SEMINOMA (Latin semen, semin[is] + - oma; synonym: spermatoblastoma, spermocytoma) — a malignant tumor from germinogenny cells.
The page makes about 40% of primary germinogenny tumors of testicles. Meets at the age of 20 — 40 years more often, at children it is observed seldom. S. can sometimes be located out of a small egg (ekstragonadny S.), napr, in a front mediastinum or retroperitoneal space that is explained by a delay of a germinogenny epithelium in the period of embryonic development (see. Teratoma ).
According to the WHO classification distinguish typical, anaplastic and spermatocytal S.
Tipichnaya S. occurs preferential at men at the age of 20 — 40 years. Often arises in not - the small egg which went down in a scrotum. The small egg is increased, is more rare than the usual sizes. The tumor consists of one, is more rare than several nodes. Surface of its section brilliant, white color, lobular. Microscopically typical S. consists of the same large cells of polygonal or rounded shape with a clear boundary, the light cytoplasm containing a glycogen, sometimes lipids. The stroma of a tumor is presented by connective tissue layers, infiltrirovanny lymphoid cells, granulematozny reaction is sometimes expressed (tuberkulopodobny granulomas with huge multinucleate cells).
Anaplastic S. clinically is considered as more malignant, it differs in the expressed polymorphism of cells and kernels, a bolshim'kolichestvo of mitoses, poorly expressed stroma with scanty lymphoid infiltration and lack of granulematozny reaction. Anaplastic S.'s sites can be found in typical seminomas and in their metastasises.
Spermatocytal S. makes about 9% of all seminomas and meets preferential aged 50 years are more senior; can reach the considerable sizes. A tumor of yellowish color, a mucous look, slightly spongy, sometimes with cysts, small sites of a necrosis and hemorrhages on a section. Microscopically consists of cells of three types: limfotsitopodobny with a clear boundary, a round basphilic kernel and eosinophilic cytoplasm; huge — to dia. to 100 microns with 1 — 3 kernels; so-called intermediate - t cells of the average sizes with round kernels and plentiful cytoplasm. Unlike typical S. spermatocytal S.'s cells do not contain a glycogen, in a stroma of a tumor there is no lymphoid infiltration.
S.'s innidiation happens in the lymphogenous and hematogenous way: in ileal and paraortalny limf, nodes, lungs, a liver, are more rare in other bodies. Typical and anaplastic S.'s metastasises approximately in 65% of cases have a structure of a seminoma, in 26% — embryonal cancer (see) and in 4% — teratomas (see). Spermatocytal S. metastasizes seldom.
The clinical picture
Klin, a picture at the beginning of a disease is characterized by increase and consolidation of a small egg; it sometimes is followed by unpleasant feelings and morbidity. Small egg (see) can reach the big sizes (to 20 — 30 cm in the diameter) that is seldom observed at other his tumors. Approximately in 10% of cases the first the wedge, manifestations are caused by metastasises in the retroperitoneal limf, nodes easy. At defeat paraortalny limf, nodes there are to an abdominal pain and a waist, hypostases of the lower extremities connected with a prelum of the lower vena cava at a prelum of ureters — an oliguria with the subsequent anury. Severe pains, development of intestinal impassability are possible (see. Impassability of intestines ).
On S.'s classification accepted in the USSR distinguish four a wedge, stages: I \the tumor of the small sizes which is not sprouting a white and not breaking a form of a small egg; II \the tumor without metastasises which is going beyond a white, breaking a form of a small egg; III \a big hilly tumor with metastasises in regional limf, nodes; IV \primary tumor as at the I—II stages, but with metastasises in regional limf, nodes and the remote bodies.
the Presumable diagnosis of S. as well as at other tumors of a small egg, it can be put on the basis of data on gradual increase and consolidation of a small egg. The puncture of a small egg with the subsequent tsitol allows to establish it, as a rule. a research, at Krom in some cases also the nature of a tumor can be established. Differential and diagnostic value has determination of content in urine chorionic gonadotrophin (see) and alpha-fetoprotein. The high caption of a chorionic gonadotrophin and alpha-fetoprotein is characteristic of a horionepitelioma (see. Trophoblastic disease ) and embryonal cancer. Patients with S. have an increase in its contents, as well as level of alpha-fetoprotein, is observed seldom. Plays an important role rentgenol. the research of lungs and zones of regional innidiation, to the Crimea according to the classification offered by the International anticarcinogenic union belong limf, the nodes located along an aorta and the lower vena cava inguinal limf, nodes (when operation on a scrotum or in inguinal area took place), and also intra pelvic, mediastinal and supraclavicular limf. nodes. At increase supraclavicular limf, nodes make their puncture with the subsequent tsitol. research. Inspection retroperitoneal limf is much more difficult, nodes, a cut usually begin with carrying out excretory urography (see). At big metastasises in retroperitoneal limf, nodes on uro-grams the shift of an ureter comes to light, sometimes its prelum, a cut leads to expansion of uric ways, sometimes up to switching off of function of a kidney. Considerably big information can be obtained with the help kavografiya (see), especially at S. of the right small egg: shift and a prelum of the lower vena cava come to light, up to its total block. Kavografiya executed in a side projection allows to differentiate metastatic defeat of front or back group limf, nodes. At the same time the metastasises which are not defined in a direct projection owing to their stratification on a shadow of the lower vena cava in some cases come to light. At small metastasises retroperitoneal limf, nodes the straight line gives valuable data on a state limfografiya (see), however completely replaced with metastasises limf, nodes on a limfogram-move do not come to light.
