Endocrine studies in testicular tumor patients with and without gynecomastia: a report of 45 cases

Multiparametric Ultrasound for Diagnosing Testicular Lesions: Everything You Need to Know in Daily Clinical Practice

BACKGROUND

Ultrasonography (US) represents the gold standard imaging method for the assessment of testicular lesions (TL). The gray-scale (GSUS) and color-Doppler (CDUS) ultrasound examination allow sonographers to investigate the size, margins, echotexture, and vascular features of TLs with the aim to differentiate benign from malignant lesions. Recently, the use of contrast-enhanced US (CEUS) and sonoelastography (SE) has led to further improvements in the differential diagnosis of TL. Although GSUS and CDUS are often sufficient to suggest the benign or malignant nature of the TL, CEUS can be decisive in the differential diagnosis of unclear findings, while SE can help to strengthen the diagnosis. The contemporary combination of GSUS, CDUS, CEUS, and SE has led to a new diagnostic paradigm named multiparametric US (mp-US), which is able to provide a more detailed characterization of TLs than single techniques alone. This narrative and pictorial review aimed to describe the mp-US appearance of several TLs.

METHODS

An extensive Medline search was performed to identify studies in the English language focusing on the mp-US evaluation of TLs.

RESULTS

A practical mp-US "identity card" and iconographic characterization of several benign and malignant TLs is provided herein.

CONCLUSIONS

The mp-US characterization of TL reported herein can be useful in daily clinical practice.

Rare Estradiol Secreting Testicular Mixed Germ Cell Tumor Presenting with Cutaneous Metastasis

Germ cell tumors (GCTs) represent the most common form of testicular neoplasms. Metastasis is common in testicular GCTs with lungs, liver, and brain being the common sites of distant tumor spread. Cutaneous metastasis is, however, seldom encountered in testicular GCTs. Herein, we report a rare case of testicular mixed GCT in a 28-year-old male presenting with cutaneous metastasis after orchiectomy. Moreover, the tumor was characterized by estradiol and human chorionic gonadotropin (hCG) cosecretion. Although hCG secretion is not uncommon, autonomous estradiol secretion from GCTs is an extreme oddity.

Is gynecomastia related to the disease characteristics and prognosis in testicular germ cell tumor patients?

PURPOSE

We aimed to assess the relationship between gynecomastia and tumor markers, histologic subtypes, and prognosis in patients with testicular germ cell tumors.

METHODS

This study included 73 testicular germ cell cancer patients with pretreatment chest, abdomen and pelvis computed tomography (CT) scans and tumor markers (β-human chorionic gonadotropin [β-hCG], lactate dehydrogenase [LDH], α-fetoprotein [AFP]). The volumetric analysis of the breast glandular tissue, the presence of gynecomastia and metastatic disease were determined using CT scans. Patients were classified according to the International Germ Cell Cancer Collaborative Group (IGCCCG) prognostic classification. The association between gynecomastia, breast glandular tissue volume, tumor markers, metastatic disease, and disease prognosis were evaluated.

RESULTS

Thirty-four of the patients (46.6%) had gynecomastia. A breast volume cutoff value of 0.78 cm3 to diagnose gynecomastia led to 85% sensitivity and 95% specificity. Serum β-hCG level correlated with the breast glandular tissue volume weakly (r=0.242, P = 0.039). Gynecomastia was more common in patients with elevated β-hCG levels (P = 0.047), and was not associated with pulmonary, nonpulmonary distant, or nodal metastases (P = 0.378, P = 0.884, P = 0.333, respectively). No significant association was found between the disease prognosis and gynecomastia (P = 0.556).

CONCLUSION

Gynecomastia was common among testicular germ cell cancer patients with elevated β-hCG. However, it was not associated with metastatic disease and prognosis.

CT measurement of breast glandular tissue and its association with testicular cancer

OBJECTIVES

To evaluate the associations between breast glandular tissues diameters as determined by CT and b-hCG levels, histological types, tumour spread and prognosis in patients with testicular germ cell tumour.

