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Evaluation of preoperative testicular volume in Japanese children with unilateral cryptorchidism. Int Urol Nephrol 2008; 40:977-81. [DOI: 10.1007/s11255-008-9385-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Accepted: 03/31/2008] [Indexed: 11/26/2022]
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Park KH, Lee JH, Han JJ, Lee SD, Song SY. Histological evidences suggest recommending orchiopexy within the first year of life for children with unilateral inguinal cryptorchid testis. Int J Urol 2007; 14:616-21. [PMID: 17645605 DOI: 10.1111/j.1442-2042.2007.01788.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine the optimal timing for orchiopexy, we evaluated the histological parameters of the cryptorchid testis. METHODS We prospectively performed testicular biopsy in a total of 65 consecutive children with palpable unilateral inguinal cryptorchid testes. For controls, we used testicular histological slides from 15 age-matched children with testicular tumor. To investigate the fertility potential, we analyzed the parameters including mean tubular diameter (MTD), mean tubular fertility index (MTFI), germ cell count/tubule (GCC), Sertoli cell index (SCI) and interstitial fibrosis index (IFI). RESULTS The MTFI and GCC in children < or =1 years of age were significantly higher than those of other older age groups. The MTFI, GCC and IFI were significantly better in patients < or =2 years of age when compared to those of > 2 years. Compared to the controls, the MTFI and GCC in the patients were significantly worse in those aged > 2 years at surgical repair. In the < or =2-year age group, the MTFI and GCC of the cryptorchid testis showed a decreasing tendency with age, which were contrasting with the ascending curves in the control and the curves crossed at 1-2 years of age in each parameter. CONCLUSIONS To protect fertility potential, we recommend, orchiopexy should be performed within the first year of life, and no later than 2 years of age in patients with palpable inguinal cryptorchid testes.
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Affiliation(s)
- Kwan Hyun Park
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, #50 Ilwon-dong, Kangnam-gu, Seoul 135-710, Korea.
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Walsh TJ, Dall'Era MA, Croughan MS, Carroll PR, Turek PJ. Prepubertal Orchiopexy for Cryptorchidism May be Associated With Lower Risk of Testicular Cancer. J Urol 2007; 178:1440-6; discussion 1446. [PMID: 17706709 DOI: 10.1016/j.juro.2007.05.166] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2007] [Indexed: 11/29/2022]
Abstract
PURPOSE Current indications for orchiopexy are to decrease the risk of infertility and to facilitate testicular self-examination. Although the increased risk of germ cell cancer in cryptorchid testes is undisputed, it is unclear whether orchiopexy affects the natural history of testis cancer development. We hypothesize that early orchiopexy is protective against subsequent development of testicular germ cell cancer. MATERIALS AND METHODS We conducted a systematic review and meta-analysis of the literature. Studies pertaining to cryptorchidism and testicular cancer risk were retrieved by searching MEDLINE, BIOSIS and the Cochrane Library, using cryptorchidism as a keyword, combined with treatment, orchiopexy, testis and cancer. For data extraction exposure was dichotomized to orchiopexy before or after age 10 to 11 years, while outcome was defined as the development of testicular germ cell cancer. Summary risk measures were calculated using the random effects model. RESULTS Four studies met our criteria. Review of all studies revealed an increased risk of testicular cancer if orchiopexy was delayed until after age 10 to 11 years or was never performed. Odds ratios ranged from 2.9 to 32.0. Meta-analysis showed that testicular cancer was nearly 6 times more likely (OR 5.8 [1.8, 19.3]) to develop in men in whom orchiopexy was delayed or was not performed, compared to those in whom it was performed early. CONCLUSIONS Prepubertal orchiopexy may decrease the risk of testicular cancer. Thus, early surgical intervention is indicated in children with cryptorchidism. These findings suggest that the testicular environment, as well as underlying genetics, may have a role in testicular carcinogenesis.
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Affiliation(s)
- Thomas J Walsh
- Department of Urology, University of California San Francisco, San Francisco, California 94143-1695, USA.
