The dissertation is devoted to studying the results of treatment of patients with germ cell testicular tumors of different stages. The study program included a comprehensive examination of patients, removal of the primary tumor and treatment using various schemes. Individualization of treatment was considered as the main goal, which allows minimizing the toxicity of treatment without worsening the incidence rate. The work is based on the results of treatment and observation of 292 patients with seminoma and 145 – with NSGCTT.
In the groups treatment outcomes studied using various chemotherapy regimens and evaluated survival. The dissertation focuses on optimizing of treatment in stage I seminoma, and also analyzes the results of chemotherapy in the more advanced seminoma stages. The issues of retroperitoneal lymphadenectomy in the treatment of NSGCTT after induction chemotherapy, the results of testicular organ-sparing surgery, the prognostic value of tumor markers are highlighted. The advantages and effectiveness of different treatment modalities for residual seminoma tumors were analyzed: surgical removal, continuation of chemotherapy and observation.
The results of relapses treatment after initial chemotherapy and refractory forms of the disease are analyzed.
Clinical, morphological, marker and molecular predictors of survival and progression in the treatment of different stages of GCTC were evaluated.
The developed treatment algorithms for patients with GCTT allow choosing an effective treatment method depending on the stage of disease and the presence of unfavorable prognostic predictors.
The obtained data were used in the risk-adapted treatment of 142 patients with seminoma stage I. Active surveillance was used in 46 patients (32,39 %) and treatment with carboplatin in 96 (67,6 %). In CT with carboplatin (AUC7) in the high-risk group, progression was diagnosed in 4,16 %, and treatment was associated with non-expressed acute toxicity. The appropriateness of the use of the risk-adapted algorithm has been confirmed, as with the observation in the low-risk group, the percentage of patients with progression was lower compared to the observation without selection according to clinical and morphological features (8,7 % vs. 19,4 %). It was also found that in carboplatin group the prognostic factors are tumor size > 40 mm (p = 0,004) and category T3 of the tumor (p = 0,001). With the use of risk-adapted treatment for stage I seminoma, the relative frequency of relapses is higher in the observed than in CT group (p < 0,05); Progression is diagnosed in the low-risk group at 8,7 %, in the high-risk group – 4,16 % of patients. Total treatment for risk-adapted algorithm from 142 patients in stage I seminoma progression is diagnosed in 8 (5,63 %). In all cases, metastases are found in the retroperitoneal lymph nodes. The dimensions of the metastases were 28,5 (18–46) mm. Subsequently, 6 patients received CT under the scheme of 3PEB and 2-4PE. The
5-year OS and PFS for the entire group are 100 % and 94,37 %.
For the whole group of 31 patients with RT of seminoma, in analyzing the probability of progression, it was determined that the appointment of CT of the II line in combination with retroperitoneal lymphadenectomy leads to improvement in survival rates. The probability of further progression in the detection of a live tumor after CT II line is higher compared with cases of detection of necrosis or fibrosis. The increase frequency of progression was associated with the following predictors: the disseminated stages at the beginning of the CT and the absence of spontaneous regression (stabilization) during the observation (p = 0,01).
Taking into account the technical complexity for the removal of RT and the detection of a viable tumor in ≤ 50 % of cases, surgical treatment should be limited. The results of PET and the lack of a tendency towards spontaneous regression (stabilization) should be taken into account in the planning of intervention. Spontaneous regression of RT can be observed for many months, therefore the active observation of seminoma RT is correct in most cases. The percentage of RT containing viable cells of seminoma is ≤ 30 %. To date, there are no radiological or clinical methods that would allow to completely exclude the probability of progression of RT. With progression in 30–50 % of patients it is possible to achieve remission while continuing CT. For RT < 3 cm. the main method of treatment is active observation.
