Guidelines on Testicular Cancer: 2015 Update

Value of Intra-Perinodular Textural Transition Features from MRI in Distinguishing Between Benign and Malignant Testicular Lesions

Purpose

To compare the performance of histogram analysis and intra-perinodular textural transition (Ipris) for distinguishing between benign and malignant testicular lesions.

Patients and Methods

This retrospective study included 76 patients with 80 pathologically confirmed testicular lesions (55 malignant, 25 benign). All patients underwent preoperative T2-weighted imaging (T2WI) on a 3.0T MR scanner. All testicular lesions were manually segmented on axial T2WI, and histogram and Ipris features were extracted. Thirty enrolled patients were randomly selected to estimate the robustness of the features. We used intraclass correlation coefficients (ICCs) to evaluate intra- and interobserver agreement of features, independent t-test or Mann–Whitney U-test to compare features between benign and malignant lesions, and receiver operating characteristic curve analysis to evaluate the diagnostic performance of features.

Results

Eighteen histogram features and forty-eight Ipris features were extracted from T2WI of each lesion. Most (60/66) histogram and Ipris features had good robustness (ICC of both intra- and interobserver variabilities >0.6). Three histogram and nine Ipris features were significantly different between the benign and malignant groups. The area under the curve values for Energy, TotalEnergy, and Ipris_shell1_id_std were 0.807, 0.808, and 0.708, respectively, which were relatively higher than those of other features.

Conclusion

Ipris features may be useful for identifying benign and malignant testicular tumors but have no significant advantage over conventional histogram features.

Immunosenescence in Testicular Cancer Survivors: Potential Implications of Cancer Therapies and Psychological Distress

Testicular cancer (TC) is the most frequent solid tumor diagnosed in young adult males. Although it is a curable tumor, it is frequently associated with considerable short-term and long-term morbidity. Both biological and psychological stress experienced during cancer therapy may be responsible for stimulating molecular processes that induce premature aging and deterioration of immune system (immunosenescence) in TC survivors, leading to an increased susceptibility to infections, cancer, and autoimmune diseases. Immunosenescence is a remodeling of immune cell populations with inversion of the CD4:CD8 ratio, accumulation of highly differentiated memory cells, shrinkage of telomeres, shift of T-cell response to Th2 type, and release of pro-inflammatory signals. TC survivors exposed to chemotherapy show features of immunological aging, including an increase in memory T-cells (CD4+ and CD8+) and high expression of the senescence biomarker p16INK4a in CD3+ lymphocytes. However, the plethora of factors involved in the premature aging of TC survivors make the situation more complex if we also take into account the psychological stress and hormonal changes experienced by patients, as well as the high-dose chemotherapy and hematopoietic stem cell transplantation that some individuals may be required to undergo. The relatively young age and the long life expectancy of TC patients bear witness to the importance of improving quality of life and of alleviating long-term side-effects of cancer treatments. Within this context, the present review takes an in-depth look at the molecular mechanisms of immunosenescence, describing experimental evidence of cancer survivor aging and highlighting the interconnected relationship between the many factors modulating the aging of the immune system of TC survivors.

Smart Intravenous Infusion Dosing System

Intravenous (IV) infusion therapy allows the infusion fluid to be inserted directly into the patient’s vein. It is used to place medications directly into the bloodstream or for blood transfusions. The probability that a hospitalized patient will receive some kind of infusion therapy, intravenously, is 60–80%. The paper presents a smart IV infusion dosing system for detection, signaling, and monitoring of liquid in an IV bottle at a remote location. It consists of (i) the sensing and computation layer—a system for detection and signaling of fluid levels in the IV bottle and a system for regulation and closing of infusion flow, (ii) the communication layer—a wireless exchange of information between the hardware part of the system and the client, and (iii) the user layer—monitoring and visualization of IV therapy reception at a remote location in real time. All layers are modular, allowing upgrades of the entire system. The proposed system alerts medical staff to continuous and timely changes of IV bottles, which can have positive effects on increasing the success of IV therapy, especially in oncology patients. The prescribed drip time of IV chemotherapy for the full effect of cytostatics should be imperative.

Intricacies of Radiographic Assessment in Testicular Germ Cell Tumors

Testicular germ cell tumors (GCTs) are malignancies with a unique biology, pathology, clinical appearance, and excellent outcomes. A correct radiographic assessment of GCTs is extremely important for the clinical management in several typical scenarios. Advancements in the field of diagnostic medicine bring an increasing number of sophisticated imaging methods to increase the performance of imaging studies. The conventional computed tomography (CT) remains the mainstay of diagnostic imaging in the management of GCTs. While certain improvements in the sensitivity and specificity are suggested with magnetic resonance (MR) imaging with lymphotrophic nanoparticles in evaluating retroperitoneal lymph nodes during the staging procedure, further exploration in larger prospective studies is needed. A common diagnostic dilemma is assessing the post-chemotherapy residual disease in GCTs. Several studies have consistently shown advantages in the utility of positron emission tomography (PET) scanning in post-chemotherapy residual retroperitoneal lymph nodes in patients with seminoma, but not with non-seminoma. Recommendations suggest that seminoma patients with a residual disease in the retroperitoneum larger than 3 cm should be subjected for PET scanning with 18-fluorodeoxyglucose. Relatively high sensitivity, specificity and a negative predictive value (80-95%) may guide clinical decision to spare these patients of high morbidity of an unnecessary surgery. However, a positive predictive value of around 50% renders PET scanning difficult to interpret in the case of positive finding. These patients often require extremely difficult surgical procedures with the high risk of post-operative morbidity. Therefore, seminoma patients with PET positive residual masses larger than 3 cm still remain a serious challenge in the decision making of nuclear medicine specialist, oncologists, and urologic surgeons. In this article, we aim to summarize data on controversial dilemmas in staging procedures, active surveillance, and post-chemotherapy assessment of GCTs based on the available published literature.

Testicular germ cell tumors type 2 have high RNA expression of LDHB, the gene for lactate dehydrogenase subunit B

This study analyzed RNA expression of genes for three serum tumor markers, alpha fetoprotein (AFP), human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH), in patients with testicular germ cell tumors (TGCT) type 2. The gene AFP encodes AFP, the gene for chorionic gonadotropin beta polypeptide 5 (CGB5) encodes a major part of the specific beta subunit of hCG, and the genes for LDH subunit A (LDHA), LDH subunit B (LDHB), and LDH subunit C (LDHC) encode three different subunits of LDH. LDHB encodes the LDHB subunit present as a tetramer in LDH isoenzyme 1 (LDH-1). We examined three datasets with 203 samples of normal testis tissue (NT) and TGCT type 2. Yolk sac tumor (YST) expressed RNA of AFP fourteen thousand times higher than seminoma (SE), embryonal carcinoma (EC), and teratoma (TER) combined (P = 0.00015). In the second microarray, choriocarcinoma (CC) expressed RNA of CGB5 ten times higher than other histologic types of TGCT combined. EC expressed RNA of LDHB twice higher than SE, YST and TER combined (P = 0.000041). EC expressed RNA of LDHB higher than that YST expressed RNA of AFP and that CC expressed RNA of CGB5. In conclusion, TGCT type 2 expressed RNA of LDHB markedly higher than the RNA of 23 other candidate genes for TGCT type 2.

Factores asociados a la histología de masa residual retroperitoneal post quimioterapia en tumor testicular de células germinales

Objetivo El objetivo de este estudio es describir las características y factores relacionados con la histología de la masa residual postquimioterapia en pacientes con tumor de células germinales de origen testicular sometidos a linfadenectomía retroperitoneal durante 12 años de seguimiento.

Métodos Retrospectivamente se recolectaron datos clínicos, quirúrgicos y patológicos de la historia clínica de los pacientes en un centro de referencia de manejo de cáncer durante un periodo de 12 años. Se estimó la asociación entre los datos recolectados con la histología del tumor residual post quimioterapia.

Resultados Se incluyeron 64 pacientes, la edad promedio fue 28.1 años, el tamaño promedio de masa residual fue de 6.7 cm. La histología de la masa residual fue teratoma en 60.9%, necrosis 26.5% y tumor viable 12.5%. El grupo pronóstico tiene asociación con la histología de la masa retroperitoneal. Las masas con histología de necrosis tuvieron menor tamaño con media 6.5 cm mientras que otras histologías tuvieron tamaño promedio de la masa residual de 10.4 cm.