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55
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Kollin C, Karpe B, Hesser U, Granholm T, Ritzén EM. Surgical treatment of unilaterally undescended testes: testicular growth after randomization to orchiopexy at age 9 months or 3 years. J Urol 2007; 178:1589-93; discussion 1593. [PMID: 17707045 DOI: 10.1016/j.juro.2007.03.173] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2006] [Indexed: 11/18/2022]
Abstract
PURPOSE We compared the growth of congenital, unilaterally undescended testes following orchiopexy at age 9 months or 3 years. MATERIALS AND METHODS Patients were randomized to surgery at age 9 months (72) or 3 years (83). Testicular volume was measured by ultrasonography at ages 6, 12, 24, 39 and 48 months. RESULTS Orchiopexy at age 9 months resulted in an increase in testicular volume at subsequent measurements at ages 2, 3 and 4 years compared to the volume at 6 months (p <0.001). In contrast, no significant growth was noted in the group treated at age 3 years. The improved testicular growth after early orchiopexy was also demonstrated by a gradual increase in the ratio of the previously retained testis and the scrotal testis in individual boys from 6 months to 4 years (0.68 to 0.81, p <0.001). For the late treatment group a significant decrease in this ratio was noted during the same period (0.68 to 0.56, p <0.01). CONCLUSIONS Surgical treatment at 9 months resulted in partial catch-up of testicular growth until at least age 4 years compared to surgery at 3 years, clearly indicating that early surgery has a beneficial effect on testicular growth. Since testicular volume is an approximate indirect measure of spermatogenic activity, this gives hope that orchiopexy at this age may improve future spermatogenesis.
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Affiliation(s)
- Claude Kollin
- Department of Woman and Child Health, Karolinska Institutet, Stockholm, Sweden.
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Abstract
We critically analysed the factors known to influence the fertility potential after orchidopexy in children. A comprehensive literature review of all publications in the English language listed in Medline using the words cryptorchidism, undescended testis, orchidopexy, fertility, semen analysis and surgery from 1970 to 2005. In unilateral ectopic, canalicular and emergent testes, as long as the surgery is carried out in early childhood, fertility outcome is good (>90%). The majority of the bilateral abdominal testes are infertile. While unilateral abdominal testes and unilateral absent or vanishing testes have favourable fertility potential, quantification has proven difficult. Despite multiple studies, fertility in crypt orchid tests is still an uncertain issue. Hormonal treatment in conjunction with early surgical correction has not been fully explored. We recommend orchidopexy soon after 6-7 months of age, corrected for term, to maximise the future fertility potential.
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Affiliation(s)
- Feilim Murphy
- Children's Research Centre, Our Lady's Hospital for Sick Children, Crumlin, Dublin 4, Ireland.
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57
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Ritzén EM, Bergh A, Bjerknes R, Christiansen P, Cortes D, Haugen SE, Jörgensen N, Kollin C, Lindahl S, Läckgren G, Main KM, Nordenskjöld A, Rajpert-De Meyts E, Söder O, Taskinen S, Thorsson A, Thorup J, Toppari J, Virtanen H. Nordic consensus on treatment of undescended testes. Acta Paediatr 2007; 96:638-43. [PMID: 17326760 DOI: 10.1111/j.1651-2227.2006.00159.x] [Citation(s) in RCA: 197] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To reach consensus among specialists from the Nordic countries on the present state-of-the-art in treatment of undescended testicles. METHODS A group of specialists in testicular physiology, paediatric surgery/urology, endocrinology, andrology, pathology and anaesthesiology from all the Nordic countries met for two days. Before the meeting, reviews of the literature had been prepared by the participants. RECOMMENDATIONS The group came to the following unanimous conclusions: (1) In general, hormonal treatment is not recommended, considering the poor immediate results and the possible long term adverse effects on spermatogenesis. Thus, surgery is to be preferred. (2) Orchiopexy should be done between 6 and 12 months of age, or upon diagnosis, if that occurs later. (3) Orchiopexy before age one year should only be done at centres with both paediatric surgeons/urologists and paediatric anaesthesiologists. (4) If a testis is found to be undescended at any age after 6 months, the patient should be referred for surgery--to paediatric rather than general surgeons/urologists if the boy is less than one year old or if he has bilateral or non-palpable testes, or if he has got relapse of cryptorchidism.
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Affiliation(s)
- E Martin Ritzén
- Department of Woman and Child Health, Karolinska Institute, Stockholm, Sweden.