METHODS

Ninety-four patients with pre-treatment CT scan and markers (b-hCG, AFP, LDH) were retrospectively collected. A radiologist measured diameters in all CT examinations and correlation between diameters and log (b-hCG) was assessed (Pearson's coefficient). The ability of measured diameters to predict lymphatic and distant haematogenous metastatic spread was evaluated (ROC curves). The associations between measured diameter cut-off values of 20 and 25 mm and International Germ Cell Cancer Collaborative Group (IGCCCG) classification, lymphatic and distant haematogenous metastatic spread and histological subtypes were evaluated (chi squared test).

RESULTS

Breast glandular diameters correlated to log(b-hCG) (r = 0.579) and predicted distant haematogenous metastatic spread (AUC = 0.78). Worse prognosis (intermediate or poor IGCCCG) was shown for 20 mm (27.3 vs. 4.2 %, p = 0.005) and 25 mm (33.3 vs. 6.1 %, p = 0.014). A diameter of 25 mm was associated with non-seminoma (91.7 vs. 48.8 %, p = 0.005).

CONCLUSION

Breast glandular tissue diameters correlated with log(b-hCG) and predicted distant haematogenous metastases. Twenty and 25 mm were associated with worse prognosis and 25 mm was able to distinguish between seminoma and non-seminoma.

KEY POINTS

• CT breast glandular tissue diameter correlates with log(b-HCG) • Gynaecomastia in CT is associated with worse prognosis • Gynaecomastia in CT is associated with non-seminoma histological subtype.

Experience of discordant beta hCG results by different assays in the management of non-seminomatous germ cell tumours of the testis

Fifty-five patients with non-seminomatous germ cell tumours (NSGCT) who were referred to a regional clinical oncology centre over a 3-year period were assessed prospectively with assays of the serum tumour markers alpha-feto protein (AFP) and beta-human chorionic gonadotropin (beta hCG). Paired baseline beta hCG assays were undertaken using a polyclonal radioimmunoassay (RIA) and a monoclonal fluoroimmunoassay (FIA). Serial paired measurements were undertaken in patients showing discordance on baseline assays. Four patients (7%; 95% confidence interval 0-14) showed discordance between the paired beta hCG assays. Of these, two showed elevated beta hCG on RIA, with normal levels on FIA; two showed elevated beta hCG on FIA, with normal levels on RIA. No discordance was noted with AFP assays. Discordance persisted in two of the patients (50%) and disappeared on treatment in one (25%); one patient died during treatment. Discordant beta hCG assays present difficulties in interpretation and have therapeutic implications in patients with NSGCT. No single currently available assay is conclusive in all patients and commercial assay kits should be chosen with care.

Ovarian dysgerminoma showing high serum levels and positive immunostaining of placental alkaline phosphatase and neuron-specific enolase associated with elevation of serum prolactin level

We report a 35-year-old Japanese female patient with ovarian dysgerminoma showing elevated serum levels of placental alkaline phosphatase (PLAP), neuron-specific enolase (NSE) and prolactin (PRL). All elevated tumor markers improved dramatically after the removal of the tumor. Immunohistochemically examined, the tumor was stained positive for PLAP and NSE and negative for PRL. Our present case is the first report of dysgerminoma showing positive immunostaining for PLAP and NSE, and the association of high serum level of PRL followed by decrease accompanied by the tumor debulking.

Pesticides: multiple mechanisms of demasculinization

Many pesticides are known to produce reproductive and developmental effects in chronically exposed non-target organisms, including humans. Recent evidence suggests that demasculinization may be an important mechanism responsible for some of these effects. Some pesticides have been shown to interact with the androgen receptor and to act as antagonists, while others have been shown to interact with the estrogen receptor and function as estrogens in both in vitro and in vivo. Many pesticides can also lower serum androgen levels by altering rates of synthesis or metabolism. Given the ubiquity of pesticides in the environment and the multiple mechanisms whereby they can elicit demasculinizing effects, synergy between such compounds may produce clinical endocrine dysfunction at current human exposure levels.

