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睾丸生殖细胞癌患者的诊断与治疗

Diagnosis and treatment of patients with testicular germ cell cancer.

作者信息

Hartmann J T, Kanz L, Bokemeyer C

机构信息

University Medical Center II, Department of Hematology/Oncology/Immunology, Eberhard-Karls-University, Tübingen, Federal Republic of Germany.

出版信息

Drugs. 1999 Aug;58(2):257-81. doi: 10.2165/00003495-199958020-00004.

Abstract

Testicular germ cell tumours are a highly curable malignancy even in the presence of metastases, with an overall survival rate of approximately 90 to 95% when all stages are considered. Current therapeutic strategies aim at risk-adapted therapy, trying to maintain favourable overall results while reducing treatment-related toxicity, particularly in non-advanced disease. In stage I disease, unilateral inguinal orchiectomy represents the standard diagnostic and therapeutic approach. For patients with clinical stage I seminoma, prophylactic para-aortic radiotherapy with 26Gy is commonly employed. In patients with nonseminomatous germ cell tumours (NSGCT) at clinical stage I, the 3 options are: (i) retroperitoneal lymphadenectomy; (ii) a wait-and-see strategy; or (iii) 2 cycles of adjuvant chemotherapy. The individual risk profile for tumour recurrence, mainly based on histopathological criteria such as vascular tumour invasion, should guide treatment decisions in this group of patients. Radiotherapy is still the standard approach in clinical stage IIA/B seminoma, whereas in patients with a low tumour burden of NSGCT, retroperitoneal lymphadenectomy is frequently used followed by surveillance or adjuvant chemotherapy. Primary chemotherapy in these stages of disease may be at least equally successful. Major progress has also been achieved in the treatment of NSGCT patients with metastatic disease greater than clinical stage IIB, for whom primary chemotherapy represents the standard approach. After cisplatin-based combination chemotherapy, between 70 and 90% of patients will achieve a durable remission. In patients with 'good risk' metastatic disease, 3 cycles of cisplatin, etoposide and bleomycin (PEB) remain the standard treatment, despite several randomised trials trying to avoid the lung-toxic bleomycin or substituting cisplatin by carboplatin. In patients with 'intermediate' and 'poor prognosis' disease, 4 cycles of PEB given at 3-week intervals are considered routine treatment. The role of high dose chemotherapy with peripheral autologous blood stem cell transplantation is currently being investigated for patients presenting initially with advanced (poor prognosis) metastatic disease and for patients with relapse after previous chemotherapy, in whom conventional-dose salvage regimens will only result in 20% long-term survival. Because of the large group of patients with metastatic disease being cured, the possible long-term adverse effects of treatment have become important. Only a slightly elevated risk for therapy-related secondary malignancies has been identified. Long-term adverse effects associated with cisplatin may affect a larger proportion of patients. Further research should focus on reducing the risk of chemotherapy-related chronic toxicity.

摘要

睾丸生殖细胞肿瘤即使存在转移也是一种高度可治愈的恶性肿瘤,若考虑所有分期,其总生存率约为90%至95%。当前的治疗策略旨在进行风险适应性治疗,在降低治疗相关毒性的同时努力维持良好的总体疗效,尤其是在非晚期疾病中。在I期疾病中,单侧腹股沟睾丸切除术是标准的诊断和治疗方法。对于临床I期精原细胞瘤患者,通常采用26Gy的预防性主动脉旁放疗。对于临床I期非精原生殖细胞肿瘤(NSGCT)患者,有3种选择:(i)腹膜后淋巴结清扫术;(ii)观察等待策略;或(iii)2个周期的辅助化疗。肿瘤复发的个体风险特征,主要基于诸如血管肿瘤侵犯等组织病理学标准,应指导这组患者的治疗决策。放疗仍是临床IIA/B期精原细胞瘤的标准治疗方法,而对于NSGCT肿瘤负荷低的患者,常采用腹膜后淋巴结清扫术,随后进行监测或辅助化疗。在疾病的这些阶段进行一线化疗可能至少同样成功。对于转移性疾病大于临床IIB期的NSGCT患者的治疗也取得了重大进展,对于他们来说,一线化疗是标准方法。基于顺铂的联合化疗后,70%至90%的患者将实现持久缓解。对于“低风险”转移性疾病患者,尽管有多项随机试验试图避免使用有肺毒性的博来霉素或用卡铂替代顺铂,但3个周期的顺铂、依托泊苷和博来霉素(PEB)仍是标准治疗。对于“中等”和“预后不良”疾病患者,每3周给予4个周期的PEB被视为常规治疗。对于最初表现为晚期(预后不良)转移性疾病的患者以及先前化疗后复发的患者,目前正在研究高剂量化疗联合外周自体造血干细胞移植的作用,在这些患者中,传统剂量的挽救方案只能带来20%的长期生存率。由于大量转移性疾病患者被治愈,治疗可能产生的长期不良影响变得很重要。仅发现与治疗相关的继发性恶性肿瘤风险略有升高。与顺铂相关的长期不良影响可能会影响更大比例的患者。进一步的研究应侧重于降低化疗相关慢性毒性的风险。

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