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Nijs SMP, Eijsbouts SW, Madern GC, Leyman PMM, Lequin MH, Hazebroek FWJ. Nonpalpable testes: is there a relationship between ultrasonographic and operative findings? Pediatr Radiol 2007; 37:374-9. [PMID: 17325824 PMCID: PMC1915603 DOI: 10.1007/s00247-007-0425-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2006] [Revised: 01/20/2007] [Accepted: 01/21/2007] [Indexed: 12/02/2022]
Abstract
BACKGROUND Ultrasonography (US) as a diagnostic tool in the work-up of boys with nonpalpable testes (NPT) is still controversial. OBJECTIVE To evaluate the relation between US and operative findings in boys with NPT. MATERIALS AND METHODS During a 7-year period we saw 135 boys with 152 NPT. All were examined by the referring physician or a paediatric surgeon, underwent US examination, and were then re-examined afterwards by a specialist. Finally, all boys were surgically explored for testicular position. RESULTS US located 103 NPT (68%), 16 within the abdomen and 87 in the inguinal canal. With knowledge of the US result, 37 testes were palpable on re-examination. The sensitivity of US was 97% for inguinal and 48% for abdominal viable testes. Of the 49 testes (32%) missed by US, 16 were viable in either the abdominal (n=14) or the inguinal (n=2) position. CONCLUSION All boys with presumed NPT should be referred to a specialist. US is useful to determine localization of NPT, which facilitates planning the surgical procedure. An inguinal exploration is called for when US identifies the testis in the inguinal canal. Because the sensitivity of US for viable abdominal testes is only 48%, we now always perform laparoscopic exploration when US is negative.
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Affiliation(s)
- Sigrid M P Nijs
- Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands.
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Jones TD, MacLennan GT, Bonnin JM, Varsegi MF, Blair JE, Cheng L. Screening for Intratubular Germ Cell Neoplasia of the Testis Using OCT4 Immunohistochemistry. Am J Surg Pathol 2006; 30:1427-31. [PMID: 17063084 DOI: 10.1097/01.pas.0000213288.50660.f7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Specific populations of patients are at high risk for the development of germ cell neoplasia. OCT4 has been shown to be a sensitive and specific marker for intratubular germ cell neoplasia of the testis. Whether or not OCT4 immunohistochemistry is a clinically useful screening tool in patients at risk for developing malignant germ cell tumors is not currently known. We undertook immunohistochemical staining for OCT4 in a large series of patients who underwent testicular biopsy or orchiectomy for reasons other than for management of a testicular mass suspicious for malignancy (infertility, cryptorchidism, atrophic testicle, etc.). OCT4 nuclear staining was identified in germ cells in 6 of 157 patients, all of whom had clinical risk factors for the development of testicular germ cell tumors. Two of the 6 patients were under 1.5 years of age, making the significance of OCT4 positivity less certain in these cases. The remaining patients with OCT4-positive germ cells consisted of 3 adults and 1 7-year-old child. Intratubular germ cell neoplasia was identified by light microscopy in only 1 of the 6 OCT4-positive cases. OCT4 immunostaining was negative in all patients who presented with infertility and who had no additional germ cell tumor risk factors. OCT4 immunohistochemistry may be useful in identifying early forms of preinvasive germ cell neoplasia in patients with risk factors for the development of malignant testicular germ cell tumors. The low incidence of OCT4 positivity in the adult infertility patients argues against the routine use of OCT4 immunostains in testicular biopsies for infertility unless additional risk factors are present.
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Affiliation(s)
- Timothy D Jones
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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Kojima Y, Hayashi Y, Mizuno K, Kurokawa S, Sasaki S, Kohri K. Assessment of Serum Follicle-Stimulating Hormone Level and Testicular Volume for Prediction of Paternity Potential in Pubertal Boys Who Underwent Bilateral Orchiopexy in Childhood. J Urol 2006; 175:2290-4. [PMID: 16697861 DOI: 10.1016/s0022-5347(06)00341-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2005] [Indexed: 11/18/2022]
Abstract
PURPOSE We examined infertile adults for the presence of spermatozoa in the testes, serum FSH level and testicular volume to predict paternity potential in pubertal boys who had undergone bilateral orchiopexy in childhood. MATERIALS AND METHODS The study included 58 idiopathic infertile men (group 1), 14 infertile men who had undergone bilateral orchiopexy in childhood (group 2) and 21 pubertal boys who had undergone bilateral orchiopexy in childhood (group 3). We evaluated the correlation between FSH level and testicular volume in all groups. In groups 1 and 2 the testes were examined for the presence of spermatozoa using bilateral testicular biopsy samples. RESULTS Judging from the presence of spermatozoa in the testes and correlation between FSH level and testicular volume, 14 patients in group 1 (24%) were categorized as being at high risk, 32 (55%) at intermediate risk and 12 (21%) at low risk for loss of paternity potential, with spermatozoa positive rates of 0%, 49% and 100%, respectively. In comparison, 4 patients in group 2 (29%) were categorized as being at high risk, 7 (50%) at intermediate risk and 3 (21%) at low risk, with spermatozoa positive rates of 0%, 43% and 100%, respectively. According to this categorization, 19% of pubertal boys in group 3 were at high risk and may already have lost their paternity potential. CONCLUSIONS Despite bilateral orchiopexy in childhood, some male adolescents may not have the potential for paternity.
