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Choriocarcinoma of the Testis
Vol.
THE JOURNAL OF UROLOGY
Copyright© 1974 by The Williams & Wilkins Co.
,July
Printed in
CHORIOCARCINOMA OF THE TESTIS STEPHEN C. HENRY,* PATRICK C. WALSHt
AND
MELVIN B. ROTNER
From the Department of Urolo{;y, Naval Hospital, San Die{;o, California
Choriocarcinoma is a rare tumor, comprising only 1 to 4 per cent of all germinal malignancies of the testis. Unlike other germinal tumors choriocarcinoma metastasizes more frequently by hematogenous routes, bypassing the usual retroperitoneal lymphatic drainage of the testis and patients usually have widespread metastases. Prior to the use of chemotherapy choriocarcinoma was uniformly fatal. In 1960 Li and associates demonstrated the effectiveness of chemotherapy in the management of metastatic choriocarcinoma 1 and more recent reports have substantiated this effect. Herein we report our experience with therapy of patients with advanced choriocarcinoma.
There were 4 patients who achieved regression of tumor, 3 had no response and 1 has survived ::i years (see table). The average survival of who had tumor regression (6.5 months) was not significantly different from those who failed to respond (4 months). No objective response could be attributed to radiotherapy. The course of our surviving patient is summarized in the case report. CASE REPORT
PATIENT POPULATION AND RESULTS
From 1960 to 1970, 8 patients with metastatic choriocarcinoma were treated at our hospital. Careful review of surgical and autopsy specimens demonstrated the typical combination of syncytial and trophoblastic elements necessary to make the pathologic diagnosis. 2 Embryonal carcinoma with trophoblastic elements was specifically eliminated from this study. The men ranged in age from 22 to 45 years. Six patients had testicular enlargement, 1 had hemoptysis and 1 had an abdominal mass. Four patients had had prior treatment for a mistaken diagnosis of epididymitis. Gynecomastia was not seen in the 3 patients who underwent a breast examination. All patients had metastatic disease to the chest and retroperitoneum as demonstrated by chest x-ray, excretory urography (IVP) and lymphangiography. Seven patients had elevated titers of human chorionic gonadotropin in the urine. Diagnosis was made by radical orchiectomy in 5 patients, supraclavicular node biopsy in 2 and biopsy of an abdominal mass in 1. All patients were managed with chemotherapy, using actinomycin D plus an alkylating agent (cytoxan or chlorambucil); 4 patients also received methotrexate. Three patients underwent adjunctive radiotherapy to symptomatic masses. Accepted for publication October 26, 1973. Read at annual meeting of Western Section, American Urological Association, Honolulu, Hawaii, June 24-30, 1973. * Current address: Naval Hospital, Long Beach, California 90801. t Current address: James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland. 1 Li, M. C., Whitmore, W. F., Jr., Golbey, R. and Grabstald, H.: Effects of combined drug therapy on metastatic cancer of the testis. J.A.M.A., 174: 1291, 1960. 2 Mostofi, F. K.: Syllabus of Genitourinary Pathology. Washington, D. C.: Armed Forces Institute of Pathology, p. 46, 1965. 105
P. V., USNH-SD 900360, was referred to this institution with a diagnosis of choriocarcinoma made at another hospital by exploratory omy and biopsy of a large retroperitoneal mass. The patient had a history of transient right testicular swelling and tenderness 7 months to hospitalization, and a recent 15-pound loss associated with mild pleuritic chest discomfort and dyspnea on exertion. Testicular examination was normal except for mild thickening of the minor of the right epididymis. There was a right upper quadrant abdominal mass. No gynecomastia was seen. Laboratory examination revealed a normal he mo gram, urinalysis and liver function studies. Urinary gonadotropin excretion was 810,000 international units (IU) per 24 hours. Chest x-ray showed multiple metastatic lesions (fig. 1, A). IVP demonstrated fullness of the right renal with lateral deviation of the lumbar ureter B). A right orchiectomy was performed and the only pathologic finding was an area of scarring. The patient was initially managed with 25 mg. diethylstilbestrol daily and 100 mg. depo-provera every 2 weeks. A course of 25 mg. oral methotrexate was given daily for 5 days with no objective response. The patient was then treated daily with 0.75 mg. actinomycin D intravenously, 300 mg. cytoxan intravenously and 15 mg. methotrexate orally, in 5-day courses every 2 weeks. This regimen was well tolerated, resulting only in alopecia and mild nausea. Marked regression of pulmonary metastases occurred 4 months after the initiation of this therapy (fig. 2, A). A month later 24-hour urinary human chorionic gonadotropin excretion was 3,740 IU. Further decrease in the size of the chest lesions, abdominal mass and human chorionic gonadotropin titer followed, culminating in the total absence of detectable metastatic disease 7 months after the beginning of treatment (fig. 2, Subsequently, maintenance chemotherapy was given in 5-day courses at monthly intervals. provera and diethylstilbestrol were discontinued after approximately a year because of impotence. Currently the patient is managed with courses of chemotherapy at monthly intervals. He
106
HENRY, WALSH AND ROTNER
Results of drug therapy in choriocarcinoma -~
Pt.