Gynecomastia as a complication of chemotherapy for testicular germ cell tumors

Among 190 patients with metastatic testicular cancer who were treated by platinum-based combination chemotherapy and achieved complete remission, 4 (2.1%) developed gynecomastia 2 to 5 months after the cessation of chemotherapy. All of these patients had normal serum levels of the beta subunit of human chorionic gonadotropin and testosterone levels at the lower range of normal, but they had elevated levels of follicle-stimulating hormone, luteinizing hormone, and estradiol. The cause of gynecomastia in our patients was probably these increased levels of gonadotropins that, in turn, stimulated increased secretion of testicular estrogen, thus altering the normal estradiol-testosterone ratio. Treatment-related gynecomastia, which may occur several months after the cessation of cytotoxic chemotherapy, does not necessarily mean the return of disease. It is important to recognize this fact so as to prevent unnecessary investigations that will cause psychological distress in a young patient with testicular cancer.

A hCG-secreting testicular seminoma revealed by male infertility: mechanism of hCG-evoked endocrine disturbances

We report a case of a hCG-producing testicular seminoma revealed by a male infertility due to oligozoospermia. No palpable tumour was found at clinical examination and the diagnosis was established on hormonal data and the echography of the testis. The endocrine patterns associated high levels of beta-hCG and 17 beta-oestradiol contrasting with low levels of LH and FSH and normal levels of testosterone. Immunohistochemical studies confirmed the ectopic production of hCG. Histological findings and the evolution of hormonal parameters suggested that hyperoestradiolaemia was probably the consequence of a hCG-evoked Leydig cells hyperplasia involving a paracrine mechanism. In fact, after removal of the tumour, a dramatic decrease of plasma sex steroid levels was observed before recovery of normal testicular endocrine and exocrine functions.

Luteinizing hormone regulation by sex steroids in men with germinal and Leydig cell tumours

OBJECTIVE

We examined the gonadotrophin secretion in patients with increased plasma concentrations of testosterone and oestradiol due to hCG-producing tumours.

DESIGN

Comparison of plasma gonadotrophin concentrations before and after stimulation by GnRH, in eight men with hCG-producing tumours resulting in increased testosterone and oestradiol plasma levels, and in 29 men with Leydig cell tumours resulting in increased oestradiol and normal to low testosterone plasma levels.

PATIENTS

Eight men with hCG-producing tumours (six with testicular tumours, two with extratesticular tumours), 29 men with Leydig cell tumours and 15 normal men. The six men with germinal cell tumours of the testis were studied before and after unilateral orchidectomy.

MEASUREMENTS

Plasma concentrations of hCG, testosterone and oestradiol were measured before and after intramuscular injection of hCG. LH and FSH were measured before and after intravenous injection of 100 micrograms GnRH.

RESULTS

Plasma LH and FSH concentrations were low in patients with germ cell tumours, who exhibited increased plasma testosterone and oestradiol concentrations, and were normal in patients with Leydig cell tumours, in whom oestradiol only was increased. Plasma LH and FSH were normalized in the five patients with successful (e.g. normal hCG, testosterone and oestradiol) unilateral orchidectomy. Basal plasma testosterone concentrations correlated positively (P < 0.01) with plasma oestradiol concentrations in patients with germ cell tumours and negatively (P < 0.01) in patients with Leydig cell tumours.

CONCLUSIONS

In patients with hCG-secreting germ cell tumours complete suppression of plasma LH and FSH with increased plasma concentrations of both testosterone and oestradiol are often discovered. No such gonadotrophin suppression is found in patients with Leydig cell tumours, but the negative correlation observed between plasma testosterone and oestradiol in these patients suggests a weak negative feedback effect of oestradiol on LH secretion, which cannot be demonstrated by basal LH measurements in plasma.