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Affiliation(s)
- Yoshiyuki Kojima
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
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61
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Taran I, Elder JS. Results of orchiopexy for the undescended testis. World J Urol 2006; 24:231-9. [PMID: 16676187 DOI: 10.1007/s00345-006-0056-4] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2006] [Accepted: 01/26/2006] [Indexed: 11/24/2022] Open
Abstract
The undescended testis is one of the most common congenital abnormalities of the genitourinary system. Outcomes of orchiopexy include (1) having a viable, palpable testis in the scrotum, (2) fertility, as measured by paternity rates or semen analysis in adulthood and (3) risk of testicular cancer. Multiple operative techniques have been described and are associated with various success rates. In the past decade, success of orchiopexy for inguinal testes has been >95%. For abdominal testes, success for orchiopexy has been >85-90% in most series with single stage orchiopexy or two stage Fowler-Stephens orchiopexy, both with open surgical or laparoscopic technique. However, having a palpable testis in the scrotum does not assure fertility, as there are iatrogenic factors that may adversely affect the outcome. In adult men with a history of unilateral orchiopexy, fertility is nearly normal, but is significantly reduced following bilateral orchiopexy. The risk of testicular carcinoma is increased by a factor of 3.7 to 7.5 times. Tumor type is most commonly seminoma if the testis is undescended, whereas tumors that occur following orchiopexy are much more likely to be nonseminomatous.
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Affiliation(s)
- Irina Taran
- Division of Pediatric Urology, Rainbow Babies and Children's Hospital, Department of Urology, Case School of Medicine, Cleveland, OH 44106, USA
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Law H, Mushtaq I, Williams S, Malone M, Sebire NJ. Risk of germ cell malignancy in children with XY intersex versus isolated cryptorchidism by immunohistochemistry. Fetal Pediatr Pathol 2006; 25:95-105. [PMID: 16908459 DOI: 10.1080/15513810600788780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The risk of subsequent development of testicular germ cell neoplasia is related to presence of underlying developmental defects such as cryptorchidism, in which the risk is around 0.5%, and XY intersex with abdominal testes, in which the risk may be as high as 20-25%. We examined the hypothesis that the increased risk of germ cell malignancy in intersex testes with Y chromosome was a direct consequence of an abnormal increase in number of PLAP/CD117+ immature germ cells into postnatal life. Archival cases of uncomplicated cryptorchidism (CO) and XY intersex (INT) were identified and anonymized, and a subgroup of aged-matched cases had sections immunostained with placental alkaline phosphatase (PLAP) and CD117. From a total of 89 intersex and 105 cryptorchid cases identified, a power calculation to detect a 20% difference in expression between groups (alpha = 0.05, power = 80%) determined that 18 intersex and 36 cryptorchid cases were required. Thus, 58 cases were examined, median age 3 (range birth-11) years, including 39 CO and 19 INT. The prevalence of any PLAP+ germ cells was 2/39 (5.1%) versus 3/19 (15.7%), respectively. (Z = 1.4, p = 0.17). In contrast, 94% of cases showed presence of any CD117+ germ cells, but the frequency of CD117+ cells was not significantly different between groups (t = 0.56, p = 0.58). CD117 and PLAP identify different populations of germ cells in pediatric testes. The extent of increased risk of malignancy in XY INT is not simply related to increased numbers of immature PLAP+/CD117+ germ cells present; additional factors play a pathogenic role.
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Affiliation(s)
- H Law
- Department of Pediatric Pathology, Great Ormond Street Hospital, London, UK
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63
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Nakane A, Kojima Y, Hayashi Y, Kurokawa S, Mizuno K, Kohri K. Effect of testicular biopsy in childhood on spermatogenesis, fertility, and paternity in adulthood--a mouse model study. Urology 2005; 66:682-6. [PMID: 16140115 DOI: 10.1016/j.urology.2005.03.076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2004] [Revised: 03/08/2005] [Accepted: 03/30/2005] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To study the effect of testicular biopsy in childhood on spermatogenesis, fertility, and paternity in subsequent adulthood using an animal model. Considerable controversy exists as to whether testicular biopsy should be performed in children. METHODS Four-week-old male ICR mice were subjected to unilateral testicular biopsy (group 1), bilateral biopsy (group 2), or a sham operation (group 3). At 8 weeks of age, the testicular weight, seminiferous tubular diameter, and manifestation of apoptosis were examined. The motility of sperm obtained from the epididymides of the same testes was also examined. Fertility and paternity was assessed in each mouse by housing it with 2 age-matched females for 2 weeks. RESULTS No significant differences were found in the testicular weight, mean seminiferous tubular diameter, or number of apoptotic germ cells between the biopsied and unbiopsied side in group 1 or between groups 2 and 3. No significant differences were noted in the average sperm motility rate between the biopsied (30.5% +/- 14.5%) and unbiopsied side (35.8% +/- 19.2%) in group 1, or between groups 2 (37.6% +/- 18.0%) and 3 (39.3% +/- 10.0%). All females who coupled with the male mice in all groups became pregnant. The average number of offspring from the 2 female mice was not significantly different among the three groups (group 1, 13.1 +/- 2.3; group 2, 12.3 +/- 2.0; and group 3, 11.3 +/- 3.0). CONCLUSIONS The spermatogenesis, fertility, and paternity of mature mice were unaffected by testicular biopsy in childhood.