Age at Dia!(IlO· SIS
Symptoms and Duration
Therapy
Operation
r------~
Current Status
Survival From Diagnosis
"Regression, 3 mos. No response
Dead
5mos.
Dead
4mos.
Regression, 4 mos. No response
Dead
9mos.
Dead
3½ mos.
Regression, 3 mos.
Dead
6mos.
No response
Dead
3mos.
Regression, 1 mo.
Dead
6mos.
Remission, 30 mos.
Alive
36 mos.
Result
(yrs.) Rt. orchiectomy
23
Testis enlargement, weight loss; 4 ½ mos. Backache, testis enlargement; 2 mos. Testis enlargement, hemoptysis; 1 mo. Neck mass, 3 mos.
JD
33
Testis pain, 1 mo.
Rt. orchiectomy
JG
33
Enlarged testis, neck mass; 4 mos.
HT
45
Enlarged testis, 2 mos.
Supraclavicular node biopsy, lt. orchiectomy Lt. orchiectomy
PV*
23
Abdominal mass, 5 mos.
RA
21
DB
24
GC
22
FD
Lt. orchiectomy Lt. orchiectomy Supraclavicular node biopsy
Biopsy of abdominal mass
Actinomycin D, cytoxan Actinomycin D, cytoxan Actinomycin D, cytoxan Actinomycin D, cytoxan, radiotherapy Actinomycin D, cytoxan, methotrexate, radiotherapy Actinomycin D, chlorambucil, methotrexate Actinomycin D, chlorambucil, methotrexate, radiotherapy Actinomycin D, cytoxan, methotrexate
* See text.
B
FIG. 1. A, chest x-ray at time of initiation of chemotherapy. B, IVP as part of initial evaluation demonstrates fullness of right renal pelvis.
is married, a full-time college student and has no detectable evidence of tumor. DISCUSSION
In 1960 Li and associates established the efficacy of chemotherapy in the management of metastatic testicular tumors when they treated 18 patients
who had choriocarcinoma with actinomycin D, methotrexate and chlorambucil, resulting in 2 patients free of disease at 12 and 18 months. 1 Since that report other investigators have confirmed the usefulness of chemotherapy. In 1966 Mackenzie reported 20 cases managed with actinomycin D, cytoxan and methotrexate in several combina-
CHORIOCARCINOMA OF TESTIS
107
Frc. 2. A, chest x-ray 4 months after beginning therapy demonstrates marked regression of pulmonary nodules. negative chest x-ray 7 months after beginning therapy.
