Fig 1: Magnetic resonance images of the brain showing the metastatic mass

We decided that these new lesions represented a recurrence of his earlier malignancy. He had remained in remission for 15 years following orchiectomy and single agent cisplatin therapy. We decided to give bleomycin, etoposide and cisplatin combination (BEP), which is considered the current standard of care. After one cycle, he developed deep vein thrombosis in the right popliteal vein and imaging studies showed progression of the intraabdominal conglomerated lymphadenopathies. AFP and LDH increased to 250000 IU/ml and 941 U/ L, respectively. Treatment was switched to high dose etoposide at a dose of 1800 mg/m² followed by G-CSF support. He tolerated the therapy well and after the 2^nd cycle evaluation a partial response could be achieved, with an AFP of 92000 IU/ml. Then we plan to give high dose chemotherapy with autologous stem cell rescue as a subsequent salvage treatment.

Patients whose late recurrences consisted of teratoma only had the most favorable outcomes. Patients whose late recurrences consisted of pure “nongerm cell malignant tumor” or pure germ cell tumor (yolk sac tumor or other types) had a much worse prognosis: Patients with two different types of nonteratomatous malignancies in their late recurrences had a dismal clinical course: Furthermore, late recurrence is not likely to respond to chemotherapy and is best treated by surgical excision when possible[5].

Teratoma was the most common type of neoplasm in late recurrences (60%) and teratoma was the only element in 22% these patients. Excluding teratoma coexisting with other types of neoplasms, yolk sac tumor was the most frequent type of tumor in patients with late recurrence. It occurred in 47% of patients either alone or with teratoma. Twenty percent of patients with late recurrence had a nonteratomatous germ cell tumor other than yolk sac tumor, either alone, with yolk sac tumor, or with a “nongerm cell malignant tumor.” Most of these nonteratomatous germ cell tumors other than yolk sac tumor were embryonal carcinoma, like our patients although rarely seminoma and choriocarcinoma were encountered. “Nongerm cell malignant tumors,” including both sarcomas and carcinomas of various types, occurred in 23% of late-recurrence patients, either alone or with a nonteratomatous germ cell tumor[5].

The possible explanations for late recurrence of germ cell neoplasms include the following: 1.) malignant degeneration of mature teratoma to germ cell malignancy; 2.) growth of an occult testicular tumor not eliminated by chemotherapy due to the presence of a blood-testicular barrier; 3.) development of a second primary germ cell neoplasm; or 4.) late relapse due to persistent microscopic viable tumor with an atypical less aggressive biologic behavior[6]. The last explanation appears to be the most plausible for our patient, as he had had orchiectomy and apparently no residual lesions after chemotherapy.

Shahidi et al.[1] have identified that positive markers at presentation of disease and the presence of differentiated teratomas in post-chemotherapy surgical specimens are significant predictors for risk of recurrence after 2 years.

Risk estimates for synchronous and metachronous contralateral testicular cancers vary widely. Fossa et al.[7] studied that for 29,515 testicular cancer cases and they found that a total of 175 men presented with synchronous contralateral testicular cancer; 287 men developed metachronous contralateral testicular cancer (O/E=12.4, 95% CI=11.0-13.9; 15-year cumulative risk=1.9%, 95% CI=1.7%-2.1%).

Second malignancies in patients with pure testicular seminoma were studied in order to look for adverse late effects of treatment and to study the significance of second malignancies during follow-up. 758 patients received radiotherapy, 76 underwent chemotherapy, 5 had surveillance only. Twenty-two second cancers (13 contralateral testicular tumors, 9 extratesticular malignancies) were recorded. The overall risk of having a second cancer was RR=4.8 (95% CI=3.0-7.3). The risk of having a subsequent testicular tumor is RR=44. 8 (95% Cl=23.9-76.7). 1.1% of the patients developed a nontesticular second tumor. The risk of having a nontesticular second cancer is RR=2.1 (95% CI=1.0-4.0). A significantly increased risk was observed for renal cell cancer as well (RR=12.5; 95% Cl=1.5-45.1). Increased RR without reaching statistical significance were found for rectal cancer (RR=5.0; 95% Cl=0.1-27.9) and non- Hodgkin lymphoma (RR=6.7; 95% CI=0.2-37.1). None of the second cancers were directly located within the radiation field; 5 neoplasms arose at the border of the radiation field. This study confirmed the increased risk of having a second testicular germ cell cancer. There is also a small but definitely increased overall risk of having a nontesticular second cancer[8].

These studies confirmed the increased risk of having a second testicular germ cell cancer. There is also a small but definitely increased overall risk of having a nontesticular second cancer. Second cancer is a real hazard following treatment of testicular cancers and should always be considered during follow-up.

Our patient presented with a life-threatening metastasis and was resistant to BEP regimen. He was then given salvage chemotherapy with high-dose etoposide, a regimen with high activity against resistant and recurrent NSGCT. With this treatment, a partial remission could be obtained and we planned to give high dose chemotherapy with autologous stem cell rescue subsequent salvage treatment[9-12].

Although the majority of recurrences are encountered in the first 2 years after treatment and later recurrences are rare, their time-course and pattern have implications for long-term follow-up. Currently, there is no consensus on the long-term follow-up policy of these patients. We believe that annual follow-up evaluations can allow detecting the majority of late relapses at an asymptomatic stage and should be extended throughout the patient’s life.

1) Shahidi M, Norman AR, Dearnaley DP, et al. Late recurrence in 1263 men with testicular germ cell tumors. Multivariate analysis of risk factors and implications for management. Cancer 2002,95:520-30.

2) Lipphardt ME, Albers P. Late relapse of testicular cancer. World J Urol 2004,22:47-54.

3) Lattouf JB, Mc Cormack M, Yelle L, et al. Recurrence of a non-seminomatous germ cell tumor in the seminal vesicle 20 years after initial diagnosis and treatment. Can J Urol 2004,11:2350-1.

4) Sekine I, Sasaki Y, Hasebe T, et al. Recurrence of a germ cell tumor 12 years after initial treatment: a case report. Jpn J Clin Oncol 1998,28:50-3.

5) Michael H, Lucia J, Foster RS, et al. The pathology of late recurrence of testicular germ cell tumors. Am J Surg Pathol 2000,24:257-73.

6) DeLeo MJ, Greco FA, Hainsworth JD, et al. Late recurrences in long-term survivors of germ cell neoplasms. Cancer 1988,62:985-8.

7) Fossa SD, Chen J, Schonfeld SJ, et al. Risk of contralateral testicular cancer: a population-based study of 29,515 U.S. men. J Natl Cancer Inst 2005,97:1056-66

8) Fatigante L, Ducci F, Campoccia S, et al. Long-term results in patients affected by testicular seminoma treated with radiotherapy: risk of second malignancies. Tumori 2005,91:144-50.

9) Nichols CR. Treatment of recurrent germ cell tumors. Semin Surg Oncol 1999,17:268-74.

10) Beyer J, Kingreen D, Krause M, et al. Long-term survival of patients with recurrent or refractory germ cell tumors after high dose chemotherapy. Cancer 1997,79:161-8.

11) de Bono JS, Paul J, Simpson A, et al. Improving the outcome of salvage treatment for non-seminomatous germ cell tumours (NSGCT). Br J Cancer 2000,83:426-30.

12) Ledermann JA, Holden L, Newlands ES, et al. The long-term outcome of patients who relapse after chemotherapy for non-seminomatous germ cell tumours. Br J Urol 1994,74:225-30.