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Affiliation(s)
- Akihiro Nakane
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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64
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Lee PA. Fertility after cryptorchidism: epidemiology and other outcome studies. Urology 2005; 66:427-31. [PMID: 16098371 DOI: 10.1016/j.urology.2005.01.017] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2004] [Revised: 12/17/2004] [Accepted: 01/11/2005] [Indexed: 11/22/2022]
Affiliation(s)
- Peter A Lee
- Department of Pediatrics, Pennsylvania State College of Medicine, The Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
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65
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von Eyben FE, Jacobsen GK, Skotheim RI. Microinvasive germ cell tumor of the testis. Virchows Arch 2005; 447:610-25. [PMID: 15968545 DOI: 10.1007/s00428-005-1257-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2004] [Accepted: 03/07/2005] [Indexed: 10/25/2022]
Abstract
Microinvasive germ cell tumor (MGCT) consists of a limited number of malignant germ cells in the intertubular tissue of the testis. The cells have large nuclei, prominent nucleoli, abundant clear cytoplasm, and distinct cellular borders in hematoxylin and eosin staining. MGCT can be the first stage of malignancy in the development of testicular germ cell tumor (TGCT). Biopsies from men with maldescended testes have been reported to contain intratubular germ cell neoplasia, unclassified (IGCN) and MGCT in 1.8% of the examined cases (95% CI 0.5-4.6%). MGCT has also been found in testes of subfertile men and in the contralateral testis of patients with TGCT. MGCT is a frequent finding (19%) in the testicular tissue adjacent to an overt TGCT. Men with a high risk of TGCT may gain from screening for precursor lesions of TGCT with ultrasonography of the testes followed by a testicular biopsy if suspicious abnormalities are found: Treatment is high-voltage radiotherapy for intratubular germ cell neoplasia (IGCN), and orchidectomy for MGCT and germ cell tumor in situ, either intratubular seminoma or intratubular embryonal carcinoma. After local treatment, patients with precursor lesions can be followed with a surveillance program. The mRNA levels of invasion-related genes were evaluated based on a DNA microarray data set, and we found two gene abnormalities most relevant for the invasion of malignant germ cells: matrix metalloproteinase 9 (MMP9) and plasminogen activator, urokinase (PLAU) genes were up-regulated in a study comparing tissue samples of TGCT and IGCN.
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66
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Hoei-Hansen CE, Rajpert-De Meyts E, Daugaard G, Skakkebaek NE. Carcinoma in situ testis, the progenitor of testicular germ cell tumours: a clinical review. Ann Oncol 2005; 16:863-8. [PMID: 15821122 DOI: 10.1093/annonc/mdi175] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Testicular germ cell tumours (TGCT), including seminomas, embryonal carcinomas, teratomas and yolk sac tumours, have a common precursor, the carcinoma in situ (CIS) cell. Recent gene expression studies displaying close similarity of CIS cells to embryonic stem cells support the longstanding theory that CIS most likely originates in utero from fetal gonocytes. The clinical association between the testicular dysgenesis syndrome components (TGCT, cryptorchidism, genital malformations, some forms of decreased spermatogenesis) also implies a prenatal origin. Despite high cure rates of TGCT, efforts should be made to obtain diagnosis at the CIS stage, as intervention is possible before an invasive tumour develops, thus reducing the necessity for intensive therapy. CIS may be suspected in patients with an assumed extragonadal GCT or cryptorchidism, and in intersex patients and selected cases with infertility (presenting with atrophic testes and ultrasonic microlithiasis). Surgical testicular biopsy seems the only reliable diagnostic method. The management of choice of unilateral CIS is orchidectomy, or localised irradiation in bilateral cases. At least 5% of TGCT patients present with contralateral CIS; therefore, contralateral biopsy is recommended at the time of orchidectomy. Further research is warranted to identify causal factors explaining the increasing incidence of TGCT and to obtain a method of non-invasive CIS detection.