tions. 3 His longest remission was in a patient who was free of disease for 85 months; 4 other remissions of shorter duration occurred. Goldstein and Piro reported 8 patients managed with similar medications, 3 of whom were alive without metastases at 8, 12 and 61 months. 4 Golbey reported 21 cases treated with actinomycin D and chlorambucil. 5 Of these 21 patients, 10 experienced regression of tumor and in 1 a complete remission occurred. Using similar chemotherapy, Ansfield and associates reported 5 cases in which 1 complete remission occurred for 92 months. 6 Thus, of the aforementioned cases complete remission occurred in approximately 14 per cent of patients treated with actinomycin D, plus an alkylating agent with or without methotrexate. Other regimens have been tried with somewhat less success. Samuels and Howe used high dose vinblastine in 9 patients with 1, 6-month remission and 1 brief partial response. 7 Mithramycin has Mackenzie, A. R.: Chemotherapy of metastatic testis cancer. Cancer, l!l: 1369, 1966. 'Goldstein, D. P. and Piro, A. ,J.: Combination chemotherapy in the treatment of germ cell tumors containing choriocarcinoma in males and females. Surg., Gynec. & Obst., 134: 61, 1972. 'Golbey, R. B.: The place of chemotherapy in the treatment of testicular tumors. J.A.M.A., 213: 101, 1970. 6 Ansfield, F. J., Korbitz, B. C., Davis, H. L., Jr. and Ramirez, G.: Triple drug therapy in testicular tumors. Cancer, 24: 442, 1969. 3
been used by Hill and associates, achieving partial response in 3 of 5 cases. 8 Using methotrexate, 2 choriocarcinomas were treated without response. 9 Although Mackenzie reports successful management of non-seminomatous tumors with actinomycin D only, none of the so treated had choriocarcinoma. 3 In a recent clinical review of bleomycin, Blum and associates reviewed 6 cases treated with bleomycin and 2 brief responses were achieved. 10 Bleomycin vinblastine was no more effective. Tumor regression without complete disappearance of metastatic disease appears to have little practical significance. In our patients in whom a partial response occurred, there was no significant prolongation of life although symptoms of metastatic disease may have been minimally palliated, Mackenzie,' and Goldstein and Piro 4 state that urinary human chorionic gonadotropin excretion 'Samuels, M. L. and Howe, C. D.: Vinblastine in the management of testicular cancer. Cancer, 25: 1009, 1970. 8 Hill, G. J., II, Sedransk, N., Rochlin, D., Bisel, Andrews, N. C,, Fletcher, W., Schroeder, J. M, Wilson, W. L.: Mithramycin (NSC 24559) therapy of testicular tumors. Cancer, 30: 900, 1972, 'Gottlieb, ,J. A. and Serpick, A, A.: Prolonged intravenous methotrexate therapy in the treatment of acute leukemia and solid tumors. Cancer Res., 30: 2132, 1970, 10 Blum, R. H., Carter, S. K. and Agre, K.: A clinical review ofbleomycin-a new antineoplastic agent. Cancer, 31: 903, 1973,
108
HENRY, WALSH AND ROTNER
titers are the most sensitive indicators of successful therapy because decrease in titers may precede any radiographic decrease in tumor size. Conversely, the persistence of human chorionic gonadotropin in the urine indicates persistence of tumor deposits. The amount of urinary gonadotropin initially found apparently has no relation to the amount of metastatic disease but serial determinations provide a good index of therapeutic effectiveness. The use of serum luteinizing hormone levels may provide a more sensitive test for residual tumor and may be elevated in the presence of normal urinary gonadotropin levels. It is reassuring that the serum luteinizing hormone levels in P. V. are now within normal limits. Although 2 of our patients (P. V. and F. D.) had normal testicular examinations at the time of hospitalization both of them had testicular symptoms prior to seeking attention for metastatic disease. In P. V. a scar was found on microscopic examination of the testis, a finding which may be consistent with an infarcted primary focus of choriocarcinoma. Neither orchiectomy nor autopsy was performed on F. D. Necrosis of the primary testicular tumor has been noted by Friedman in choriocarcinomas and he suggests examination of step sections of the testis before making a definite diagnosis of an extragenital ongm of a choriocarcinoma. 11 Neither of these patients fulfills Abell and associates' criteria for the establishment of this diagnosis. 12 11 Friedman, N. B.: The comparative morphogenesis of extragenital and gonadal teratoid tumors. Cancer, 4: 265, 1951. 12 Abell, M. R., Fayos, J. V. and Lampe, I.: Retroperi-
No factor of prognostic significance could be identified in our cases. Our surviving patient had findings on physical and laboratory examination that were similar to those of patients who exhibited no response to therapy. Combination chemotherapy with actinomycin D, an alkylating agent, and methotrexate seems to be the best therapeutic regimen. Experience with the management of choriocarcinoma is too limited to make a definite recommendation as to the appropriate length of therapy after remission. Our patient is receiving maintenance therapy approximately 30 months after remission. Mackenzie recommends at least 2 to 5 years of maintenance therapy for non-seminomatous tumors. Ansfield and associates suggest therapy for 2 to 3 years, based on 1 long-term remission which was treated for 30 months. SUMMARY
Of 8 patients with choriocarcinoma treated with combination chemotherapy in a 10-year period, 1 complete remission for 3 years has occurred. Review of the literature indicates that a combination of actinomycin D, an alkylating agent, and methotrexate is the most effective form of management, yielding a remission rate of approximately 14 per cent. Urinary and possibly serum levels of gonadotropin provide a sensitive index of response to chemotherapy. The appropriate length of time for maintenance chemotherapy is as yet undetermined. toneal germinomas (seminomas) without evidence of testicular involvement. Cancer, 18: 273, 1965.
