severe except for one treatment-related death. Most were treated as outpatients. Patients 70 years of age or older were treated less intensively and only 3 of 14 survive. We conclude that treatment with ACOP is simple and effective in the management of high grade nonHodgkin's lymphoma. Currently our protocol includes the same agents, but at higher dosage, with the addition of methotrexate; we believe this should be tested against the recent more intensive, multiagent alternating regimens in a prospective, randomised clinical trial.

B cell lymphoma presenting as carcinoma of the lung.

A patient presented with superior vena caval obstruction caused by a tumour which resembled carcinoma of the lung both clinically and histologically. However, immunologic and cytogenetic analyses carried out on the mediastinal biopsy and on pleural fluid revealed that the tumour was of B cell origin, Burkitt-like in sub-type, and had the t(8;14) translocation. The nature of many poorly differentiated tumours may be more clearly identified with the help of immunological and cytogenetic analyses.

Cis-platinum and distal renal tubule toxicity.

Glomerular filtration rate (GFR) and plasma electrolyte concentrations were evaluated prospectively in 22 consecutive patients treated with serial courses of cisplatinum combination chemotherapy. In addition, renal distal tubular function was assessed in the first 12 by measurement of overnight urinary concentration after intranasal desamino-d-arginine vasopressin inhalation and by a standard short urinary acidification test following the administration of oral ammonium chloride. Cumulative and dose-related hypomagnesaemia was observed in all patients but was unassociated with clinical symptoms. No significant fall in GFR was seen in the group as a whole but four of the 12 patients studied more comprehensively developed impairment of urinary concentrating and acidifying abilities, independent of any change in GFR. This indicates a selective effect on the renal distal tubule.

Clinical examination, xeromammography, and fine-needle aspiration cytology in diagnosis of breast tumours.

The diagnostic accuracy of clinical examination, xeromammography, and fine-needle aspiration cytology was compared with definitive histological findings in 255 breast lumps excised during one year. When suitable aspirates were obtained for cytological examination the diagnostic accuracy of aspiration cytology was higher than clinical examination or xeromammography. A diagnostic accuracy of 99% was achieved when all three screening tests were in agreement. As well as confirming a clinical diagnosis of malignancy, cytology is useful in identifying malignancy when clinical findings suggest that the tumour is benign. The availability of accurate cytology has affected patient management in many ways. Xeromammography did not enhance the diagnostic accuracy of clinical examination and aspiration cytology in patients presenting with a breast lump and, as a procedure with potential hazard, the benefit of routine xeromammography is questionable when an efficient cytological service is available.

Aminoglutethimide in treatment of metastatic breast carcinoma.

42 patients with metastatic breast carcinoma were treated with aminoglutethimide, which inhibits adrenal steroid hormone synthesis. Treatment was stopped in 2 patients before response could be assessed; of the other 40, 15 (37.5%) had an objective response, 1 (2.5%) showed a response in bone but not in soft tissue, and 4 (10%) had complete or very great relief of metastatic bone pain but no radiological evidence of improvement. 19 (53%) of 36 patients with bone metastases responded to treatment (15 had X-ray evidence and 4 had pain relief), as did 5 (45%) of 11 patients with soft tissue metastases, 2 (25%) of 8 with malignant marrow infiltration, 1 (14%) of 7 with lung metastases, and none of 13 with liver metastases. Response was commonest in patients who had previously responded to other forms of endocrine therapy. Side-effects, usually mild and transient, occurred in a few patients; the most important were an initial period of somnolence in 9 patients and a rash in 5.