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Affiliation(s)
- C E Hoei-Hansen
- University Department of Growth, Rigshospitalet, Copenhagen, Denmark.
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67
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Irkilata HC, Yildirim I, Onguru O, Aydur E, Musabak U, Dayanc M. THE INFLUENCE OF ORCHIOPEXY ON SERUM INHIBIN B LEVEL: RELATIONSHIP WITH HISTOLOGY. J Urol 2004; 172:2402-5; discussion 2405. [PMID: 15538279 DOI: 10.1097/01.ju.0000145223.75776.cd] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Since inhibin B is the endocrine marker of spermatogenesis, basal inhibin B levels may reflect germ cell status in children. The aims of this study were to determine the changes in endocrine parameters after orchiopexy in patients with cryptorchidism and to compare these findings with testicular biopsy parameters. MATERIALS AND METHODS A total of 27 boys with undescended testis were included in this study. Inguinal orchiopexy was performed in all patients and 15 underwent testicular biopsy at orchiopexy. Spermatogonia per tubular transverse section and fertility index values were determined. Before and 6 months after orchiopexy serum basal inhibin B and other serum hormone levels were measured in all patients. RESULTS Mean serum basal inhibin B levels significantly increased 6 months after successful orchiopexy (p = 0.001). However, inhibin B level did not increase in patients who had a low testicular biopsy score. Other reproductive hormone levels did not change after orchiopexy. CONCLUSIONS Basal inhibin B level could be used as a followup parameter after orchiopexy. If basal inhibin B level does not increase in the postoperative period, the amount of germ cells in the testis may be too low or the orchiopexy might not have been implemented appropriately.
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Affiliation(s)
- H Cem Irkilata
- Department of Urology, Gülhane Military Medical Academy, School of Medicine, Ankara, Turkey
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68
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Abstract
Cryptorchidism is the most common genitourinary disorder of childhood, resulting in 27,000 surgical cases each year in the United States. Of the 3% of full-term infants affected, most will have testes that will descend normally within a few months. The remaining 1%, who have a cryptorchid condition that persists, should consider medical or surgical intervention. In addition, although the effect of cryptorchidism on testicular development and fertility has been studied extensively, the only fact of certainty is that untreated men with bilateral abdominal testes will be infertile. The remaining scenarios (unilateral, inguinal, gliding, and medically or surgically treated conditions) offer unpredictable levels of fertility. Fortunately, based on recent research, the correlation between testis maldescent and infertility may not be as prevalent as previously reported.
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Affiliation(s)
- J C Trussell
- Penn State College of Medicine, The Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033-0850, USA
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Lee MM, Misra M, Donahoe PK, MacLaughlin DT. MIS/AMH in the assessment of cryptorchidism and intersex conditions. Mol Cell Endocrinol 2003; 211:91-8. [PMID: 14656481 DOI: 10.1016/j.mce.2003.09.014] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Mullerian inhibiting substance (MIS), also known as anti-Mullerian hormone (AMH), causes Mullerian duct involution during male sexual differentiation and also has a postnatal regulatory role in the gonads. Serum MIS/AMH has a gonad specific pattern of expression and its concentrations are sexually dimorphic in children; hence measurement of serum MIS/AMH helps in the evaluation of children with gonadal disorders. In boys with cryptorchidism (non-palpable gonads), serum MIS/AMH correlates with testicular tissue. A measurable value is predictive of undescended testes while an undetectable value is highly suggestive of anorchia. In minimally virilized phenotypic females, MIS/AMH helps differentiate between gonadal and non-gonadal causes of virilization. In children with intersex conditions, MIS/AMH values assist differential diagnosis: a value above the normal female range is predictive of testicular tissue, while an undetectable value is suggestive of absent testicular tissue. Thus, MIS/AMH is useful for delineating gonadal pathology and facilitates the differential diagnosis and management of children with diverse gonadal disorders.
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Affiliation(s)
- Mary M Lee
- Pediatric Endocrine Division, Duke University Medical Center, PO Box 3080, Room 308, Bell Building, Durham, NC 27710, USA.