THE JOURNAL OF UROLOGY
Copyright© 1974 by The Williams & Wilkins Co.
,July
Printed in
CHORIOCARCINOMA OF THE TESTIS STEPHEN C. HENRY,* PATRICK C. WALSHt
AND
MELVIN B. ROTNER
From the Department of Urolo{;y, Naval Hospital, San Die{;o, California
Choriocarcinoma is a rare tumor, comprising only 1 to 4 per cent of all germinal malignancies of the testis. Unlike other germinal tumors choriocarcinoma metastasizes more frequently by hematogenous routes, bypassing the usual retroperitoneal lymphatic drainage of the testis and patients usually have widespread metastases. Prior to the use of chemotherapy choriocarcinoma was uniformly fatal. In 1960 Li and associates demonstrated the effectiveness of chemotherapy in the management of metastatic choriocarcinoma 1 and more recent reports have substantiated this effect. Herein we report our experience with therapy of patients with advanced choriocarcinoma.
There were 4 patients who achieved regression of tumor, 3 had no response and 1 has survived ::i years (see table). The average survival of who had tumor regression (6.5 months) was not significantly different from those who failed to respond (4 months). No objective response could be attributed to radiotherapy. The course of our surviving patient is summarized in the case report. CASE REPORT
PATIENT POPULATION AND RESULTS
From 1960 to 1970, 8 patients with metastatic choriocarcinoma were treated at our hospital. Careful review of surgical and autopsy specimens demonstrated the typical combination of syncytial and trophoblastic elements necessary to make the pathologic diagnosis. 2 Embryonal carcinoma with trophoblastic elements was specifically eliminated from this study. The men ranged in age from 22 to 45 years. Six patients had testicular enlargement, 1 had hemoptysis and 1 had an abdominal mass. Four patients had had prior treatment for a mistaken diagnosis of epididymitis. Gynecomastia was not seen in the 3 patients who underwent a breast examination. All patients had metastatic disease to the chest and retroperitoneum as demonstrated by chest x-ray, excretory urography (IVP) and lymphangiography. Seven patients had elevated titers of human chorionic gonadotropin in the urine. Diagnosis was made by radical orchiectomy in 5 patients, supraclavicular node biopsy in 2 and biopsy of an abdominal mass in 1. All patients were managed with chemotherapy, using actinomycin D plus an alkylating agent (cytoxan or chlorambucil); 4 patients also received methotrexate. Three patients underwent adjunctive radiotherapy to symptomatic masses. Accepted for publication October 26, 1973. Read at annual meeting of Western Section, American Urological Association, Honolulu, Hawaii, June 24-30, 1973. * Current address: Naval Hospital, Long Beach, California 90801. t Current address: James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland. 1 Li, M. C., Whitmore, W. F., Jr., Golbey, R. and Grabstald, H.: Effects of combined drug therapy on metastatic cancer of the testis. J.A.M.A., 174: 1291, 1960. 2 Mostofi, F. K.: Syllabus of Genitourinary Pathology. Washington, D. C.: Armed Forces Institute of Pathology, p. 46, 1965. 105
P. V., USNH-SD 900360, was referred to this institution with a diagnosis of choriocarcinoma made at another hospital by exploratory omy and biopsy of a large retroperitoneal mass. The patient had a history of transient right testicular swelling and tenderness 7 months to hospitalization, and a recent 15-pound loss associated with mild pleuritic chest discomfort and dyspnea on exertion. Testicular examination was normal except for mild thickening of the minor of the right epididymis. There was a right upper quadrant abdominal mass. No gynecomastia was seen. Laboratory examination revealed a normal he mo gram, urinalysis and liver function studies. Urinary gonadotropin excretion was 810,000 international units (IU) per 24 hours. Chest x-ray showed multiple metastatic lesions (fig. 1, A). IVP demonstrated fullness of the right renal with lateral deviation of the lumbar ureter B). A right orchiectomy was performed and the only pathologic finding was an area of scarring. The patient was initially managed with 25 mg. diethylstilbestrol daily and 100 mg. depo-provera every 2 weeks. A course of 25 mg. oral methotrexate was given daily for 5 days with no objective response. The patient was then treated daily with 0.75 mg. actinomycin D intravenously, 300 mg. cytoxan intravenously and 15 mg. methotrexate orally, in 5-day courses every 2 weeks. This regimen was well tolerated, resulting only in alopecia and mild nausea. Marked regression of pulmonary metastases occurred 4 months after the initiation of this therapy (fig. 2, A). A month later 24-hour urinary human chorionic gonadotropin excretion was 3,740 IU. Further decrease in the size of the chest lesions, abdominal mass and human chorionic gonadotropin titer followed, culminating in the total absence of detectable metastatic disease 7 months after the beginning of treatment (fig. 2, Subsequently, maintenance chemotherapy was given in 5-day courses at monthly intervals. provera and diethylstilbestrol were discontinued after approximately a year because of impotence. Currently the patient is managed with courses of chemotherapy at monthly intervals. He
106
HENRY, WALSH AND ROTNER
Results of drug therapy in choriocarcinoma -~
Pt.
