Staging and prognostic factors in testicular cancer

The role of imaging in staging and monitoring testicular cancer

The prognosis for testicular cancer is excellent, with a 5-year survival rate greater than 95%. Patients affected can therefore expect to be cured after treatment. Successful treatment requires assessment of the condition at the various stages of its management. Imaging plays a major role in initial analysis of the lymphatic extension and in looking for metastases. It is essential for evaluating the response to treatment and during follow-up after treatment. CT is the most commonly used imaging method in this context, but the role of PET is currently developing. The purpose of this paper is to review the role of the imaging methods commonly used in the management of testicular cancer.

Clinicopathological Features Predicting Nodal Metastasis of Testicular Seminoma: Results from 100 Cases in a Single Institute

BACKGROUND/AIMS

To investigate the clinical and pathological features which predict nodal metastasis and/or the prognosis of testicular seminoma and to evaluate the current treatment strategy in a single institute.

METHODS

We retrospectively analyzed 100 patients who had been pathologically diagnosed as having testicular seminoma in our institute. Ninety-one patients (91%) had stage I disease, 9 patients (9%) were stage II and none stage III. The median follow-up was 63.2 months (range 0.5-249).

RESULTS

The duration between the tumor recognition and the first outpatient visit ranged from 0 to 144 weeks, with a median of 5 weeks, which did not influence the clinical stage. The tumor diameter and the preoperative serum lactate dehydrogenase (LDH) level were the significant predictors of stage II disease. Following orchiectomy, 68 patients (74.7%) with stage I disease received radiotherapy. Only 1 patient who had not received adjuvant radiotherapy died from the recurrent disease. The 5-year survival was 100% for the irradiation group but 95% for the surveillance group, although the difference was not statistically significant. All the stage II patients were successfully treated with chemotherapy following orchiectomy.

CONCLUSION

The maximum tumor diameter and the preoperative serum LDH level were the significant predictors of nodal metastasis. Adjuvant radiotherapy in patients with stage I seminoma did not influence the survival. Systemic chemotherapy promised good survival for the seminoma, even with nodal metastasis, in this series. Our results support the good prognosis of testicular seminoma with the current treatment strategy.

Scrotal pain as the first clinical manifestation of testicular seminoma: A case report

Seminomas are the malignant testicular tumors most commonly diagnosed in young adult males. It consists of undifferentiated cells derived from the embryonic gonad. The tumor presents as a scrotal mass that may or may not be associated with pain. On ultrasonography, the mass appears hypoechoic with well-defined margins and an echo structure that tends to be homogeneous. Color Doppler studies reveal rich vascularization. This report describes a case of seminoma that presented with scrotal pain. The typical findings on ultrasonography and color Doppler were fundamental for correct diagnosis of this tumor.

Testicular germ cell tumours in Iceland

The purpose of this study was to examine the pathology of all germ cell tumours of the testis diagnosed in Iceland 1955-2002. A total of 214 patients were included in the study. The current age-standardized incidence was found to be 6.1 per 100,000 and had increased almost fourfold during the study period. Seminoma was diagnosed in 55% of cases. Non-seminomas were diagnosed in 45%, and these were further classified as mixed germ cell tumours (33%), embryonal carcinoma (8%), teratoma (3%), and yolk sac tumour (n=1). The mean age at diagnosis was significantly higher for the seminomas than the non-seminomas (38 years versus 29 years) (p<0.001) and the non-seminomas were diagnosed at a significantly higher stage than the seminomas (p<0.001). Thus, in seminoma patients the tumour was localized to the testis (stage I) in 81% of cases, in 17% of patients the tumour had spread to the lymph nodes (stage II or III), and only 2% had extranodal metastasis at diagnosis (stage IV). In contrast, in the non-seminoma patients, the tumours were found to be stage I in 56%, stage II or III in 24%, and stage IV in 20% of cases. No significant difference in staging was found between non-seminoma subtypes. Identification of necrosis or vascular invasion was significantly associated with metastatic disease at diagnosis (p=0.002). During the study period a significant increase in stage I tumours was found as well as a decrease in the size of the tumours.