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Brucker-Davis F, Pointis G, Chevallier D, Fenichel P. Update on cryptorchidism: endocrine, environmental and therapeutic aspects. J Endocrinol Invest 2003; 26:575-87. [PMID: 12952375 DOI: 10.1007/bf03345224] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Cryptorchidism is the most frequent developmental abnormality in boys, present in more than 1% of infants above three months of age. It is associated with an increased risk of infertility and testicular cancer. The etiological quest is often disappointing, except in bilateral cases or associated malformations. Recent focus is on genetic and environmental aspects. Animal models have revealed the role of genes encoding for proteins implicated in testicular migration (InsI3, Hoxa 10), but in humans results are less convincing. While some degree of endogenous hormonal abnormality is suspeeted in some patients, the endocrine disruptor hypothesis is also tested. It is unclear whether the incidence of cryptorchidism has really increased, or whether there is only a better screening for this condition. However, other male reproductive problems, such as subfertility, hypospadias and testicular cancer seem on the rise. This secular trend suggests the possible in utero impact of hormonally active environmental factors, such as pesticides with estrogenic or antiandrogenic effect, and is consistent with the increased risk of cryptorchidism observed in the sons of mothers exposed to diethylstilbestrol during pregnancy. From a therapeutic point of view, there is an agreement that the correction of cryptorchidism is needed, but there is controversy on the best medical and/or surgical approach and on the optimal timing. There is a recent trend in proposing early therapeutic intervention, before 1 yr of age, in the hope of improving fertility; however, there is no proof that such a strategy can reduce the risk of testicular cancer.
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Affiliation(s)
- F Brucker-Davis
- Centre Hospitalier Universitaire de Nice, Service d'Endocrinologie, Diabétologie et Médecine de la Reproduction, Hôpital l'Archet 1, Nice, France.
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Cortes D, Thorup J, Lindenberg S, Visfeldt J. Infertility despite surgery for cryptorchidism in childhood can be classified by patients with normal or elevated follicle-stimulating hormone and identified at orchidopexy. BJU Int 2003; 91:670-4. [PMID: 12699482 DOI: 10.1046/j.1464-410x.2003.04177.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To analyse infertility despite orchidopexy in childhood. PATIENTS AND METHODS The study comprised patients with cryptorchidism (70 bilateral and 65 unilateral) who had a simultaneous biopsy taken at orchidopexy in childhood, and in adulthood had analyses of semen and FSH. In adulthood 42 formerly bilateral cryptorchid boys had repeat testicular biopsies taken. Infertility was suspected in men with < 5 million sperm/mL in the best sample of semen and concomitant poor sperm motility, and who were classified by follicle-stimulating hormone (FSH) values. At orchidopexy the number of spermatogonia/tubule and the germ cell differentiation were measured. In adulthood the percentage of tubules with complete spermatogenesis, spermatogenic arrest and Sertoli-cell only status was assessed. RESULTS Infertility was suspected in 38 of 70 (54%) of formerly bilateral and six of 65 (9%) formerly unilateral cryptorchid patients. High FSH values were expected in these suspected infertile patients, but 15 of 38 (59%) formerly bilateral and five of six formerly unilateral cryptorchid patients had normal FSH values. These patients were identified in childhood at orchidopexy; those with bilateral cryptorchidism generally presented with germ cells, but the mean number of spermatogonia per tubule was < 30% of the lowest normal value, and the germ cells were seldom normally differentiated, whereas those with unilateral cryptorchidism generally lacked germ cells in the biopsies. No patients had a decreased FSH value. CONCLUSION Despite surgery for cryptorchidism, infertility was probable in a third (44 of 135) of the patients. We expected high FSH values in these patients, but in 45% (20/44) the FSH values were normal. These patients may have relative FSH deficiency. At orchidopexy these patients were identified to be bilaterally cryptorchid with few germ cells and those unilaterally cryptorchid had none in the biopsy. After orchidopexy in childhood, additional hormonal treatment, e.g. recombinant FSH or buserelin, may be indicated in these patients.
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Affiliation(s)
- D Cortes
- Department of Paediatric Surgery, Rigshospitalet, University of Copenhagen, Denmark
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Venn A, Healy D, McLachlan R. Cancer risks associated with the diagnosis of infertility. Best Pract Res Clin Obstet Gynaecol 2003; 17:343-67. [PMID: 12758104 DOI: 10.1016/s1521-6934(02)00128-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The effects of infertility and its treatment on cancer risk are of concern to many infertile couples. Infertile women appear to be at no higher risk for breast cancer although they may be more at risk for cancers of the uterus, particularly if they have ovulation disorders. Most studies show no increase in the risk of invasive ovarian cancer in infertile women, but ovarian tumours of borderline malignancy are more common. There seems to be no overall increase in cancer risk associated with fertility drug treatment, but questions remain about risk in subgroups of infertile women. Male infertility has been associated with an increased risk of testis cancer. Cancer incidence in children born after fertility treatment appears to be similar to that in the general population. Discussion of cancer risks in the context of other reproductive and community risks can be helpful to patients.