Conclusiones La LNDRP-PC es el estándar de tratamiento en masas residuales retroperitoneales después de quimioterapia y puede generar sobre-tratamiento hasta en 50% de los casos. El teratoma en la histología testicular está relacionado mayor tamaño de la masa residual retroperitoneal. Las características histológicas de la masa residual son comparables con otras series.

Surveillance of postchemotherapy subcentimeter residual retroperitoneal mass in metastatic nonseminomatous germ cell tumor: Does how you measure matter?

BACKGROUND

Approximately 70% to 80% of patients with metastatic nonseminomatous germ cell tumor (NSGCT) treated with cisplatin-based chemotherapy achieve a complete response, defined as normalization of serum tumor markers and either no residual retroperitoneal mass (RRM) or an RRM <1.0 cm. While there is universal agreement that patients with an RRM ≥1.0 cm should undergo retroperitoneal lymph node dissection (RPLND), many institutions including ours recommend surveillance for patients who achieve a complete response. However, studies have not defined which axis of the RRM should be considered when deciding between surveillance and RPLND.

PATIENTS AND METHODS

Good-risk metastatic NSGCT patients treated with cisplatin-based chemotherapy who achieved a complete response and underwent surveillance were identified using our institution's electronic medical records. A post-hoc review was performed by a blinded radiologist. The RRM dimensions in the transaxial short axis (TSA), transaxial long axis (TLA), and craniocaudal axis (CCA) were recorded. Differences in the frequency of recurrence between groups with an RRM <1.0 cm and ≥1.0 cm in the TLA and CCA were assessed using the Fisher exact test.

RESULTS

Thirty-nine patients who met study criteria were included. At a median follow-up of 63.8 months, 2 patients (5.1%) recurred. Both were successfully treated with salvage chemotherapy and RPLND. Thirteen (33%) and 27 (69%) patients had an RRM ≥1.0 cm in the TLA and CCA, respectively. There were no statistically significant differences in the risk of recurrence between patients with an RRM <1.0 cm and ≥1.0 cm in the TLA (P = 0.54) or CCA (P = 0.53).

CONCLUSIONS

Surveillance is an effective strategy in good-risk NSGCT patients with a postchemotherapy RRM <1.0 cm in the TSA. Our study suggests referencing the TSA and not the TLA or CCA may avoid unnecessary postchemotherapy RPLNDs.

Clinical stage I synchronous bilateral testicular germ cell tumor with different histopathology: a case report

Bilateral testicular germ cell tumors (BTGCT) occur in 1 to 4% of patients with testicular cancer and of these, 10-15% are synchronous. Overall, BTGCT represents less than 0.5% of all new cases of testicular cancer. There are few reports in the literature of synchronous BTGCT with different histology. We present the case of a 30-year-old man who presented to our genitourinary tumor unit with a bilateral increase of testicular volume. After initial assessment, a testicular ultrasound showed the presence of solid tumors in both testes. Staging studies were negative for metastatic disease. The patient was referred to the fertility clinic for sperm banking and later underwent a bilateral radical orchiectomy. The histopathology evaluation revealed a 5.5 cm right-sided mixed germ cell tumor and a 1.5 cm left-sided testicular seminoma. Because patient's poor compliance for surveillance was identified as a risk factor for relapse and poor outcome, adjuvant chemotherapy was favored. The patient underwent one cycle of bleomycin, etoposide and cisplatin (BEP). After four years of follow up, the patient shows no evidence of relapse, either clinically or radiologically. In men unlikely to carry out successful surveillance; active treatment is the preferred option for preventing disease recurrence, even in patients with no risk factors. The physician must consider all available therapeutic measures in this scenario to achieve the best possible therapeutic result.

Should We Use Contrast-Enhanced Ultrasound (CEUS) for the Characterization of Nonpalpable Testicular Lesions? An Analysis from a Cost-Effectiveness Perspective

PURPOSE

 Accurate characterization of testicular lesions is crucial to allow for correct treatment of malignant tumors and to avoid unnecessary procedures in benign ones. In recent years, contrast-enhanced ultrasound (CEUS) proved to be superior in specifying the dignity of small, nonpalpable testicular lesions (< 1.5 cm) compared to native B-mode and color Doppler ultrasound which were previously regarded as the primary imaging method. However, the cost-effectiveness of CEUS has not been evaluated yet. The aim of this study was to analyze the cost-effectiveness of CEUS as compared to unenhanced ultrasound for the characterization of nonpalpable testicular lesions.

METHODS

 A decision model based on Markov simulations estimated lifetime costs and quality-adjusted life years (QALYs) associated with unenhanced ultrasound and CEUS. Model input parameters were obtained from recent literature. Deterministic sensitivity analysis of diagnostic parameters and costs was performed. Also, probabilistic sensitivity analysis using Monte-Carlo Modelling was applied. The willingness-to-pay (WTP) was set to $100 000/QALY.

RESULTS

 In the base-case scenario, unenhanced ultrasound resulted in total costs of $5113.14 and an expected effectiveness of 8.29 QALYs, whereas CEUS resulted in total costs of $4397.77 with 8.35 QALYs. Therefore, the unenhanced ultrasound strategy was dominated by CEUS in the base-case scenario. Sensitivity analysis showed CEUS to be the cost-effective alternative along a broad range of costs.

CONCLUSION

 Contrast-enhanced ultrasound is a cost-effective imaging method for the characterization of nonpalpable testicular lesions.

Impact of circulating microRNA test (miRNA-371a-3p) on appropriateness of treatment and cost outcomes in patients with Stage I non-seminomatous germ cell tumours

OBJECTIVES

To determine whether utilisation of a serum microRNA (miRNA) test could improve treatment appropriateness and cost-effectiveness for patients with Stage I non-seminomatous germ cell tumours (NSGCTs).

PATIENTS AND METHODS

A decision tree model was built to investigate treatment course, clinical and cost outcomes for patients with Stage IA (T1N0M0S0) and IB (T2-4N0M0S0) NSGCT. The model compared outcomes and cost of standard approach using histopathology, conventional serum tumour markers and radiographic staging (standard model) to a miRNA-based approach using the standard model + post-orchidectomy serum miR-371a-3p (marker model). Probabilities of expected treatment and outcomes were based on presence/absence of cancer upon entering into the model. Overtreatment was defined as adjuvant chemotherapy or primary retroperitoneal lymph node dissection in a patient without cancer. Undertreatment was defined as initial surveillance for a patient with cancer.

RESULTS

Utilising the miRNA marker-based approach, 26% of patients avoid overtreatment and 8% avoid undertreatment in Stage IA NSGCT; 27% avoid overtreatment and 23% avoid undertreatment in Stage IB disease. Appropriate treatment decision-making increased from 65% to 94% and 50% to 92% for Stage IA and IB, respectively. The miRNA-based approach remained cost-effective over a wide range of performance characteristics with savings of ~$1400 (American dollars)/patient for both Stage IA and IB disease.

CONCLUSION

A miRNA-based approach may potentially select patients with Stage I NSGCT for correct treatment in a cost-effective manner. Identification of residual teratoma-only remains an issue. Prospective studies are necessary to validate these findings.

Serum levels of microRNA-371a-3p are not elevated in testicular tumours of non-germ cell origin

Purpose

Serum levels of microRNA-371a-3p (M371) have been shown to be a highly sensitive and specific biomarker for testicular germ cell tumours (TGCT). Little information exists on the expression of this marker in testicular neoplasms deriving from the gonadal stroma or other structures of the gonad. This study presents an expression analysis of the novel TGCT-biomarker M371 in a large cohort of testicular non-germ cell tumours.

Methods

The M371 expression was measured by quantitative real time PCR in serum of 99 patients with testicular tumours of non-germ cell origin, thereof 30 patients with malignant testicular lymphomas and 61 patients with gonadal stroma tumours such as Leydig cell tumours, Sertoli cell tumours and 8 cases with miscellaneous benign testicular tumours. Their M371 levels were compared to those of 20 patients with TGCT and to 37 tumour-free male controls.

