[Histopathology of testicular germ cell tumors]

The most common type of testicular tumor is the germ cell tumor, which shows peculiar histological and biological features. The histopathology of germ cell tumors of the testis is illustrated here according to the WHO classification except for extremely rare polyembryoma and teratoma with malignant transformation. The tumors are divided roughly into 2 groups, one histological type including seminoma, spermatocytic seminoma, embryonal carcinoma, yolk sac tumor, choriocarcinoma and teratoma, and more than one histological type including many possible combinations of one histological type. Seminoma and spermatocytic seminoma show some similar features to the germ cell line, while embryonal carcinoma, yolk sac tumor, choriocarcinoma, and teratoma show differentiation toward a variety of structures appearing at any stage of embryogenesis instead of the original testicular tissue. The histology of the metastatic disease may or may not be the same as that of the primary lesion. The reasons for the occurrence of histological differences between primary and metastatic tumors is discussed. Two major tumor markers of the germ cell tumor, HCG and AFP, are analyzed using immunohistochemical procedure, and the significance of immunostaining for these markers in clinicopathological study is stressed.

Identification of vessels by lectin-immunoperoxidase staining of endothelium: possible applications in urogenital malignancies

Ulex europaeus agglutinin I binds specifically to vascular endothelium of various human tissues irrespective of the blood group type or secretive status of the tissue. Using this property, we have developed an immunoperoxidase technique to identify vessel structures in urogenital tissues. Most vessels in malignant and nonmalignant tissues of bladder, prostate and testis of different blood types (A, B, AB and O) can be readily identified by this method. This technique has potential application in detecting tumor cell invasion of vessels and in studying distribution of vessels in relation to various normal and pathological events.

Prognostic factors in testicular germ cell tumours. Experiences from 1058 consecutive cases

Prognostic factors in carcinoma of the testis were studied in 1058 adult patients treated in Denmark from 1976 to 1980. Separate analyses of the prognostic factors were carried out within the subgroups formed by a classification of the patients according to main histologic type (seminoma, non-seminoma) and the clinicoradiologic stage (I, II and III). The prognosis was measured by relapse-free survival (stage I and II), and survival (stage II and III). The prognostic value of 19 clinical and histologic parameters was evaluated using logrank tests and multiple regression analyses. An elevated HCG level and the size of retroperitoneal metastases were associated with a significantly adverse prognosis for seminoma in stage II. For non-seminomas the following parameters had a significant influence on the prognosis. Stage I: postoperative HCG level, local invasion and number of mitoses. Stage II: size of retroperitoneal metastases, postoperative HCG level, tumour size and local invasion. Stage III: presence of liver or lung metastases, postoperative HCG level, presence of choriocarcinoma or endodermal sinus tumour, and age.

Should an elevated human chorionic gonadotropin titer alter therapy for seminoma?

We reviewed the clinical courses of 55 patients with pure seminoma of the testis to determine the influence of elevated levels of beta-human chorionic gonadotropin on prognosis. Of 44 patients with stage I and 11 with stage IIA seminomas 42 and 36 per cent, respectively, had elevated gonadotropin levels after orchiectomy and before radiotherapy. At followup, ranging from 12 to 64 months, 54 patients (98 per cent) were free of disease. We concluded that an elevated gonadotropin level after orchiectomy is not a significant prognostic indicator and that these patients should be treated with standard radiotherapy techniques.

Tumour markers in testicular germ cell tumours. Five-year experience from the DATECA Study 1976-1980

Since Jan. 1, 1976, nearly all new cases of testicular germ cell tumours have been included in the Danish Testicular Carcinoma Study (DATECA), and have been monitored by the tumour markers alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG). During the first five years, 1058 patients participated in the investigation, but only 603 of these patients were followed by preoperative as well as postoperative marker determinations in serum. The overall prevalence of marker positivity, i.e. elevated preoperative values for AFP and/or HCG, was 8 per cent for seminoma patients and 60 per cent for non-seminoma patients. Elevated levels of serum AFP and HCG were correlated to the presence of endodermal sinus tumour and choriocarcinoma elements, respectively, in the primary tumour. The presence of increased marker concentration in serum was correlated stage (higher percentage in higher stages) and to prognosis (marker negative patients had a better prognosis than marker positive patients). Marker production by seminoma patients seems to indicate a poor prognosis, especially for HCG producing seminomas.