Hormonal perturbations in patients with testicular cancer treated with cisplatin

Patients with testicular cancer treated with cisplatin can undergo feminization that is understood poorly. Rat model studies recently showed that cisplatin can feminize in part the profile of hepatic steroid-metabolizing enzymes and circulating hormone levels. This study was undertaken to determine whether cisplatin similarly might contribute to the perturbations in gonadotropin or steroid hormone levels that can occur in patients undergoing cisplatin-based treatment for testicular cancer. Analysis of serum free testosterone, total testosterone, and androstenedione levels revealed that these hormones were not altered significantly in patients during a 38-week period of cisplatin-based treatment and follow-up. Estradiol levels were elevated before chemotherapy and were reduced to normal levels during treatment. This reduction was attributed to the cytotoxic effect of chemotherapy on the tumors and the resultant reduction in serum chorionic gonadotropin levels. Serum dihydrotestosterone (DHT) levels were normal before chemotherapy but progressively became elevated during treatment with cisplatin in five of ten patients examined. The rise in DHT may relate to the previously described increase in hepatic androgen 5 alpha-reductase activity in cisplatin-treated rats. Levels of the gonadotropins, luteinizing hormone, and follicle-stimulating hormone (FSH) were normal before cisplatin-based treatment was administered; however, FSH was elevated selectively during chemotherapy. This selective induction of FSH may reflect an effect of cisplatin on the hypothalamic secretion of gonadotropin-releasing hormone. Taken together, these findings suggest that cisplatin contributes to the perturbation of steroid and peptide hormone levels in patients with testicular cancer and perhaps in others undergoing cisplatin-based chemotherapy.

Postmenopausal uterine bleeding due to estrogen production by gonadotropin-secreting lung tumors

Two postmenopausal women are described who had uterine bleeding due to hormone production by lung tumors--a large cell carcinoma in one case and a choriocarcinoma in the other. Both tumors stained positively for one or more placental peptides (human chorionic gonadotropin [hCG], placental lactogen, or pregnancy-specific beta-1 glycoprotein) and both patients had extremely elevated serum levels of hCG, suggesting the tumors had some placental-like endocrine function. Clinical and hormonal data supported the concept that the uterine bleeding resulted from estrogen excess due to steroid bio-transformation by the tumors.

Polycythemia and steroid overproduction in a gonadotropin-secreting seminoma of the testis

While investigating the cause of mild polycythemia in a young man, a testicular seminoma was discovered with unusual and tumor-dependent features: an absolute polycythemia with high plasma erythropoietin (EPO) levels, an overproduction of estradiol and testosterone, and a dramatic Leydig cell hyperplasia surrounding the tumor tissue. The authors attempted to gain insight into the relationship between this testicular tumor and the hormonal overproduction, i.e., of EPO, estradiol, and testosterone. Their results favored the conclusion that the high EPO levels and the polycythemia were an indirect effect secondary to the steroid overproduction rather than a direct EPO-producing activity. Moreover, the steroid overproduction by the testis could be caused by a paracrine mechanism through human chorionic gonadotropin activity on the Leydig cells.

Gynaecomastia

This paper reviews the development of excess breast tissue in the male. Gynaecomastia is a common problem and may have a physiological or pathological basis. It can be dealt with in most cases by reassurance or simple surgery.

Adolescent gynecomastia. Differential diagnosis and management

Gynecomastia signifies a transient or permanent disturbance in steroid hormone physiology and occurs when the male breast is exposed to a decreased ratio of androgen to estrogen. This article discusses pubertal and pathologic gynecomastia, diagnostic approach, and treatment.

Testicular cancer

Although testicular cancer is a relatively rare tumor, it is the most common cancer among men aged 15 to 35 years. In the United States in 1989 approximately 5,500 men will be diagnosed with testicular cancer. Up until 2 decades ago, testicular cancer was the most common cause of a cancer death in this age group. The advances in diagnosis and treatment that will be described in this monograph represent one of the major achievements in the treatment of solid tumors. Testicular cancer is now one of the most curable of all cancers; the 5-year relative survival rate is in excess of 90%. In the U.S. fewer than 500 men will die from this disease in 1989. The primary goals in the treatment of testicular cancer as the 1990s approach will be to further decrease the mortality from this disease and to decrease the morbidity of treatment that has led to this dramatic improvement in survival.