Results

The median expression levels of benign testicular tumours and testicular lymphoma are close to zero, thus, identical with those of controls and significantly lower than those of TGCT. In summary, this study provides further evidence for the notion that M371 is exclusively expressed by germ cell tumours and not by testicular neoplasms of the non-germ cell subtypes.

Conclusion

Clinically, the test might be of value in preoperative characterization of benign testicular tumours eligible for conservative surgery.

Considerations When Treating Patients with Good-risk Germ Cell Tumors

Three cycles of bleomycin, etoposide, and cisplatin or four cycles of etoposide and cisplatin are options for patients with good-risk germ cell tumors. Despite no significant differences in clinical outcomes in a randomized trial, studies suggest variable impact on postchemotherapy retroperitoneal lymph node dissection histology, which may help inform treatment decisions.

Short-term and long-term outcomes after resection of thoracic growing teratoma syndrome

PURPOSE

Thoracic growing teratoma syndrome (TGTS) is a rare disease in patients with germ cell tumors. Other than a few case reports and a limited number of case series, studies of this topic are not available.

METHODS

We retrospectively analyzed the data from our patients who received surgery for TGTS between 1999 and 2016. Descriptive statistical analyses were performed to analyze the characteristics of the patients, tumors, and short-term outcomes. Furthermore, the long-term outcomes and survival curves were analyzed using the Kaplan-Meier method.

RESULTS

Twenty-nine patients underwent surgery for TGTS. The median age was 32 years (range: 19-50 years). All patients received cisplatin-based chemotherapy. Many of the patients had multilocalized TGTS (n = 10). The median tumor size was 64.5 mm (range 10-210 mm). In all cases, R0 resection was achieved. The minor morbidity, major morbidity, and mortality rates were 3.4%, 6.9%, and 0%, respectively. Altogether, 28 patients were included in the long-term follow-up analysis, with a median follow-up time of 94 months (13-237 months). The 5-, 10-, and 15-year survival rates were 93%, 93%, and 84%, respectively.

CONCLUSIONS

TGTS may occur in multiple localizations and grow to a large tumor size. The resection of TGTS can be performed with low morbidity and mortality rates and is associated with good overall survival after complete resection. Important are an early detection and knowledge of the systemic treatment options by the oncologist and urologist, as well as a thoracic surgeon with a large experience in extended thoracic resections.

Outcomes of adolescent males with extracranial metastatic germ cell tumors: A report from the Malignant Germ Cell Tumor International Consortium

BACKGROUND

Adolescents with extracranial metastatic germ cell tumors (GCTs) are often treated with regimens developed for children, but their clinical characteristics more closely resemble those of young adult patients. This study was designed to determine event-free survival (EFS) for adolescents with GCTs and compared them with children and young adults.

METHODS

An individual patient database of 11 GCT trials was assembled: 8 conducted by pediatric cooperative groups and 3 conducted by an adult group. Male patients aged 0 to 30 years with metastatic, nonseminomatous, malignant GCTs of the testis, retroperitoneum, or mediastinum who were treated with platinum-based chemotherapy were included. The age groups were categorized as children (0 to <11 years), adolescents (11 to <18 years), and young adults (18 to ≤30 years). The study compared EFS and adjusted for risk group by using Cox proportional hazards analysis.

RESULTS

From a total of 2024 individual records, 593 patients met the inclusion criteria: 90 were children, 109 were adolescents, and 394 were young adults. The 5-year EFS rate was lower for adolescents (72%; 95% confidence interval [CI], 62%-79%) than children (90%; 95% CI, 81%-95%; P = .003) or young adults (88%; 95% CI, 84%-91%; P = .0002). The International Germ Cell Cancer Collaborative Group risk group was associated with EFS in the adolescent age group (P = .0020). After adjustments for risk group, the difference in EFS between adolescents and children remained significant (hazard ratio, 0.30; P = .001).

CONCLUSIONS

EFS for adolescent patients with metastatic GCTs was similar to that for young adults but significantly worse than for that children. This finding highlights the importance of coordinating initiatives across clinical trial organizations to improve outcomes for adolescents and young adults.

LAY SUMMARY

Adolescent males with metastatic germ cell tumors (GCTs) are frequently treated with regimens developed for children. In this study, a large data set of male patients with metastatic GCTs across different age groups has been built to understand the outcomes of adolescent patients in comparison with children and young adults. The results suggest that adolescent males with metastatic GCTs have worse results than children and are more similar to young adults with GCTs. Therefore, the treatment of adolescents with GCTs should resemble therapeutic approaches for young adults.

Restoration of the apoptosis pathways' proteins levels after orchiectomy in testicular tumour patients

Seminal plasma proteins already demonstrated to reflect the testicular environment function and important regulatory mechanisms. However, it is crucial to understand which of these proteins participate in probable altered pathways in testicular germ cell tumours and after unilateral orchiectomy. In this study, we proposed to verify, by a multiplex approach, the levels of DNA damage and apoptosis pathways' proteins, in seminal plasma of men before and after unilateral orchiectomy, and also in control men. Comparing pre- and post-orchiectomy groups, just the apoptosis pathways' proteins presented different levels, in which Bad was lower and Bcl2, Akt, caspase-9, p53 and caspase-8 were higher after orchiectomy. When comparing pre- and post-orchiectomy groups with control, both presented lower levels of ChK1, Chk2, H2AX, p53 and p21, for DNA damage pathway. Regarding the apoptosis pathway, lower levels of JNK, Bcl2, Akt, caspase-9, p53 and caspase-8 and higher levels of Bad were observed before orchiectomy. The post-orchiectomy group did not differ from controls, demonstrating a probable restoration on its proteins levels. We can conclude that testicular tumours can alter both of the assessed pathways, and its removal is associated with a probable restoration of the apoptosis pathway.

Familial aggregation of testicular cancer among early-onset cancer survivors. A prospective observational cohort data from Finland

Testicular cancer (TC) is the most common form of cancer in men aged 15-35 years. Familial risk for TC is among highest of all cancers.

MATERIAL AND METHODS

A prospective observational cohort of 9111 relatives in 2,188 families of early-onset TC patients, called probands, diagnosed at age ≤40 years in Finland between 1970 and 2012. Standardized incidence ratios (SIR) were used as measures of familial aggregation for early-onset (≤40 years) TC. Follow-up ended at diagnosis of TC, death or 31 December 2014 whichever earliest.

RESULTS

Among first-degree relatives of early-onset TCs, in all 12 early-onset TC cases (0.24%) were diagnosed over the follow-up; the SIR for any first-degree relative was 4.59 (95% confidence interval (CI): 2.37-8.01) and for brothers the SIR was 6.51 (95% CI 3.12-11.96).

DISCUSSION

Familial aggregation of TC shows substantial risk for early-onset TC among first-degree relatives of early-onset TC patients in Finland. This is important to acknowledge to avoid diagnostic delay especially of TC.

Testis Sparing Surgery in Pediatric Testicular Tumors

Simple Summary

Testis sparing surgery (TSS) is a safe treatment option in selected cases of testicular tumors in adults, focusing on technical feasibility, oncologic safety, preserving of testicular function, and long-term outcome. This surgical technique is also increasingly being considered in children, as benign tumors are more common in this population. With this systematic review, we aim to evaluate outcome of TSS and to investigate under which circumstances TSS can be considered safe in boys with testicular tumors. Based on the current practice described in this systematic review, combined with the outcome of TSS, we would like to suggest an algorithm to guide clinicians in determining the appropriate surgical treatment in prepubertal patients less than 12 years of age with a testicular tumor. TSS may lead to improved testicular function and quality of life in boys with testicular tumors.

Abstract

Objective: The purpose of this review is to evaluate the outcomes of testis sparing surgery (TSS) and to investigate under which circumstances TSS can be considered a safe treatment option in pediatric patients with testicular tumors. Methods: A database search was performed in Cochrane, Pubmed, and Embase for studies that focused on TSS as treatment for testicular tumors in the pediatric population, excluding reviews and single case reports. Results: Twenty studies, describing the surgical treatment of 777 patients with testicular tumors, were included in the analysis. The majority of pediatric patients with benign germ cell tumors (GCTs) (mean age: 3.7 years) and sex cord-stromal tumors (SCSTs) (mean age: 6.6 years) were treated with TSS, 61.9% and 61.2%, respectively. No cases of testicular atrophy occurred. Four of the benign GCTs, i.e., three teratomas and one epidermoid cyst, recurred. No cases of recurrence were reported in patients with SCSTs. Of the 243 malignant GCTs (mean age: 4.2 years), only one patient had TSS (0.4%). Conclusion: TSS is a safe treatment option for prepubertal patients less than 12 years of age with benign GCTs and low grade SCSTs.