Age at Dia!(IlO· SIS
Symptoms and Duration
Therapy
Operation
r------~
Current Status
Survival From Diagnosis
"Regression, 3 mos. No response
Dead
5mos.
Dead
4mos.
Regression, 4 mos. No response
Dead
9mos.
Dead
3½ mos.
Regression, 3 mos.
Dead
6mos.
No response
Dead
3mos.
Regression, 1 mo.
Dead
6mos.
Remission, 30 mos.
Alive
36 mos.
Result
(yrs.) Rt. orchiectomy
23
Testis enlargement, weight loss; 4 ½ mos. Backache, testis enlargement; 2 mos. Testis enlargement, hemoptysis; 1 mo. Neck mass, 3 mos.
JD
33
Testis pain, 1 mo.
Rt. orchiectomy
JG
33
Enlarged testis, neck mass; 4 mos.
HT
45
Enlarged testis, 2 mos.
Supraclavicular node biopsy, lt. orchiectomy Lt. orchiectomy
PV*
23
Abdominal mass, 5 mos.
RA
21
DB
24
GC
22
FD
Lt. orchiectomy Lt. orchiectomy Supraclavicular node biopsy
Biopsy of abdominal mass
Actinomycin D, cytoxan Actinomycin D, cytoxan Actinomycin D, cytoxan Actinomycin D, cytoxan, radiotherapy Actinomycin D, cytoxan, methotrexate, radiotherapy Actinomycin D, chlorambucil, methotrexate Actinomycin D, chlorambucil, methotrexate, radiotherapy Actinomycin D, cytoxan, methotrexate
* See text.
B
FIG. 1. A, chest x-ray at time of initiation of chemotherapy. B, IVP as part of initial evaluation demonstrates fullness of right renal pelvis.
is married, a full-time college student and has no detectable evidence of tumor. DISCUSSION
In 1960 Li and associates established the efficacy of chemotherapy in the management of metastatic testicular tumors when they treated 18 patients
who had choriocarcinoma with actinomycin D, methotrexate and chlorambucil, resulting in 2 patients free of disease at 12 and 18 months. 1 Since that report other investigators have confirmed the usefulness of chemotherapy. In 1966 Mackenzie reported 20 cases managed with actinomycin D, cytoxan and methotrexate in several combina-
CHORIOCARCINOMA OF TESTIS
107
Frc. 2. A, chest x-ray 4 months after beginning therapy demonstrates marked regression of pulmonary nodules. negative chest x-ray 7 months after beginning therapy.