In a crust, time the particularly important in diagnosis of retroperitoneal metastasises becomes the computer tomography (see the Tomography computer) revealing the increased limf, nodes, their relationship with the main blood vessels (an aorta, the lower vena cava, renal vessels) by both the next bodies and fabrics. This method allows to receive at the same time the layer-by-layer image of a liver, kidneys, adrenal glands, a pancreas, in to-rykh S.'s metastasises
Treatment complex can be quite often found; begin it with an orkhifunikulektomiya. Performance only of an orkhiektomiya is inadmissible (see. Castration ), it is necessary to remove and seed cord (see). The nature of further treatment is defined after obtaining results gistol. researches of a tumor.
At I and II stages of a typical seminoma after an orkhifunikulektomiya carry out radiation therapy of zones of regional innidiation, or courses of preventive chemotherapy. Except ways limf, outflow, the stump of a seed cord is subject to radiation.
In III and IV stages of a disease apply most often the combined treatment (chemotherapy and radiation therapy). Radiation therapy is given preference in the presence of single massive metastasises. Chemotherapy appoint preferential sick with multiple metastasises or in cases when it is necessary to gain bystry effect, napr, at the oliguria and an anury caused by a prelum of ureters retroperitoneal metastasises. In similar cases it is admissible to enter so-called shock doses of sarcolysine (on 100 — 120 mg in one step). As a rule, a retroperitoneal limfadei-ektomiya (see. Shevassyu — Grégoire operation ) at typical S. do not make since radiation therapy and treatment by antineoplastic means are rather effective.
Radiation therapy of primary tumor is carried out in cases of its neofeather-belnosti or failure of the patient from operation.
Contraindications to radiation therapy are the serious general condition of the patient caused by extensive dissimination of a tumor, a cachexia, the expressed anemia and a leukopenia.
Need of radiation of large volumes of fabrics defines use of remote radiation therapy (see) by megavoltny sources of ionizing radiation. At radical radiation therapy the total focal dose is equal 3000 — 4000 is glad (30 — 40 Gr); radiation is carried out during 4 — 5 weeks. At radiation therapy with the palliative purpose the total focal dose makes 2000 — 3000 is glad (20 — 30 Gr). Dermahemia in the field of fields of radiation, a leukopenia, and also dysfunctions of a stomach and intestines are possible. (See) treat late beam damages hron. gastroenterocolitis (see) and beam nephrosclerosis (see) at radiation of kidneys.
The most effective antineoplastic remedies at S.'s treatment are sarcolysine and Cyclophosphanum. Sarcolysine is usually appointed on 50 mg intravenously once a week to a total dose by 200 — 250 mg; Cyclophosphanum is entered intravenously on 0,4 g every other day to a total dose of 6 — 8 g. Courses of chemotherapy are conducted 1 time in 3 — 4 months within 2 years.
Spermatocytal and anaplastic S. is worse, than typical S., will respond to treatment, and anaplastic S. of a rezistentn to radiation therapy and antineoplastic means. At resistance of a tumor to the carried-out treatment or during the obtaining incomplete effect it is necessary to pass to the schemes and methods of treatment applied at other malignant tumors of a small egg, napr dysgermoinomas (see). It belongs also to tumors of a small egg more than odtsy gistol. type, containing elements C.
Five-year survival, according to Johnson (D. E. Johnson) and soavt. (1976), at typical Page 1,11 and III of stages makes respectively 93,7%, 90% and 57,9%. At anaplastic Page I and II of a stage, according to Perkar-pio (V. of Percarpio) et al. (1979), 5 10-year survival makes respectively 96 and 87%. It is established that decrease in maintenance of a chorionic gonadotrophin in the course of radiation therapy or chemotherapy testifies to efficiency of treatment, and increase in its contents in the course of treatment and at the subsequent observation — an adverse predictive sign.
Bibliography: Berman N. A. Klinikomorfologicheskaya characteristic of seminomas, Vopr. onkol., t. 25, No. 1, page 69, 1979; Ganina K. P. Morphology and pathogeny of tumors of a small egg, Kiev, 1964; D at r N about in L. A., Voinov E. A. and Korneev Yu. E. Children's onkourologiya, page 119, Kiev, 1981; Clinical oncology, under the editorship of H. N. Blochina and B. E. Peterson, t. 2, page 446, M., 1979; Kozlova A. V. Radiation therapy of malignant tumors, page 185, M., 1976; M and r and N and x E. B. Tumors of a small egg and its appendage, M., 1972, bibliogr.; M about with t about f and T. and With about and L. G N. Histologic classification of tumors of a small egg, the lane with English, M., 1981; Pathoanatomical diagnosis of tumors of the person, under the editorship of N. A. Krayevsky, etc., page 298, M., 1982; Yunda I. F. Malignant tumors of a small egg, Kiev, 1971, bibliogr.; Cochran J. S. The seminoma decoy, J. Urol. (Baltimore), v. 116, p. 465, 1976; Johnson D. E., Gomez J. J. a. Ayala A. G. Histologic factors affecting prognosis of pure seminoma of the testis, Sth. med. J. (Bgham, Ala.) v. 69, p. 1173, 1976; M about s-t about f i F. K. a. Price E. B. Tumors of the male genital system, Washington, 1973; Mulkerin L. E. Practical points in radiatio oncology, p. 107, Bern a. o., 1979; Percarpio B. o. Anaplastic seminoma, Cancer, v. 43, p. 2510, 1979; Radiotherapy in modern clinical practice, ed. by H. F. Hope-Stone, p. 275, St Louis, 1976.
B. P. Matveev; A. I. Strashinin (is glad).