A Canadian approach to the regionalization of testis cancer: A review

At the Canadian Testis Cancer Workshop, the rationale and feasibility of regionalization of testis cancer care were discussed. The two-day workshop involved urologists, medical and radiation oncologists, pathologists, radiologists, physician's assistants, residents and fellows, and nurses, as well as patients and patient advocacy groups.This review summarizes the discussion and recommendations of one of the central topics of the workshop - the centralization of testis cancer in Canada. It was acknowledged that non-guideline-concordant care in testis cancer occurs frequently, in the range of 18-30%. The National Health Service in the U.K. stipulates various testis cancer care modalities be delivered through supra-regional network. All cases are reviewed at a multidisciplinary team meeting and aspects of care can be delivered locally through the network. In Germany, no such network exists, but an insurance-supported online second opinion network was developed that currently achieves expert case review in over 30% of cases. There are clear benefits to regionalization in terms of survival, treatment morbidity, and cost. There was agreement at the workshop that a structured pathway for diagnosis and treatment of testis cancer patients is required.Regionalization may be challenging in Canada because of geography; independent administration of healthcare by each province; physicians fearing loss of autonomy and revenue; patient unwillingness to travel long distances from home; and the inability of the larger centers to handle the ensuing increase in volume. We feel the first step is to identify the key performance indicators and quality metrics to track the quality of care received. After identifying these metrics, implementation of a "networks of excellence" model, similar to that seen in sarcoma care in Ontario, could be effective, coupled with increased use of health technology, such as virtual clinics and telemedicine.

Role of primary retroperitoneal lymph node dissection in stage I and low-volume metastatic germ cell tumors

PURPOSE OF REVIEW

Early-stage testicular cancers are highly curable. Following orchidectomy, management options for stage I disease include active surveillance, nerve-sparing retroperitoneal lymph node dissection (nsRPLND) and primary chemotherapy as recommended by the current guidelines. Primary RPLND has for decades played an integral part of treatment in patients with early-stage testicular germ cell tumors (TGCT), particularly in nonseminomatous germ cell tumors (NSGCT) with focus on reducing the long-term morbidity. We review the role of RPLND in stage I NSCGT as well as stage II A/B NSGCT and as seminoma.

RECENT FINDINGS

Radiation therapy and systemic chemotherapy are established treatments for seminoma; however, long-term data has demonstrated the association of such therapies with late toxicity including secondary malignancies, hearing loss, cardiovascular disease as well as metabolic syndromes. Given the well established role of RPLND in NSGCTs, clinicians have developed an interest in utilization of surgery for low-volume retroperitoneal metastatic disease. Two prospective clinical trials (SEMS and PRIMETEST) are underway to determine the role of RPLND alone in low volume metastatic seminoma.

SUMMARY

RPLND is a highly effective treatment for early-stage germ cell tumors but represents overtreatment in low-volume stage I disease where active surveillance is recommended. RPLND has shown a promising role in low-volume stage II seminomas. Two phase II clinical trials are underway to further determine the curative potential of this approach.

Major complications of post-chemotherapy retroperitoneal lymph node dissection in a contemporary cohort of patients with testicular cancer and a review of the literature

Background

Post-chemotherapy retroperitoneal lymph node dissection (pc-RPLND) is one cornerstone in the clinical management of patients with nonseminomatous testicular germ cell tumours (GCT). A wide range of complication rates in this type of surgery is reported so far. We retrospectively evaluated the frequency of major complications by using the Clavien-Dindo classification and analysed the influence of various clinical factors on complication rates in pc-RPLND.

Methods

We retrospectively analysed 146 GCT patients undergoing pc-RPLND. Complications of grade III–V according to the Clavien-Dindo classification occurring within 30 days after surgery were registered along with the following clinical factors: age, body mass index (BMI), duration of surgery, number of anatomic fields resected, side of primary tumour, histology of surgical specimen, histology of primary tumour, and total dose of cisplatin applied prior to surgery. For comparison, we also evaluated 35 chemotherapy-naïve patients with primary RPLND and 19 with laparoscopic RPLND. We analysed types and frequencies of the various complications as well as associations with clinical factors using descriptive statistical methods.

Results

A total of 14.4% grade III–IV complications were observed in pc-RPLND, and 8.6% and 5.3% in primary and in laparoscopic RPLND, respectively. There was no perioperative mortality. Lymphocele was the most frequent adverse event (16% of grade III–IV complications). Operation time > 270 min (p = 0.001) and vital cancer in the resected specimen (p = 0.02) were significantly associated with higher complication rates. Left-sided resection fields involved two-fold higher complication rates, barely missing statistical significance (p = 0.06).

Conclusions

Pc-RPLND involves a grade III–V complication rate of 14.4%. Prolonged operation time and vital cancer in the residual mass are significantly associated with higher complication rates. The Clavien-Dindo classification system may allow inter-observer variation in rating complication grades, which may represent one reason for the wide range of reported RPLND complication rates. RPLND represents major surgery and surgeons active in this field must be competent to manage adverse events.

Active surveillance in stage 1 disease: standard of care independent of risk factors?

PURPOSE OF REVIEW

Approximately 30% of clinical stage 1 (CS1) nonseminomatous germ cell tumours (NSGCT) and 15-20% of CS1 seminoma relapse without adjuvant treatment. Despite this, the 5-year survival for CS1 is 99%. The purpose of this review is to assess if active surveillance should be standard for all patients with CS1 testis cancer independent of risk factors.

RECENT FINDINGS

Recent data from Princess Margaret Cancer Centre suggest a nonrisk-adapted surveillance approach avoids treatment in ∼70% of patients. Most relapse early at a median time of 7.4 months. The majority of relapses are confined to the retroperitoneum (66%) and only one modality of treatment is required: chemotherapy only in 61% and RPLND only in 73%.

SUMMARY

Surveillance is the preferred option and a safe proven strategy for the management of CS1 disease independent of risk factors. The prognosis for CS1 disease is excellent and the decision to offer surveillance or adjuvant treatment needs to highlight the treatment-related morbidity in an otherwise fit and healthy young man.

Management of Germ Cell Tumors During the Outbreak of the Novel Coronavirus Disease-19 Pandemic: A Survey of International Expertise Centers

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has become a public health emergency affecting frail populations, including patients with cancer. This poses the question of whether cancer treatments can be postponed or modified without compromising their efficacy, especially for highly curable cancers such as germ cell tumors (GCTs).

MATERIALS AND METHODS

To depict the state-of-the-art management of GCTs during the COVID-19 pandemic, a survey including 26 questions was circulated by e-mail among the physicians belonging to three cooperative groups: (a) Italian Germ Cell Cancer Group; (b) European Reference Network-Rare Adult Solid Cancers, Domain G3 (rare male genitourinary cancers); and (c) Genitourinary Medical Oncologists of Canada. Percentages of agreement between Italian respondents (I) versus Canadian respondents (C), I versus European respondents (E), and E versus C were compared by using Fisher's exact tests for dichotomous answers and chi square test for trends for the questions with three or more options.

RESULTS

Fifty-three GCT experts responded to the survey: 20 Italian, 6 in other European countries, and 27 from Canada. Telemedicine was broadly used; there was high consensus to interrupt chemotherapy in COVID-19-positive patients (I = 75%, C = 55%, and E = 83.3%) and for use of granulocyte colony-stimulating factor primary prophylaxis for neutropenia (I = 65%, C = 62.9%, and E = 50%). The main differences emerged regarding the management of stage I and stage IIA disease, likely because of cultural and geographical differences.

CONCLUSION

Our study highlights the common efforts of GCT experts in Europe and Canada to maintain high standards of treatment for patients with GCT with few changes in their management during the COVID-19 pandemic.