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Affiliation(s)
- Alison Venn
- Menzies Centre for Population Health Research, University of Tasmania, 17 Liverpool Street, Hobart, TAS 7000, Australia.
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Cortes D, Thorup JM, Visfeldt J. Cryptorchidism: aspects of fertility and neoplasms. A study including data of 1,335 consecutive boys who underwent testicular biopsy simultaneously with surgery for cryptorchidism. HORMONE RESEARCH 2001; 55:21-7. [PMID: 11423738 DOI: 10.1159/000049959] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE An attempt to make a rational strategy for treatment of cryptorchidism. MATERIALS AND METHODS 1,335 cryptorchid boys with biopsy at surgery (1,638 specimens). We studied: frequency of no germ cells in biopsies from 698 patients <12 years at surgery; fertility potential of 140 patients who were now adults, and apperance of testicular neoplasia in all biopsies. RESULTS Lack of germ cells appeared from 18 months. The frequency increased with increasing age. It appeared in 30% (61/202) bilateral, and 18% (88/496) unilateral cases. In men who had undergone bilateral or unilateral orchiopexy, respectively, there was normal sperm count in 19% (14/75) and 83% (54/65), and infertility was suspected in 56% (42/75) and 8% (5/65) (FE, p < 0.00005, p < 0.00005), respectively. The lowest, the mean, and the highest age-matched spermatogonia count per tubule at orchiopexy was associated with sperm count (Spearman test, p < 0.0001, p < 0.005, p < 0.05). Isolated, this was demonstrated for the 75 formerly bilateral (Spearman, p < 0.0001, p < 0.0001, p < 0.0001), but not the 65 formerly unilateral cases (Spearman, p = 1.0). No germ cells at orchiopexy was associated with suspected infertility. Risk was 78-100% in bilateral (dependent on one or both testes affected), and 33% in unilateral cryptorchidism. There was one invasive germ cell tumor, six cases of carcinoma in situ testis, and one Sertoli cell tumor. Three neoplasms were diagnosed in intra-abdominal testes, four in boys with abnormal external genitalia, and two in boys with known abnormal karyotype. Risk of neoplasia was 5% (7/150) in patients with intra-abdominal testis, abnormal external genitalia or diagnosed abnormal karyotype, versus 0% (0/1,185) in patients without these characteristics (FE, p < 0.00005). CONCLUSION We recommend surgery for cryptorchidism before 15-18 months of age because: (a) lack of germ cells is very rare before, and (b) lack of germ cells is associated with subsequent risk of infertility. At primary surgery for cryptorchidism, we recommend examination for testicular neoplasia in cases of intra-abdominal testis, abnormal external genitalia or known abnormal karyotype.
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Affiliation(s)
- D Cortes
- Department of Pediatric Surgery, Rigshospitalet, Denmark
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Abstract
A report of a 5-year survival rate of 39% for all patients with testis cancer in Kenya contrasts sharply with the 62% 5-year survival rate after tandem high-dose chemotherapy in first-line salvage of metastatic nonseminoma, and this figure provides a stark reminder of the differences in level of health care in the world. Nothing matches, however, the international significance of the success of Lance Armstrong in winning the Tour de France for the second time. It brings home the message of how complete the cure of this disease is and the need for more to be done to educate people about this success and encourage us to seek to discover the scientific basis for why this cancer is so different from all other cancers. The discovery that Lance Armstrong's brain metastases were totally necrotic at day 21 after the first treatment, taken with a report on the use of day 21 computed tomograph response to predict outcome, reinforces that message. With a second report suggesting that there are regions of the world that may have escaped the environmental damage to fertility that is now increasingly accepted as the most significant risk factor for development of this disease, we also need to remember the importance of germ cells as a weather vane of the environment. The first breakthrough in identifying a specific genetic region on the X chromosome with susceptibility to germ cell cancer of the testis by its association with development of undescended testis was one of the scientific landmarks of this past year. Clinically, with such high cure rates after salvage treatments, most of the controversy focuses now on early management of this disease. Debate continues regarding the need for orchidectomy or node dissection before chemotherapy in patients with metastases. There is also considerable debate concerning the need for any adjuvant treatment in stage 1 disease, whether surgical, chemotherapeutic, or radiotherapeutic. With reviews on late events highlighting the possibility that cisplatin dosage may be critical in synergizing with etoposide in causing leukemia and late cardiovascular events and reports suggesting that circulating cisplatin can be detected in the plasma as long as 20 years after treatment, the message of the year is clearly how to safely minimize the amount of treatment.
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Affiliation(s)
- R T Oliver
- Department of Medical Oncology, St Barts & Royal London School of Medicine, London, UK.
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