OBJECTIVE: Updated Recommendations for the management of testicular germ cell cancer.
METHODS: Comprehensive review of the literature on PubMed since 2020 concerning the diagnosis, treatment and follow-up of testicular germ cell cancer (TGCT), and the safety of treatments. The level of evidence of the references was evaluated.
RESULTS: The initial work-up for patients with testicular germ cell cancer is based on a clinical examination, biochemical (AFP, total hCG and LDH serum markers) and radiological assessment (scrotal ultrasound and thoracic-abdominal-pelvic [TAP] CT). Inguinal orchiectomy is the first therapeutic step whereby the histological diagnosis can be made, and the local stage and risk factors for stage I non-seminomatous germ cell tumours (NSGCT) can be determined. For patients with pure stage-I seminoma, the risk of progression is 15 to 20%. Therefore, surveillance in compliant patients is preferable; adjuvant chemotherapy with carboplatin AUC 7 is an option; and indications for para-aortic radiotherapy are limited. For patients with stage I NSGCT, there are various options between surveillance and a risk-adapted strategy (surveillance or 1 cycle of BEP [Bleomycin Etoposide Cisplatin] depending on the absence or presence of vascular emboli within the tumour). Retroperitoneal lymph node dissection for staging has a very limited role. The treatment for metastatic TGCT is BEP chemotherapy in the absence of any contraindication to bleomycin, for which the number of cycles is determined according to the prognostic risk group of the International Germ Cell Cancer Consortium Group (IGCCCG). Para-aortic radiotherapy is still a standard in stage IIA seminomatous germ cell tumours (SGCT). After chemotherapy, the size of residual masses should be assessed by TAP scan for NSGCT: retroperitoneal lymph node dissection is recommended for any residual mass of more than 1 cm, and all other metastatic sites should be excised. For SGCT, reassessment by 18F-FDG PET is required to specify the surgical indication for residual masses>3cm. Surgery is still rare in these situations.
CONCLUSIONS: By adhering to TGCT management recommendations, excellent disease-specific survival rates are achieved; 99% for stage I and over 85% for metastatic stages.

The purpose of this work was reducing treatment-related toxicity for Hodgkin lymphomas using practical procedure inspired by the ILROG guidelines. Reporting the first case of localized Hodgkin lymphoma treated with protontherapy in France. A 24-year-old female with mediastinal, bulky, localized, mixed-cellularity, classic Hodgkin lymphoma required an involved-site radiation therapy after complete response following polychemotherapy. Three-dimensional conformal radiation therapy was not acceptable due to high doses to breasts, heart and lungs. We realized a four-dimensional computed tomography (CT) to evaluate target movements and another CT with gating and breath-hold technique. Delineation was performed on both CT using the initial fluorodeoxyglucose positron-emission tomography/CT. One dosimetric plan with rotational intensity-modulated radiation therapy with a helical Tomotherapy© was realized and compared to another one with conformational protontherapy. Ninety-five percent of the planning target volume was covered by 98 and 99% of the prescribed dose with protontherapy and helical Tomotherapy©. Protontherapy provided the best organ at risk protection. Lung and heart protections were better with protontherapy: lung mean dose (3.7Gy vs. 8.4Gy) and median dose (0.002Gy vs. 6.9Gy), heart mean dose (2.6Gy vs. 3.7Gy). Breast sparing was better for both breasts using protontherapy: right breast mean dose (2.4Gy vs. 4.4Gy) and left (1.9Gy vs. 4.6Gy). The biggest difference was seen with low doses, which were better with protontherapy: volume of lung receiving 5Gy was 17.5% vs. 54.2% with Helical Tomotherapy©. In view of these results, we decided to treat our patient with protontherapy using respiratory assessment. We delivered 30Gy (15 fractions) using protontherapy with one direct anterior field using pencil beam scanning and deep inspiration breath-hold technique. We observed only grade 1 skin erythema during treatment and no toxicity during early follow-up.

Bleomycin, a cytotoxic chemotherapy agent, forms a key component of curative regimens for lymphoma and germ cell tumours. It can be associated with severe toxicity, long-term complications and even death in extreme cases. There is a lack of evidence or consensus on how to prevent and monitor bleomycin toxicity. We surveyed 63 germ cell cancer physicians from 32 cancer centres across the UK to understand their approach to using bleomycin. Subsequent guideline development was based upon current practice, best available published evidence and expert consensus. We observed heterogeneity in practice in the following areas: monitoring; route of administration; contraindications to use; baseline and follow-up investigations performed, and advice given to patients. A best-practice clinical guideline for the use of bleomycin in the treatment of germ cell tumours has been developed and includes recommendations regarding baseline investigations, the use of pulmonary function tests, route of administration, monitoring and patient advice. It is likely that existing heterogeneity in clinical practice of bleomycin prescribing has significant economic, safety and patient experience implications. The development of an evidence-based consensus guideline was supported by 93% of survey participants and aims to address these issues and homogenise practice across the UK.