Imaging of testicular germ cell tumours

In testicular germ cell tumour (GCT), imaging plays a central role in assessment of tumour bulk, sites of metastases, monitoring response to therapy, surgical planning and accurate assessment of disease at relapse. The primary modality used for imaging patients with GCT is computed tomography (CT) but plain film radiography, ultrasound, magnetic resonance imaging (MRI) and positron emission tomography (PET) may all have roles to play. This article reviews the role of imaging of testicular germ cell tumours.

A pilot study of lymphotrophic nanoparticle-enhanced magnetic resonance imaging technique in early stage testicular cancer: a new method for noninvasive lymph node evaluation

OBJECTIVES

To evaluate whether lymphotrophic nanoparticle-enhanced magnetic resonance imaging (LNMRI) can be used as a method for detecting metastatic disease within retroperitoneal nodes in patients with testicular cancer.

METHODS

Stage I testicular cancer patients were prospectively enrolled and underwent a pelvic MRI both before and 24 hours after intravenous ferumoxtran-10 administration. Nodal sampling was performed by computed tomography-guided biopsy or laproscopic surgery and reviewed by a pathologist without knowledge of the LNMRI results.

RESULTS

In 18 patients, 42 nodes were sampled, of which 25 were benign and 17 were malignant. The sensitivity of LNMRI for malignant lymph node involvement was 88.2%, specificity was 92%, and the accuracy was 90.4%. On the other hand, the sensitivity of size criteria for detecting malignant nodes was 70.5%, the specificity was 68%, and the accuracy was 69%.

CONCLUSIONS

Lymphotrophic nanoparticle-enhanced MRI is safe and accurate for detecting nodal metastases in patients with testicular cancer. Lymphotrophic nanoparticle-enhanced MRI yields higher sensitivity and specificity when compared with unenhanced MRI or conventional CT scanning. Although our results are encouraging, the precise role of this tool in early stage testicular cancer remains to be determined.

The reproductive tract

Diagnostic imaging has played a major role in the evaluation of patients with the cancers of the reproductive tract. The imaging modalities have included ultrasonography, computed tomography, magnetic resonance imaging, hysterosalpingography, and scintigraphy with radiolabeled monoclonal antibodies. Positron emission tomography (PET) with [F-18]fluorodeoxyglucose also has been shown to be useful in the imaging evaluation of these patients. Clinical applications have included initial staging and posttherapy restaging of disease, detecting metastatic disease, differentiating posttherapy anatomic alterations from recurrent or residual disease, and predicting and evaluating treatment response. In this article, we review the diagnostic utility of dedicated PET and combined PET-computed tomography systems in the imaging assessment of reproductive tract malignancies (excluding prostate cancer) in both sexes with an emphasis on fluorodeoxyglucose applications.

Considerations of psychosocial illness phase in cancer survival

Rarely are biomedical, clinical and psychosocial data considered simultaneously as influences on cancer patient outcomes. This study utilized medical record and interview data from 152 adult cancer patients with various tumor types in a model of survival estimation. Predictors included disease stage of the neoplasm (TNM stage), clinical functioning of the patient (Karnofsky performance status), and psychosocial demands of the disease course (psychosocial illness phase). Psychosocial illness phase captures developmental time phases of illness (i.e. 'crisis', 'early chronic', 'late chronic' and 'terminal'), essentially locating patients along the disease course relative to treatment and treatment response. The analysis utilized the Kaplan-Meier (product-limit) method to estimate stratum specific survival functions. Model comparisons employed the differences in the likelihood ratio chi-squares between nested models, and Cox proportional hazard models assisted in explaining the effects of the predictors on survival times. Results indicate that psychosocial illness phase makes an independent contribution to survival time estimation (p<0.05) when all three dimensions are considered simultaneously.