IMPLICATIONS FOR PRACTICE

Despite the chaos, disruptions, and fears fomented by the COVID-19 illness, oncology care teams in Italy, other European countries, and Canada are delivering the enormous promise of curative management strategies for patients with testicular cancer and other germ cell tumors. At the same time, these teams are applying safe and innovative solutions and sharing best practices to minimize frequency and intensity of patient contacts with thinly stretched health care capacity.

Clinical dilemmas in local and regional testis cancer

At the Canadian Testis Cancer Workshop, the multidisciplinary management of testis cancer care was discussed. The two-day workshop involved urologists, medical and radiation oncologists, pathologists, radiologists, physician's assistants, residents, fellows, nurses, patients, and patient advocacy group members.This review summarizes the discussion regarding clinical dilemmas in local and regional testis cancer. We present cases that highlight the need for a coordinated approach to individualize care. Overarching themes include the importance of a multidisciplinary approach to testis cancer, willingness to involve a high-volume experienced center, and given that the oncological outcomes are excellent, a reminder that clinical decisions need to prioritize selecting a strategy with the least treatment-related morbidity when safe.

Role of GPER-Mediated Signaling in Testicular Functions and Tumorigenesis

Estrogen signaling plays important roles in testicular functions and tumorigenesis. Fifteen years ago, it was discovered that a member of the G protein-coupled receptor family, GPR30, which binds also with high affinity to estradiol and is responsible, in part, for the rapid non-genomic actions of estrogens. GPR30, renamed as GPER, was detected in several tissues including germ cells (spermatogonia, spermatocytes, spermatids) and somatic cells (Sertoli and Leydig cells). In our previous review published in 2014, we summarized studies that evidenced a role of GPER signaling in mediating estrogen action during spermatogenesis and testis development. In addition, we evidenced that GPER seems to be involved in modulating estrogen-dependent testicular cancer cell growth; however, the effects on cell survival and proliferation depend on specific cell type. In this review, we update the knowledge obtained in the last years on GPER roles in regulating physiological functions of testicular cells and its involvement in neoplastic transformation of both germ and somatic cells. In particular, we will focus our attention on crosstalk among GPER signaling, classical estrogen receptors and other nuclear receptors involved in testis physiology regulation.

Organ-Sparing Surgery in Testicular Tumor: Is This the Right Approach for Lesions ≤ 20 mm?

Background: This study was conducted in order to analyze factors predicting malignancy in patients undergoing organ-sparing surgery (OSS) for small testicular lesions. Methods: Patients with small (≤20 mm) marker-negative clinical stage I testicular tumors were managed by OSS with tumor enucleation and frozen section examination (FSE) for the past 15 years at our institution. Benign and malignant cases were compared, focusing on preoperative and postoperative lesion sizes. Results: Eighty-nine patients were enrolled in this retrospective study. Ten (11.2%) of them were treated for synchronous bilateral tumors. Sixty-seven (67.7%) of ninety-nine lesions were benign, confirming a high concordance rate (98%) between FSE and final histology. Patients with benign tumors were significantly older than patients with malignant tumors (p = 0.026), and benign tumors were detected more frequently during urologic work-up of hormone disorders (p = 0.001). Preoperative tumor size was a strong predictor of malignancy (area under the curve (AUC) = 0.726; p < 0.001). According to the Youden index, the best cutoff to predict tumor dignity was 13.5 mm, resulting in a sensitivity and specificity of 53% and 85%, respectively. No cases of local recurrence or distant metastasis were confirmed after a median follow-up of 42 months. Conclusion: Our findings are consistent with previous reports, supporting an OSS approach in small testicular tumors whenever possible. Most tumors ≤ 20 mm were benign, and in the case of malignancy, OSS with FSE and consecutive orchiectomy is oncologically safe due to the high concordance rate of FSE and final histology, thus preventing a two-stage procedure.

Long-term Surveillance of Patients with Complete Response Following Chemotherapy for Metastatic Nonseminomatous Germ Cell Tumor

BACKGROUND

There is controversy regarding the management of patients with normal markers and residual masses (≤1 cm) after chemotherapy for nonseminomatous germ cell tumors (NSGCTs).

OBJECTIVE

To determine long-term outcomes of a surveillance strategy in such patients.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective review of our multidisciplinary testicular cancer database was performed. All patients who underwent primary chemotherapy for metastatic NSGCTs were identified between 1981 and 2016. A complete response (CR) was defined as normalization of serum tumor markers and a ≤1 cm residual mass in the largest axial dimension following chemotherapy. All such patients were surveilled.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Outcome variables of interest were time to death, time to cancer-specific survival, and time to relapse. Overall survival and relapse-free survival were calculated using the Kaplan-Meier method, and the cumulative incidence of cause-specific survival rates was calculated using competing risk analysis. The impact of risk group and chemotherapy regimen on relapse-free survival was assessed using log-rank test.

RESULTS AND LIMITATIONS

During the study period, 1429 metastatic germ cell tumor patients were treated with primary chemotherapy. CR was achieved in 191 (18.5%) NSGCT patients. The median age at diagnosis was 27.4 yr, with a median follow-up of 81.1 mo. The majority had American Joint Committee on Cancer stage II at diagnosis (I: 23.8%; II: 49.2%; III: 27%) and International Germ Cell Cancer Collaborative Group good-risk disease (good: 78%; intermediate: 17.8%; poor: 4.2%). Of the 191 patients with a CR, 175 (91.6%) never relapsed and remain disease free. Sixteen (8.4%) patients relapsed after a median of 11.3 mo (range 1-332 mo), with over half (nine patients; 4.7%) relapsing in the retroperitoneum only and salvaged successfully with postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) alone. Of these nine patients, only two (1%) had viable disease in the PC-RPLND specimen. The remaining seven patients had relapses outside the retroperitoneum and received salvage chemotherapy ± postchemotherapy resection. Overall, nine (4.7%) patients have died, but only four (2.1%) from testis cancer.

CONCLUSIONS

Our data, the largest series to date, confirm that surveillance is safe and effective for men who achieve a CR following chemotherapy for metastatic NSGCTs.

PATIENT SUMMARY

Surveillance is a safe strategy for patients who achieve a complete response following chemotherapy for metastatic testis cancer.

Clinical presentation, management and follow-up of 83 patients with Leydig cell tumors of the testis: a prospective case-cohort study

STUDY QUESTION

When should ‘not so rare’ Leydig cell tumors (LCTs) of the testis be suspected, diagnosed, and treated?

SUMMARY ANSWER

LCTs are more frequent than generally believed, are associated with male infertility, cryptorchidism and gynecomastia, and should be treated conservatively (in compliant patients) with active surveillance, which appears to be a safe alternative to surgical enucleation.

WHAT IS KNOWN ALREADY

Increasing referrals for testicular imaging have led to an increase in findings of LCTs. The features and natural history of these tumors remain largely unknown, as the available studies are small and heterogeneous. LCTs were previously treated aggressively and follow-up data are lacking.

STUDY DESIGN, SIZE, DURATION

A case-cohort study of consecutive patients diagnosed with LCTs over a 10-year period was prospectively enrolled from 2009 to 2018 and compared to matched cohorts of patients with seminomas or no testicular lesions screened in the same timeframe.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Of the 9949 inpatients and outpatients referred for scrotal ultrasound, a total of 83 men with LCTs were included. Enrolled subjects underwent medical history and clinical examination and were asked to undergo routine blood tests, hormone investigations (FSH, LH, total testosterone, estradiol, inhibin B, sex hormone-binding globulin (SHBG), prolactin), and semen analysis. Patients who consented also underwent contrast-enhanced ultrasound, elastography, gadolinium-enhanced scrotal magnetic resonance imaging, and hCG stimulation test (5000 IU i.m.) with serum total testosterone and estradiol measured at 0, 24, 48, and 72 hours.