Kaposi\'s sarcoma is the most common malignancy associated with HIV infection, and the morbidity and mortality attributable to AIDS-related Kaposi\'s sarcoma (AIDS-KS) may be increasing. No curative therapy is available for AIDS-KS, but palliative therapy can eliminate or reduce cosmetically unacceptable lesions, reduce painful or unsightly oedema or lymphadenopathy, shrink symptomatic oral lesions and relieve symptoms caused by visceral involvement. Strategies currently employed to treat the various clinical problems encountered in AIDS-KS include single- and multi-agent cytotoxic chemotherapy, treatment with interferon-alpha, radiotherapy, and other local therapies. Current clinical research is focusing on use of liposome-encapsulated cytotoxic agents and treatment with substances that inhibit angiogenesis. Any treatment plan for AIDS-KS must be flexible and must be based on the patient\'s overall clinical and immunological status as well as therapeutic goals. Limited local disease is usually amenable to treatment with local measures. Extensive, symptomatic AIDS-KS warrants systemic treatment. The response of mucocutaneous lesions to low dose systemic cytotoxic chemotherapy is typically excellent. Treatment with interferon-alpha may also be beneficial in this setting. Multi-agent chemotherapeutic regimens are usually reserved for treatment of patients most severely affected by AIDS-KS. It is hoped that liposome-encapsulated cytotoxic chemotherapy and antiangiogenic therapies will prove more effective and less toxic than the treatment strategies currently in use.

Anaphylactoid systemic reactions to bleomycin are potentially lethal. Test dosing is recommended to prevent or quickly detect immediate hypersensitivity reactions in patients receiving bleomycin for the first time. Specific test dosage recommendations vary but general considerations include the patient\'s age, body size, and previous allergy history, and the care setting. Facilities administering bleomycin should implement guidelines that address bleomycin test dosing since the prevention and recognition of anaphylactoid reactions is a primary responsibility of the nurse administering chemotherapy.

Twenty patients with advanced seminoma were treated with chemotherapy. Fourteen patients were previously untreated (group 1) and received vinblastine, bleomycin, and cisplatin (VPB) at presentation. Six patients had received prior radiation therapy (group 2), and at relapse received either VPB or VP-16-213 (etoposide)-cisplatin. Within group 1, five patients received no further therapy after VPB (group 1A), six patients received radiation to residual radiographic abnormalities (group 1B), and three patients underwent surgery to remove residual radiographic areas following VPB (group 1C). The complete response rate in group 1 was 14/14 (100%). At present within group 1A, 5/5 patients (100%) are alive and disease-free (NED) for a median follow-up of 32 + months. In group 1B, 6/6 patients (100%) are alive and NED for a median follow-up of 17+ months. In group 1C, 3/3 patients (100%) had residual fibrosis at the time of surgical resection. Two of these patients died of postoperative complications with no evidence of disease and the third is alive and NED at 19+ months. In group 2, 4/6 patients (67%) achieved a complete remission, including two patients who are NED at 22+ and 85+ months, respectively. Two have died and two are alive with progressive disease. Doses of chemotherapy to group 2 patients were substantially lower than the doses given to group 1 patients. We conclude that chemotherapy is acceptable initial therapy for advanced seminoma, and prior extensive radiation therapy may impair the ability to give adequate doses of chemotherapy in patients who relapse. Residual masses after chemotherapy are often fibrotic and the role of postchemotherapy radiation therapy in these patients is uncertain.

The development of pulmonary side effects, especially pulmonary fibrosis, during treatment with bleomycin is well documented in adult oncology patients, but not in children. A report of fatal pulmonary fibrosis which developed after exposure to oxygen while under anesthesia in a 3-year-old boy treated with bleomycin exemplifies the problem. The prevention of long-term complications associated with bleomycin is especially important in children, since a child cured of a malignant neoplasm may enjoy many years of productive life. Given the present limitations, guidelines for management of pediatric patients given bleomycin include: discontinuation of bleomycin therapy with the onset of symptoms; serial pulmonary function testing during the course of treatment; and early treatment with high-dose corticosteroids (prednisone 2 mg/kg/day) if symptoms occur.

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