tions. 3 His longest remission was in a patient who was free of disease for 85 months; 4 other remissions of shorter duration occurred. Goldstein and Piro reported 8 patients managed with similar medications, 3 of whom were alive without metastases at 8, 12 and 61 months. 4 Golbey reported 21 cases treated with actinomycin D and chlorambucil. 5 Of these 21 patients, 10 experienced regression of tumor and in 1 a complete remission occurred. Using similar chemotherapy, Ansfield and associates reported 5 cases in which 1 complete remission occurred for 92 months. 6 Thus, of the aforementioned cases complete remission occurred in approximately 14 per cent of patients treated with actinomycin D, plus an alkylating agent with or without methotrexate. Other regimens have been tried with somewhat less success. Samuels and Howe used high dose vinblastine in 9 patients with 1, 6-month remission and 1 brief partial response. 7 Mithramycin has Mackenzie, A. R.: Chemotherapy of metastatic testis cancer. Cancer, l!l: 1369, 1966. 'Goldstein, D. P. and Piro, A. ,J.: Combination chemotherapy in the treatment of germ cell tumors containing choriocarcinoma in males and females. Surg., Gynec. & Obst., 134: 61, 1972. 'Golbey, R. B.: The place of chemotherapy in the treatment of testicular tumors. J.A.M.A., 213: 101, 1970. 6 Ansfield, F. J., Korbitz, B. C., Davis, H. L., Jr. and Ramirez, G.: Triple drug therapy in testicular tumors. Cancer, 24: 442, 1969. 3
been used by Hill and associates, achieving partial response in 3 of 5 cases. 8 Using methotrexate, 2 choriocarcinomas were treated without response. 9 Although Mackenzie reports successful management of non-seminomatous tumors with actinomycin D only, none of the so treated had choriocarcinoma. 3 In a recent clinical review of bleomycin, Blum and associates reviewed 6 cases treated with bleomycin and 2 brief responses were achieved. 10 Bleomycin vinblastine was no more effective. Tumor regression without complete disappearance of metastatic disease appears to have little practical significance. In our patients in whom a partial response occurred, there was no significant prolongation of life although symptoms of metastatic disease may have been minimally palliated, Mackenzie,' and Goldstein and Piro 4 state that urinary human chorionic gonadotropin excretion 'Samuels, M. L. and Howe, C. D.: Vinblastine in the management of testicular cancer. Cancer, 25: 1009, 1970. 8 Hill, G. J., II, Sedransk, N., Rochlin, D., Bisel, Andrews, N. C,, Fletcher, W., Schroeder, J. M, Wilson, W. L.: Mithramycin (NSC 24559) therapy of testicular tumors. Cancer, 30: 900, 1972, 'Gottlieb, ,J. A. and Serpick, A, A.: Prolonged intravenous methotrexate therapy in the treatment of acute leukemia and solid tumors. Cancer Res., 30: 2132, 1970, 10 Blum, R. H., Carter, S. K. and Agre, K.: A clinical review ofbleomycin-a new antineoplastic agent. Cancer, 31: 903, 1973,
108
HENRY, WALSH AND ROTNER
titers are the most sensitive indicators of successful therapy because decrease in titers may precede any radiographic decrease in tumor size. Conversely, the persistence of human chorionic gonadotropin in the urine indicates persistence of tumor deposits. The amount of urinary gonadotropin initially found apparently has no relation to the amount of metastatic disease but serial determinations provide a good index of therapeutic effectiveness. The use of serum luteinizing hormone levels may provide a more sensitive test for residual tumor and may be elevated in the presence of normal urinary gonadotropin levels. It is reassuring that the serum luteinizing hormone levels in P. V. are now within normal limits. Although 2 of our patients (P. V. and F. D.) had normal testicular examinations at the time of hospitalization both of them had testicular symptoms prior to seeking attention for metastatic disease. In P. V. a scar was found on microscopic examination of the testis, a finding which may be consistent with an infarcted primary focus of choriocarcinoma. Neither orchiectomy nor autopsy was performed on F. D. Necrosis of the primary testicular tumor has been noted by Friedman in choriocarcinomas and he suggests examination of step sections of the testis before making a definite diagnosis of an extragenital ongm of a choriocarcinoma. 11 Neither of these patients fulfills Abell and associates' criteria for the establishment of this diagnosis. 12 11 Friedman, N. B.: The comparative morphogenesis of extragenital and gonadal teratoid tumors. Cancer, 4: 265, 1951. 12 Abell, M. R., Fayos, J. V. and Lampe, I.: Retroperi-
No factor of prognostic significance could be identified in our cases. Our surviving patient had findings on physical and laboratory examination that were similar to those of patients who exhibited no response to therapy. Combination chemotherapy with actinomycin D, an alkylating agent, and methotrexate seems to be the best therapeutic regimen. Experience with the management of choriocarcinoma is too limited to make a definite recommendation as to the appropriate length of therapy after remission. Our patient is receiving maintenance therapy approximately 30 months after remission. Mackenzie recommends at least 2 to 5 years of maintenance therapy for non-seminomatous tumors. Ansfield and associates suggest therapy for 2 to 3 years, based on 1 long-term remission which was treated for 30 months. SUMMARY
Of 8 patients with choriocarcinoma treated with combination chemotherapy in a 10-year period, 1 complete remission for 3 years has occurred. Review of the literature indicates that a combination of actinomycin D, an alkylating agent, and methotrexate is the most effective form of management, yielding a remission rate of approximately 14 per cent. Urinary and possibly serum levels of gonadotropin provide a sensitive index of response to chemotherapy. The appropriate length of time for maintenance chemotherapy is as yet undetermined. toneal germinomas (seminomas) without evidence of testicular involvement. Cancer, 18: 273, 1965.