Hormone profiles in Klinefelter's syndrome with and without testicular epidermoid cyst

Hormonal studies were performed in patients of Klinefelter's syndrome with and without testicular epidermoid cyst. Mean levels of plasma gonadotropins were elevated above normal ranges. The mean testosterone level in plasma was abnormally low. The mean prolactin level in plasma was within the normal limit. However, mean plasma levels of these hormones were not significantly different between the two groups. The administration of LH-RH resulted in low response of plasma gonadotropins. The response of plasma testosterone to the administration of hCG was also abnormally low. However, in the LH-RH and hCG tests there were no significant differences between the two groups. These data suggested that the hormonal disturbance in Klinefelter's syndrome is unrelated to the occurrence of testicular epidermoid cyst.

A multidisciplinary approach to primary nonseminomatous germ cell tumors of the mediastinum

The introduction of cis-platinum-based chemotherapy has dramatically improved the prognosis for patients with primary nonseminomatous germ cell tumors of the mediastinum. Since 1978, 12 male patients (mean age, 29 years) have been seen with a large mediastinal mass, normal testes, and abnormal testicular tumor markers. Eleven patients had raised alpha-fetoprotein levels (median, 1,300 micrograms/L; normal, less than 10 micrograms/L), and 3 had elevated levels of the beta fraction of human chorionic gonadotropin (median, 8,000 IU/L; normal, less than 5 IU/L). Two patients were treated by primary surgical intervention followed by chemotherapy. Ten patients were treated with primary chemotherapy (cis-platinum, vinblastine sulfate or etoposide, and bleomycin sulfate), and this was followed by timed surgical excision of the tumor mass in 7. Six (60%) patients responded to primary chemotherapy with normalization of tumor markers. In this group there was 1 postoperative death and 1 recurrence. The 4 remaining patients are alive and free from disease at a mean of five years. Of the 4 patients with persistently elevated tumor markers, 2 died within six months, 1 is alive with recurrence, and 1 is lost to follow-up at three months. Patients whose tumor markers return to normal after cis-platinum-based chemotherapy have a good long-term prognosis following radical surgery. If the tumor markers remain elevated, the prognosis is poor.

Serum estradiol as a tumour marker for non-seminomatous germinal cell tumours (NSGCT) of the testis

Radioimmunoassay (RIA) determinations of serum alphafetoprotein (AFP), beta human chorionic gonadotropin (BHCG) and estradiol (E2) levels have been made at various stages of the disease in 52 patients with testicular carcinoma. In non-seminomatous tumours of the testis, E2 has been found to be a highly specific tumour marker, helping to reduce clinical staging error. Increases in serum E2 levels have been observed in all patients with HCG-secreting tumours, but E2 has indicated tumour recurrence alone in 4 patients with normal AFP and BHCG levels. Gynecomastia, always accompanied by a rise in serum E2 and BHCG levels has been a bad prognostic sign. E2 had no significance as a marker in seminomatous tumours.

Ectopic prolactin secretion from a gonadoblastoma

A 6.5-year-old girl developed isosexual, pseudoprecocious puberty secondary to a gonadoblastoma. The tumor was found to produce and secrete both immunoassayable and bioassayable prolactin based on immunohistochemical techniques and the presence of a prolactin gradient between the tumor vein and peripheral vein. The source of the prolactin was a Sertoli-like cell. Neither growth hormone nor growth hormone-releasing hormone was detected within the tumor. This case confirms the ectopic production of prolactin by neoplastic tissue.

Testicular failure in patients with extragonadal germ cell tumors

Eight patients with mediastinal or retroperitoneal germ cell tumors who had undergone testicular biopsy or orchiectomy were retrospectively analyzed for primary testicular abnormalities, subfertility, and abnormal sex hormone levels. Testicular tissue was abnormal in all patients, revealing peritubular fibrosis (six), decreased spermatogenesis (eight), interstitial edema (five), Sertoli cells only (one), and Leydig cell hyperplasia (two). Detailed hormone analysis in five patients revealed elevations of luteinizing hormone in four, decreased serum testosterone in two, elevations of estradiol in two, and elevation of human chorionic gonadotropin in one patient. A history of infertility was documented 2 months to 13 years before presentation in four patients and suspected in another. Extragonadal germ cell tumors, like their testicular counterparts are associated with primary germ cell defects, some of which seem to be independent of gonadotropin production by the tumor. In addition, the rather high incidence of antecedent infertility suggests that either a congenital or acquired primary germ cell defect contributes to defective spermatogenesis and the development of cancer in incompletely migrated germ cells.