[A case of advanced testicular seminoma--chemotherapy and serum marker]

A 52 year-old male with advanced testicular seminoma (stage II N4) underwent right radical orchiectomy, followed by chemotherapy with vinblastine, bleomycin and cis-platinum. This resulted a partial response and he was well for 24 months after the operation. Serial monitoring of serum HCG and HCG-beta has been done, using three kinds of double antibody radioimmunoassays. A substance with immunological similarity to free HCG-beta was detected in sera and tumor extract. The serum level of this substance was reduced in parallel with the cytoreduction of metastasis by chemotherapy. A rational therapeutic approach to advanced seminoma and its serum marker are discussed briefly.

Endocrine profiles of patients with testicular tumors treated with radiotherapy

Blood samples for hormone analysis were obtained 5 to 20 years post-therapy from 12 men with testicular tumors who were originally treated by unilateral orchiectomy followed by abdominal and/or pelvic irradiation. In nine patients (75%) the levels of FSH and LH, and in one patient (8%) the testosterone values, were outside the ranges found in age- and sex-matched controls. From this retrospective study we conclude that, even when the remaining testis is kept outside the field of radiation, significant radiation damage occurs, mainly through scatter. This damage is more likely to occur if the hemiscrotum is irradiated. Methods of shielding are available to reduce the dose received by the contralateral testis.

Experience with beta-HCG-positive seminoma

The clinical findings, diagnosis and course of disease of eight patients with histological pure seminoma of the testis and positive serum beta-HCG levels are presented. In addition to routine investigations, immunohistochemical examination of the formalin-fixed specimen by the immunoperoxidase technique was also carried out. Serum alpha-feto-protein levels of all eight patients remained normal. There was no correlation between serum beta-HCG level and tumour stage. The longest period of observation was 48 months, the shortest 11 months. All patients were treated primarily by radiotherapy. One patient also received chemotherapy and one patient underwent bilateral lymphadenectomy 13 months after radiotherapy.

Multiple biochemical tumor markers in seminoma. A double-blind study

The value of certain biochemical tumor markers have been well established in nonseminomatous testicular cancer. However, the lack of frequent tumor markers in the sera of patients with seminoma has prompted us to embark on this double blind study. The authors studied 89 patients with the histologic diagnosis of seminoma utilizing placental alkaline phosphatase (PLAP), gamma-glutamyl transpeptidase (gamma GT), human chorionic gonadotropin (hCG), and alpha-fetoprotein (AFP). It was found that 12/30 patients (40%) with active tumor had elevated serum PLAP and 10/30 (33%) of these patients had elevated serum levels of GGT. Eighty percent of the patients with clinically active tumors had detectable serum levels of one or more of these biochemical markers. Since the frequency of the previous tumor markers have been scarce in seminoma, these serial utilization of these biochemical markers should assist the clinician to detect and monitor seminoma patients more efficaciously. However, the false-positive, false-negative, rates, and biologic half lifes of these markers should be taken in account.

Problems of interpretation of serum concentrations of alpha-foetoprotein (AFP) in patients receiving cytotoxic chemotherapy for malignant germ cell tumours