MAIN RESULTS AND THE ROLE OF CHANCE

In total, 83 patients diagnosed with LCTs were compared against 90 patients diagnosed with seminoma and 2683 patients without testicular lesions (NoL). LCTs were diagnosed by enucleation (48.2%), orchiectomy (13.3%), or clinical surveillance (38.5%). Testicular volume, sperm concentration, and morphology were lower (P = 0.001, P = 0.001, and P < 0.001, respectively) in patients with LCTs than in the NoL group. FSH, LH, and SHBG were higher and the testosterone/LH ratio was lower in LCTs than in the NoL group (P < 0.001). The LCT group showed higher SHBG (P = 0.018), lower sperm concentration (P = 0.029), and lower motility (P = 0.049) than the seminoma group. Risk factors for LCTs were cryptorchidism (χ² = 28.27, P < 0.001), gynecomastia (χ² = 54.22, P < 0.001), and low testicular volume (χ² = 11.13, P = 0.001). Five cases were recurrences or bilateral lesions; none developed metastases during follow-up (median, 66 months).

LIMITATIONS, REASONS FOR CAUTION

This study has some limitations. First, hCG and second-line diagnostic investigations were not available for all tumor patients. Second, ours is a referral center for infertility, thus a selection bias may have altered the baseline features of the LCT population. However, given that the comparison cohorts were also from the same center and had been managed with a similar protocol, we do not expect a significant effect.

WIDER IMPLICATIONS OF THE FINDINGS

LCTs are strongly associated with male infertility, cryptorchidism, and gynecomastia, supporting the hypothesis that testicular dysgenesis syndrome plays a role in their development. Patients with LCTs are at a greater risk of endocrine and spermatogenesis abnormalities even when the tumor is resected, and thus require long-term follow-up and prompt efforts to preserve fertility after diagnosis.

LCTs have a good oncological prognosis when recognized early, as tissue-sparing enucleation is curative and should replace orchiectomy. Conservative surgery and, in compliant patients, active surveillance through clinical and radiological follow-up are safe options, but require monitoring of testicular failure and recurrence.

STUDY FUNDING/COMPETING INTEREST(S)

The project was funded by the Ministry of University and Research Grant MIUR 2015ZTT5KB. There are no conflicts of interest.

TRIAL REGISTRATION NUMBER

ALCeP trial (ClinicalTrials.gov Identifier: NCT01206270).

Population-based analysis of cost and peri-operative outcomes between open and robotic primary retroperitoneal lymph node dissection for germ cell tumors

PURPOSE

To compare perioperative outcomes and perform the first cost analysis between open retroperitoneal lymph node dissection (O-RPLND) and Robotic-RPLND (R-RPLND) using a national all-payer inpatient care database.

METHODS

Nationwide Inpatient Sample (NIS) was queried between 2013-2016 for primary RPLND and germ cell tumor. We compared cost, length of stay (LOS), and complications between O-RPLND and R-RPLND. Linear regression plots identified point of cost equivalence between R-RPLND and O-RPLND. A multivariable linear regression model was generated to analyze predictors of cost.

RESULTS

44 cases of R-RPLND and 319 cases of O-RPLND were identified. R-RPLND was associated with lower rate of complications (0% vs. 16.6%, p < 0.01) and shorter LOS [Median (IQR): 1.5 (1-3) days vs. 4 (3-6) days, p < 0.01]. Rates of ileus, genitourinary complications, and transfusions were lower with R-RPLND, but did not reach significance. On multivariable analysis, robotic approach independently contributed $4457, while each day of hospitalization contributed to an additional $2,431 to the overall model of cost. Linear regression plots determined point of cost equivalence between an R-RPLND staying a mean of 2 days was 4-5 days for O-RPLND, supporting the multivariable analysis. Total hospitalization cost was equivalent between R-RPLND and O-RPLND [Median (IQR): $15,681($12,735-$21,596) vs $16,718($11,799-$24,403), p = 0.48]-suggesting that the cost equivalency of R-RPLND is, at least in part, attributable to shorter LOS.

CONCLUSION

While O-RPLND remains the gold standard and this study is limited by selection bias of a robotic approach to RPLND, our findings suggest primary R-RPLND may represent a cost-equivalent option with decreased hospital LOS in select cases.

Improved outcomes in metastatic germ cell cancer: results from a large cohort study

Purpose

Treatment of metastatic germ cell cancer (GCC) is based on the International Germ Cell Cancer Collaborative Group (IGCCCG) prognostic classification published in 1997. 5-year survival rates were reported to be 91%, 79%, and 48% for patients with good, intermediate and poor prognosis, respectively. However, treatment results may have improved over time due to cumulative experience, improved supportive care and modern-type chemotherapy.

Methods

Patients with metastatic GCC who received cisplatin-based chemotherapy at two institutions in Munich between 2000 and 2013 were retrospectively studied. Clinical characteristics, treatment and outcomes were analyzed with respect to the IGCCG prognostic classification.

Results

Of 225 patients (median age 35 years), 72 (32%) had seminoma (S) and 153 (68%) nonseminoma. 175 (78%), 30 (13%) and 20 patients (9%) had good, intermediate and poor prognosis according to the IGCCCG classification. The 2-year-progression free survival of patients with good, intermediate and poor prognosis was 91%, 83% and 37%, and the 5-year-overall survival (OS) was 98%, 96%, and 66%, respectively. There was no significant difference in the OS between patients in the good and intermediate prognosis group.

Conclusion

Compared to data from the original IGCCCG classification system, the outcome of patients with metastatic GCC has considerably improved over time. While the prognosis of intermediate-risk patients is excellent, treatment in the poor-prognosis group remains to be improved.

Germ Cell Tumors in Adolescents and Young Adults

Germ cell tumors (GCTs) are rare in childhood, representing only 3.5% of childhood cancers, but a common malignancy in adolescents and young adults (AYAs), accounting for 13.9% of neoplasms in adolescents between age 15 and 19 years. The overall outcomes of patients treated for GCTs are excellent. However, as seen in other cancers, outcomes for AYA patients are significantly worse. Understanding the reasons for this observation has led to different approaches to diagnosis, staging, and treatment. The Malignant Germ Cell International Consortium was created to bring together pediatric, gynecologic, and testicular cancer specialists to promote research initiatives and provide evidence-based approaches in the management of GCTs across different age groups. Collaboration between multiple subspecialties is essential to further understand the disease continuum, the underlying biologic characteristics, and the development of appropriate therapeutic approaches. This review focuses on the unique characteristics of patients with extracranial GCTs in the AYA group.

Testicular cancer incidence predictions in Europe 2010-2035: A rising burden despite population ageing

Testicular cancer is the most common cancer among young men of European ancestry, with about one-third of all cases occurring in Europe. With the historically increasing trends in some high-incidence populations reported to have stabilised in recent years, we aimed to assess recent trends and predict the future testicular cancer incidence burden across Europe. We extracted testicular cancer (ICD-10 C62) incidence data from Cancer Incidence in Five Continents Volumes VII-XI and complemented this with data published by registries from 28 European countries. We predicted cancer incidence rates and the number of incident cases in Europe in the year 2035 using the NORDPRED age-period-cohort model. Testicular cancer incidence rates will increase in 21 out of 28 countries over the period 2010-2035, with trends attenuating in the high-incidence populations of Denmark, Norway, Switzerland and Austria. Although population ageing would be expected to reduce the number of cases, this demographic effect is outweighed by increasing risk, leading to an overall increase in the number of cases by 2035 in Europe, and by region (21, 13 and 32% in Northern, Western and Eastern Europe, respectively). Declines are however predicted in Italy and Spain, amounting to 12% less cases in 2035 in Southern Europe overall. In conclusion, the burden of testicular cancer incidence in Europe will continue to increase, particularly in historically lower-risk countries. The largest increase in the number of testicular cancer patients is predicted in Eastern Europe, where survival is lower, reinforcing the need to ensure the provision of effective treatment across Europe.

Updates in Staging and Reporting of Genitourinary Malignancies

CONTEXT.—

The 8th edition of the American Joint Committee on Cancer (AJCC) staging manual changed the tumor, node, metastasis (TNM) classification systems of genitourinary malignancies in 2017. However, some of the changes appear not well appreciated or recognized by practicing pathologists.

OBJECTIVE.—

To review the major changes compared with the 7th edition in cancers of the prostate, penis, testis, bladder, urethra, renal pelvis/ureter, and kidney and discuss the challenges that pathologists may encounter.

DATA SOURCES.—

Peer-reviewed publications and the 8th and 7th editions of the AJCC Cancer Staging Manual.