Gynaecomastia following cytotoxic therapy for testicular cancer

Sixteen patients in complete remission after chemotherapy or radiotherapy for testicular cancer developed gynaecomastia which appeared 2 to 9 months after the end of therapy and had a mean duration of 4.8 months. These patients had statistically significant higher levels of oestradiol, FSH and oestradiol/testosterone ratio than a control group without gynaecomastia that had received similar treatment. Both groups tended to have testosterone levels in the lower normal range and all patients had normal levels of beta-HCG, prolactin and progesterone. The gynaecomastia in our patients was probably the result of an absolute increase in oestradiol or an increase relative to testosterone. Cytotoxic therapy affects both spermatogenesis and Leydig cell function, with a resultant rise in gonadotrophins which may in turn increase testicular oestrogen secretion. In testicular cancer patients, gynaecomastia may be a sign of tumour activity but it may also be caused by hormonal changes resulting from cytotoxic therapy. It is our experience that the latter treatment-related type is harmless, transient and unrelated to the patient's prognosis.

Endocrine and exocrine profiles of men with testicular tumors before orchiectomy

In 15 patients with germ cell testicular tumors serum hormone profiles and semen analysis before orchiectomy were evaluated to determine the incidence of defective spermatogenesis associated with testicular tumors. Defective spermatogenesis was noted in 10 patients (66 per cent) on the basis of low sperm concentration, motility or semen volume. Of the 10 patients 7 had sperm concentrations less than 10 million per cc. Endocrine abnormalities occurred in 10 patients, the most common of which were elevations in serum human chorionic gonadotropin and estradiol, and a relative decrease in follicle-stimulating hormone. Three patients who presented with subfertile semen analyses were treated with orchiectomy alone. Repeat semen analyses 4 to 12 months after orchiectomy showed improvement in spermatogenesis and 2 patients achieved a normal semen analysis. Endocrine abnormalities and defective spermatogenesis are common in patients with testicular tumors. These abnormalities precede orchiectomy and imply that a primary germ cell defect exists in these patients.

Elevated beta-human chorionic gonadotropin and a search for cancer

Elevated human chorionic gonadotropin levels may be an early, and occasionally the only, manifestation of embryonal cell carcinoma. A 24-year-old man presented with gynecomastia, galactorrhea, and elevated beta-human chorionic gonadotropin levels, which led to an extensive (but nonrevealing) search, including computed tomography and selective testicular vein catheterization, for malignancy. Since the testicle was considered as the most likely site of tumor, right orchiectomy and right common iliac lymph node biopsy were performed. The testicle was normal, but the lymph node contained elements of embryonal and choriocarcinoma. Following chemotherapy, beta-human chorionic gonadotropin levels were normalized and the patient appears "cured." This case emphasizes the need for an extensive search for malignancy and consideration of orchiectomy in such instances in order to achieve a favorable outcome.

Pure seminoma of the testis: the results of radiation therapy in patients with elevated human chorionic gonadotropin titers

The management and prognosis of human chorionic gonadotropin-producing seminoma still are controversial issues. In a review of 210 patients irradiated between 1950 and 1982, 10 had elevated human chorionic gonadotropin values: 3 with stage I, 6 with stage II and 1 with stage IV disease. All human chorionic gonadotropin values became negative: 4 postoperatively and 6 following radiotherapy. All patients are well with a mean followup of 6 years. One patient who suffered liver metastases only was salvaged by chemotherapy. Based on these patients human chorionic gonadotropin production is not an unfavorable prognostic sign in cases of pure seminoma.