Serial determinations of serum alpha-foetoprotein (AFP) concentrations are well established in monitoring the response to therapy of malignant germ cell tumours. Using a radioimmunoassay (RIA) with a sensitivity down to 2kul-1 the majority (57%) of 28 patients with non-AFP producing germ cell tumours had measurable immunologically-reactive AFP in their serum while on treatment. Follow-up for 11-43 months (mean 27) without evidence of tumour activity indicated that this immunologically-reactive AFP was unlikely to be produced by tumour. In patients where the initial serum AFP was raised prior to chemotherapy the AFP concentration did not fall to the normal range at the end of the treatment in 16 (32%) of 41 patients. Follow-up of these patients for 9-48 months (mean 27) has resulted in 5 (12%) relapses in this group. Serum AFP greater than 20kul-1 three months after stopping chemotherapy was a good indicator of residual active tumour and 4 (57%) of 7 patients in this group relapsed. The production of detectable serum AFP is probably related to the type of chemotherapy used and only 7 (14%) of 51 patients treated for gestational choriocarcinoma had detectable AFP concentrations while on cytotoxic chemotherapy. The problem of interpretation of serum AFP concentration in patients with malignant germ cell tumour stresses the need to determine whether there are differences between AFP produced by germ cell tumours and that produced at other sites as a basis for a sensitive assay system able to discriminate between them.

Growth-hormone-releasing factor in growth hormone deficiency: demonstration of a hypothalamic defect in growth hormone release

Four patients with hypothalamic tumours or idiopathic growth hormone (GH) deficiency, who were GH deficient by conventional criteria, responded to 200 micrograms synthetic hpGRF-40 with a clear rise in circulating GH.

[Tumor marker in urology]

Tumor marker for tumors in urology has been widely used to testicular and prostatic tumors. A part of testicular tumor produces alpha-fetoprotein (AFP) and HCG, thus these markers can not be used for early detection of disease. However, they are very useful in typing testicular tumor, and in monitoring a course of disease which produces them. beta-HCG seems to be more specific than HCG. In case of prostatic cancer, prostatic acid phosphatase (PAP) assayed immunochemically is sensitive and specific marker. Prostate antigen seems to be another excellent marker for this tumor, and this is well correlated with PAP. In reactivated case, tissue polypeptide antigen was elevated, suggesting use of this marker.

[Primary mediastinal seminoma. Value of the assay of tumor markers before any surgery. Study of a case]

An excessive surgical excision of pulmonary parenchyme preceded the histological diagnosis of a mediastinal seminoma, concerning a 43 year-old man. Absence of all tumoral tracer during surgery did not permit to establish the difference between radiosensitive pure seminoma and impure seminoma of which repeated dosages should have improved medical strategy. In order to avoid, in the future, a similar error, in case of an anterior mediastinal tumor, the authors formally recommended, before all surgery, a dosage of HCG and AFP.

Evaluation of five tumor markers (AFP, CEA, hCG, hPL and SP1) in monitoring therapy and follow-up of patients with testicular germ cell tumors

61 patients with seminoma and 113 with nonseminomatous germ cell tumors of the testis were treated according to the histology, stage of disease, and serum levels of tumor markers (CEA, AFP, hCG, hPL and SP1). 33 were stage I, 63 stage II, and 78 stage III patients. Most patients with seminoma, mature teratoma, immature teratoma, and 'pure type' embryonal carcinoma, as well as the latter three types with seminomatous admixture, had normal serum levels of the markers. Sometimes, slightly elevated levels of hCG suggested the presence of metastases. But, serial measurements of the markers were seldom useful in monitoring therapy. The 5-year tumor-free survival rates were favorable: 100% for stage I and II disease; and 57 or 44% for, respectively, stage III seminoma or the other tumors amounting to 10% of the nonseminomatous group. The role of the five markers was significant in patients with teratoma with malignant transformation, choriocarcinoma, endodermal sinus tumor (EST), and embryonal carcinoma or teratocarcinoma with an admixture of EST or choriocarcinoma or both. Elevation of a marker was a grave prognostic sign. The 5-year survival rates were 100, 16, and 4% for stages I, II and III disease, respectively. An elevated level of one or more of the markers assayed was always useful for monitoring therapy. Decreasing level indicated regression. However, return of an elevated level to normal did not indicate eradication of all tumor and called for diagnosis by imaging modalities. Constantly elevated or increasing marker levels during treatment indicated resistance to therapy. An increasing level from any nadir during remission indicated recurrence. Elevated levels of any of the five markers tested were as important as imaging modalities, and often more sensitive.