CONCLUSIONS.—

This article summarizes the updated staging of genitourinary malignancies, specifically highlighting changes from the 7th edition that are relevant to the pathologic staging system. Pathologists should be aware of the updates made in hopes of providing clarification and the remaining diagnostic challenges associated with these changes.

Primary Robot-assisted Retroperitoneal Lymph Node Dissection for Men with Nonseminomatous Germ Cell Tumor: Experience from a Multi-institutional Cohort

BACKGROUND

Primary robot-assisted retroperitoneal lymph node dissection (RA-RPLND) for men with nonseminomatous germ cell tumor (NSGCT) is an alternative to open RPLND for stage I and select stage II patients.

OBJECTIVE

To report the complication rates and oncologic outcomes from a multi-institutional series, and to estimate reduction in chemotherapy by using upfront minimally invasive surgery.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective chart review of men undergoing primary robot-assisted RPLND between 2014 and 2019 in five institutions by eight urologists experienced in testis cancer and robotic surgery.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Variables such as demographic and clinicopathologic information, operative parameters and complication rates, oncologic outcomes, sexual recovery, and hospital length of stay were collected. Descriptive statistics are presented.

RESULTS AND LIMITATIONS

Forty-nine patients were analyzed with a median follow-up of 15.0 mo (interquartile range 6.5-29.1 mo). Median operative time was 288 min, estimated blood loss was 100 ml, and lymph node yield was 32. Median length of stay was 1 d. There were nine postoperative complications, 44% (4/9) of which were Clavien grade 1. There were no Clavien grade IV complications. Twenty-one patients had metastatic NSGCT (42.8%), of whom nine (18.4%) received adjuvant chemotherapy. Four patients experienced recurrence (three out-of-field and one in-field recurrence). Limitations include the retrospective study design and various surgical techniques among surgeons.

CONCLUSIONS

Primary robot-assisted RPLND for NSGCT can be performed safely, with low complication rates and acceptable oncologic outcomes reducing the need for chemotherapy. For a population in which compliance with surveillance is typically challenging, robot-assisted RPLND may improve quality of care and outcomes for patients with NSGCT.

PATIENT SUMMARY

In experienced centers, robot-assisted retroperitoneal lymph node dissection can be performed safely with similar oncologic outcomes to an open approach, while providing an option that may reduce the need for chemotherapy.

Immune-related genes play an important role in the prognosis of patients with testicular germ cell tumor

Background

Testicular cancer is a very common malignancy in young men. Although testicular cancer has a high cure rate, patients have a high long-term risk of secondary malignant tumors and cardiovascular disease. In addition, for patients resistant to traditional treatment methods, new treatment methods and methods for predicting prognosis are also urgently needed.

Methods

Gene expression profiles of 165 normal testicular tissues and 156 testicular germ cell tumor (TGCT) tissues from GTEx database and TCGA database were used to obtain differentially expressed genes (DEGs) in TGCT. Through the ImmPort database, we obtained immune-related genes (IRGs). Univariate Cox regression analysis was used to identify prognostic IRGs. A transcription factor regulatory network was constructed to clarify the possible regulatory mechanism for the differential expression of these IRGs. Multivariate Cox regression analysis was used to establish a prognostic model. Gene expression data and related survival data of 108 TCGT patients from GEO database were used for external validation. Survival analysis, receiver operating characteristic curves (ROC) curve analysis, independent prognostic analysis, principal component analysis (PCA) and clinical correlation analysis were performed to evaluate this model.

Results

Three hundred and thirty-three IRGs were differentially expressed between TGCT and normal testicular tissues. We established a prognostic model (riskScore) based on 5 risk genes (SEMA6B, SEMA3G, OBP2B, INSL6 and RETN). Whether in the training cohort, the testing cohort or the entire TCGA cohort, this model could accurately stratify patients with different survival outcomes. The prognostic value of riskScore and 5 risk genes was also confirmed in the GEO database. GSEA analysis showed that DEGs in patients with better prognosis were enriched in immune-related pathways, while DEGs in patients with poorer prognosis were enriched in cancer-related pathways and cardiovascular disease-related pathways. Finally, a new Nomogram with higher prognostic value was constructed to better predict the 1-year PFS, 3-year PFS and 5-year PFS of TCGT patients.

Conclusions

We successfully established an immune-related risk model with high prognostic value and created a new Nomogram. We found that different immune status in tumor microenvironment may be responsible for the different survival outcomes among TGCT patients.

SPANXN2 functions a cell migration inhibitor in testicular germ cell tumor cells

Background

SPANX family members are thought to play an important role in cancer progression. The SPANXN2 is a gene expressed mainly in normal testis, but its role in testicular germ cell tumors (TGCTs) has yet to be investigated. TGCT is one of the most common solid tumors in young men and is associated with poor prognosis; however, effective prognostic indicators remain elusive. Therefore, we investigated the role of SPANXN2 in TGCT development.

Methods

SPANXN2 expression levels were validated by quantitative real-time polymerase chain reaction (qRT-PCR) analyses of 14 TGCT samples and five adjacent normal tissue samples. SPANXN2 was transiently overexpressed in TGCT cells to study the consequences for cell function. The effects of SPANXN2 on cell migration were evaluated in transwell and wound healing assays. The effects on cloning ability were evaluated in colony formation assays. MTT assays and cell cycle analysis were used to detect the effects of SPANXN2 on cell proliferation. The expression levels of EMT- and AKT-related proteins in cells overexpressing SPANXN2 were analyzed by Western blotting.

Results

Compared with adjacent normal tissues, the Gene Expression Profiling Interactive Analysis database showed SPANXN2 expression was downregulated in TGCTs which was consistent with the qRT-PCR analysis. SPANXN2 overexpression reduced cell migration and colony formation capability and downregulated expression of EMT- and AKT-related proteins, Vimentin, Snail, AKT, and p-AKT.

Conclusion

Our results suggest that SPANXN2 regulates TGCT cell migration via EMT- and AKT-related proteins although its role in the occurrence and development of TGCT remains to be fully elucidated.

The role of partial orchidectomy in the management of small testicular tumours: Fertility and endocrine function

BACKGROUND

Radical orchidectomy in patients who are subsequently diagnosed with benign testicular tumours represents an overtreatment due to the deleterious effects on endogenous testosterone, fertility and body image. For these reasons, the option of partial orchidectomy (PO) should be considered in certain groups of patients. Patients with bilateral tumours (synchronous or metachronous) or a solitary testis where the lesion is no greater than 30% of the volume of the testis could be considered for a PO. Evidence has shown that PO is effective for small testicular masses with excellent survival and recurrence rates.

OBJECTIVES

Highlight the feasibility of maintaining post-operative fertility or normal semen parameters and endocrine function following PO.

MATERIALS AND METHODS

Data for this review were obtained through a search of the PubMed database. Papers were required to be in English and focus on adult human males.

RESULTS

Eligible and relevant papers were assessed for data regarding fertility, semen parameters and endocrine function following PO for a small testicular mass (STM).

CONCLUSION

It is possible to preserve both fertility and endocrine function after PO. Although patients may still require adjuvant radiotherapy for concomitant intratubular germ cell neoplasia (ITGCN) which results in subfertility, endocrine function is still conserved. However, it is possible to postpone radiotherapy and continue with clinical surveillance for the purposes of fertility preservation.

Genome-wide identification of estrogen receptor binding sites reveals novel estrogen-responsive pathways in adult male germ cells

Spermatogenesis occurs in the seminiferous epithelium that shows the presence of estrogen receptors alpha (ERα) and beta (ERβ), both of which regulate gene transcription by binding to the DNA. Estrogen responsive phases of spermatogenesis are well documented; however, the genes regulated remain inexplicit. To study the regulation of genes by estrogen in male germ cells, we performed chromatin immunoprecipitation (ChIP) sequencing for ERα and ERβ under normal physiological conditions. A total of 27 221 DNA binding regions were enriched with ERα and 20 926 binding sites with ERβ. Majority of the peaks were present in the intronic regions and located 20 kb upstream or downstream from the transcription start site (TSS). Pathway analysis of the genes enriched by ChIP-Seq showed involvement in several biological pathways. Genes involved in pathways whose role in spermatogenesis is unexplored were validated; these included prolactin, GnRH, and oxytocin signaling. All the selected genes showed the presence of estrogen response elements (EREs) in their binding region and were also found to be significantly enriched by ChIP-qPCR. Functional validation using seminiferous tubule culture after treatment with estrogen receptor subtype-specific agonist and antagonist confirmed the regulation of these genes by estrogen through its receptors. The genes involved in these pathways were also found to be regulated by the respective receptor subtypes at the testicular level in our in vivo estrogen receptor agonist rat models. Our study provides a genome-wide map of ERα and ERβ binding sites and identifies the genes regulated by them in the male germ cells under normal physiological conditions.