Gynecomastia in testicular cancer patients. Prognostic and therapeutic implications

Eighty-one patients with advanced testicular cancer were evaluated for gynecomastia or severe breast tenderness at diagnosis and after platinum-based chemotherapy. The prognostic significance of gynecomastia in these two settings was explored. At presentation, 10% (8 patients) had gynecomastia or breast tenderness and elevated HCG levels. The likelihood of gynecomastia was greater with increasing HCG level (P = 0.002). However, gynecomastia at presentation was a more powerful independent discriminant of poor survival than the initial HCG level by multivariate analysis (P = 0.004). Fifteen percent (12 patients) developed transient gynecomastia after chemotherapy not attributable to other known causes. HCG levels were normal. Endocrine evaluation typically revealed elevated FSH, LH, and estradiol/testosterone ratios. This may have reflected damage to testicular germinal epithelium. All 12 patients are alive without disease in contrast to the 8 patients who had gynecomastia at diagnosis. Therapy decisions should therefore be based on the time of onset of gynecomastia and in the context of appropriate clinical markers and evaluation.

Gynecomastia in association with a complex tumor of the testis secreting chorionic gonadotropin: studies on the testicular venous effluent

The levels of progesterone, 17 alpha-hydroxyprogesterone, androstenedione, testosterone and estradiol were measured in the testicular venous effluent from a testis containing a complex malignant tumor associated with gynecomastia and increased serum levels of beta-human chorionic gonadotropin. An abnormally low testosterone/estradiol ratio was encountered (83 in the peripheral serum and 101 in the spermatic venous effluent). On the basis of the available data no delineation could be made as to the relative contributions to estradiol production of tumor tissue and Leydig cells.

Endocrinology of testicular neoplasms

The hypothalamic-pituitary-testicular axis finely regulates levels of circulating sex steroids--especially testosterone and estradiol--and spermatogenesis. Testosterone, directly as an androgen and as a prehormone for estradiol, regulates LH secretion at both hypothalamic and pituitary levels. Leydig cells, principally under the control of LH, produce testosterone. Sertoli cells, under the control of FSH, and sensitive to intratesticular levels of testosterone, produce estradiol. This locally produced estrogen seems to be necessary for maturation of the germ cells. An abnormality in this sensitive control system, leading to elevations in gonadotrophins or steroid levels, may be etiologically important in both germ cell and nongerm cell neoplasia. Testicular cancers are associated frequently with endocrinologic manifestations, which may be more disabling to the patient than the malignant potential of the tumor, especially with childhood Leydig cell tumors. Estrogen dominance with an elevated estrogen/testosterone ratio can be seen in any testicular neoplasm and may result in gynecomastia. It may be due to a decrease in circulating testosterone or to an increase in estrogens. Virilization is seen frequently in Leydig cell tumors of adolescents. Further elucidation of hormonal interrelationships should lead to better understanding of the genesis of testicular neoplasia and to more effective therapy.

LH, FSH, TSH, prolactin, HCG and prostaglandin F2 alpha in patients with treated testis tumors

Various kinds of treatments of testicular cancer results in significant changes in peptide hormones, particularly LH and FSH. In some cases, compensated hypothyroidism as indicated by increased TSH with normal T3 are observed. Serum levels of prostaglandin F2 alpha are also elevated after therapy without relation to the stage of the disease. During followup, these patients are found to complain of impotence and infertility, and the evaluation of serum analysis of peptide hormones must consider both the normal hormonal findings of treated testicular cancer patients and recurrence of endocrine active tumor. The hormonal changes from hypophyseal origin are secondary to the primary testicular damages in patients complaining of impotence without tumor recurrence.

The serum prolactin level in testicular tumours--a new tumour marker?

Serum prolactin levels were elevated above the range seen in normal male subjects of 7 of 11 patients with non-seminomatous testicular tumours, particularly in patients with metastatic disease. In contrast, the mean prolactin level in patients with seminomas was not significantly different from normal, and only one of eight patients had a serum prolactin concentration beyond the normal range. In two subjects with non-seminomatous testicular tumours serial measurements of prolactin and chorionic gonadotrophin showed a striking parallelism and accurately predicted clinical progress. Serum prolactin may be a useful additional tumour marker in patients with non-seminomatous testicular tumours.