Clinical characteristics and prognostic factors of male yolk sac tumor: a Surveillance, Epidemiology, and End Results program study

INTRODUCTION

Yolk sac tumor (YST) is a rare malignant germ cell tumor, which usually affects young males. Because of the low incidence, few studies on YST have been published. In our study, we aim to investigate the clinical characteristics, survival and risk factors of male YST patients based on the Surveillance, Epidemiology, and End Results (SEER) program.

METHODS

We identified 569 male YST patients from the SEER-18 database with additional treatment fields. Clinical characteristics, survival and prognostic factors were described in the study. Chi-square tests were applied to analyze categorical and continuous variables between different groups. Univariate and multivariate Cox proportional hazard model were performed to assess the relative impacts of risk factors on cancer-specific survival (CSS) in YST patients. Kaplan-Meier method and the log-rank test were used to analyze differences in survival that were significant.

RESULTS

The major primary sites of YST were testis (74.69%), mediastinum (15.47%), retroperitoneum (2.64%) and central nervous system (1.24%). The 3-year and 5-year CSS was 70.0%, 56.5% vs. 97.2%, 96.0% for the mediastinal and testicular YST patients, respectively (p < 0.001). Primary site of mediastinum, distant SEER Summary stage were independent factors of poor prognosis (hazard ratio (HR) = 2.010 (1.094-3.695), p = 0.025; HR = 6.501 (2.294-18.424), p < 0.001, respectively). Receiving surgery was a good prognosis factor for all patients (HR = 0.495 (0.260-0.940), p = 0.032) and for the mediastinal group (p = 0.0019). Being treated with chemotherapy indicated poor outcome in all patients (HR = 3.624 (1.050-12.507), p = 0.042) and in the localized testicular YST patients (p = 0.0077).

CONCLUSION

For the first time, our study revealed the primary site distribution of male YST, and summarized the clinical characteristics, survival and prognostic factors based on the SEER database, which provided important epidemiological evidence for clinical practice.

Discrepancy in pathology reports upon second review of radical orchiectomy specimens for testicular germ cell tumors

INTRODUCTION

We sought to evaluate the discrepancies between primary pathology report and second pathology review of radical orchiectomy (RO) specimens.

METHODS

A retrospective review was performed of RO specimens from the Ontario Cancer Registry. All cases required both a primary pathology report and a second pathology review from another institution. Histopathological variables assessed included histological subtype and components of mixed germ cell tumor (GCT), pathological tumor (pT) stage, lymphovascular invasion (LVI), spermatic cord invasion, and surgical margin.

RESULTS

Between 1994 and 2015, 5048 ROs were performed with 2719 (53.9%) seminoma and 2029 (40.2%) non-seminoma. Of these, 519 (10.3%) received a second pathology review. There was concordance between primary pathology report and second pathology review in 326 (62.8%) cases. The most common discrepancies involved a change in pT stage (n=148, 28.5%), with upstaging in 83 (16%) and downstaging in 65 (12.5%) cases relative to the original pT stage. The second most common discrepancy regarded the reporting of LVI (n=121, 23.3%), with 62 (11.9%) reporting presence of LVI when the primary pathology report did not. Other discrepancies included a change in the histological subtype in 28 (5.4%) cases and spermatic cord margin status in five (9.6%) cases.

CONCLUSIONS

Only 10% of orchiectomy specimens underwent a second pathology review, with nearly 40% of reviews leading to a meaningful change in parameters. Such variation could lead to incorrect tumor staging, estimate of relapse risk, and inappropriate treatment decisions. Expert pathology review of RO specimens should be considered, as it has significant implications for decision-making.

Controversies in the management of clinical stage 1 testis cancer

In November 2018, The Canadian Testis Cancer Workshop was convened.  The two-day workshop involved urologists, medical and radiation oncologists, pathologists, radiologists, physician’s assistants, residents and fellows, nurses, patients and patient advocacy groups.   One of the goals of the workshop was to discuss the challenging areas of testis cancer care where guidelines may not be specific.  The objective was to distill through discussion around cases, expert approach to working through these challenges. Herein we present a summary of discussion from the workshop around controversies in the management of clinical stage 1 (CS1) disease. CS1 represents organ confined non-metastatic testis cancer that represents approximately 70-80% of men at presentation. Regardless of management, CS1 has an excellent prognosis. However, without adjuvant treatment, approximately 30% of CS1 nonseminomatous germ cell tumors (NSGCT) and 15% of CS1 seminoma relapse. The workshop reviewed that while surveillance has become the standard for the majority of patients with CS1 disease there remains debate in the management of patients at high-risk of relapse. The controversy in the management of CS1 testis cancer surrounds the optimal balance between the morbidity of overtreatment and the identification of patients who may derive most benefit from adjuvant treatment. The challenge lies in a shared decision process where discussion of options extends beyond the simple risk of relapse but to include the long-term toxicities of adjuvant treatments and the favorable cancer-specific survival.    

Testicular cancer: Determinants of cisplatin sensitivity and novel therapeutic opportunities

Testicular cancer (TC) is the most common solid tumor among men aged between 15 and 40 years. TCs are highly aneuploid and the 12p isochromosome is the most frequent chromosomal abnormality. The mutation rate is of TC is low, with recurrent mutations in KIT and KRAS observed only at low frequency in seminomas. Overall cure rates are high, even in a metastatic setting, resulting from excellent cisplatin sensitivity of TCs. Factors contributing to the observed cisplatin sensitivity include defective DNA damage repair and a hypersensitive apoptotic response to DNA damage. Nonetheless, around 10-20% of TC patients with metastatic disease cannot be cured by cisplatin-based chemotherapy. Resistance mechanisms include downregulation of OCT4 and failure to induce PUMA and NOXA, elevated levels of MDM2, and hyperactivity of the PI3K/AKT/mTOR pathway. Several pre-clinical approaches have proven successful in overcoming cisplatin resistance, including specific targeting of PARP, MDM2 or AKT/mTOR combined with cisplatin. Finally, patient-derived xenograft models hold potential for mechanistic studies and pre-clinical validation of novel therapeutic strategies in TC. While clinical trials investigating targeted drugs have been disappointing, pre-clinical successes with chemotherapy and targeted drug combinations fuel the need for further investigation in clinical setting.

Evaluation of the "Shared Community Follow-up" after a germ cell tumour-A novel initiative for remote cancer follow-up enhanced by online patient-reported outcome measures

OBJECTIVE

Replying to germ cell tumour patients' needs, we implemented "Shared Community Follow-up"-a collaborative initiative, enabling remote delivery of specialist cancer care across large geographical areas. Blood, radiological investigations and patient-reported outcome measures (PROMs) are completed remotely and integrated within the electronic patient records for specialist review without patients requiring appointments. We describe the service evaluation estimating the feasibility, safety and acceptability of this initiative versus traditional Standard Follow-up.

METHODS

This cross-sectional evaluation estimated feasibility (uptake, adherence) and safety (via missed appointments, timeliness, cancellations) using routinely collected service process data. An acceptability questionnaire, evaluating patient satisfaction, was administered to 91 patients.

RESULTS

The new service is feasible. Across 2 years (2014-2016), uptake increased 54% (N = 123 to N = 270) and only 4.8% (N = 13) of patients were non-adherent. Fewer missed/cancelled investigations (N = 39, 5.9% vs. N = 566, 85.5%), timelier investigations (seven vs. 14 timely investigations) and equal relapse detection suggest its safety. PROMs replaced 3 appointments/patient. Patients were as satisfied with both services (3.4/4 vs. 3.6/4).

CONCLUSION

New follow-up services, with investigations completed remotely and shared between community providers and cancer centres, offer an alternative to traditional appointments with advantages for patients and the National Health Service.