Testicular failure in patients with extragonadal germ cell tumors

Tumor germinativo extra-gonadal e síndrome de Klinefelter - Relato de caso

Muitos relatos vêm sugerindo a associação entre a síndrome de Klinefelter e o tumor germinativo. Um risco elevado de tumor germinativo extragonadal (mediastinal) ocorre a partir da adolescência até 30 anos. O autor apresenta ocaso de um jovem de 19 anos de idade com sintomas respiratórios, massa torácica e características clínicas de síndrome de Klinefelter. O cariótipo do sangue periférico foi de 47 XXY e o estudo da lesão torácica foi de teratoma imaturo O paciente foi tratado com quimioterapia combinada seguida de toracotomia, estando em remissão completa há seis anos após o diagnóstico. Este estudo discute as características clínicas e laboratoriais dos pacientes com tumor germinativo 235 extragonadal associado a síndrome de Klinefelter, e sua participação na gênese dos tumores de células germinativas.

Infertility and testis cancer

Testicular cancer is the most common solid organ tumor in young men and affects men during their reproductive years. Current therapeutic regimens have significantly improved survival but often adversely impact fertility. Understanding the effects of testicular cancer, the systemic effects of neoplasia, and the effects of treatment protocols, such as radiotherapy, chemotherapy, and retroperitoneal lymph node dissection, is essential to restoring and maintaining fertility in men who have germ cell neoplasms.

Fertility after chemotherapy for testicular cancer

Disseminated testicular cancer has largely become curable with cisplatin-based chemotherapy. The prospect of fertility after treatment is an important consideration for both patients and clinicians. While there may be an irreversible impairment of spermatogenesis at a cumulative cisplatin dose of greater than 400 mg/m2, a low sperm count does not necessarily appear to prevent fatherhood. This review summarizes currently available data on the effects of chemotherapy on male fertility and steps that can be taken to preserve fertility in this patient population.

Diagnosis, staging, and clinical characteristics of the patient with mediastinal germ cell carcinoma

When an anterior mediastinal mass is found in a young male patient, mediastinal germ cell tumors should always be one of the leading diagnostic considerations. The staging evaluation and diagnostic procedures should be performed rapidly. Every patient with a mediastinal germ cell tumor should be approached with curative intent, and appropriate treatment should be initiated as soon as the brief diagnostic procedure has been completed. Currently, treatment is curative in most patients (> 80%) with pure mediastinal seminoma, even in patients with huge mediastinal tumors and evidence of distant metastases. Although the cure rate is lower for patients with nonseminomatous germ cell tumors, the overall cure rate of 35% to 40% makes these tumors one of the most effectively treated advanced cancers. Further details regarding the treatment of mediastinal germ cell tumors are presented elsewhere in this issue.

Extragonadal retroperitoneal germ cell tumor: evidence of origin in the testis

BACKGROUND

The origin of extragonadal retroperitoneal germ cell tumors remains controversial. Whether they develop primarily in the retroperitoneum or whether they are metastases of a primary testicular tumor has long been debated.

PATIENTS AND METHODS

We retrospectively analyzed 26 patients treated as having primary extragonadal retroperitoneal germ cell tumors based upon the findings of testicular palpation by the referring physician. Testicular evaluation was then extended with ultrasonographical and histological examinations.

RESULTS

Biopsy of the extragonadal tumor was performed in 25 patients, confirming diagnosis of extragonadal retroperitoneal germ cell tumor. Prior to treatment patients were clinically evaluated by several physicians and the testes were not considered suspicious for testicular cancer. At urological workup, testes were found to be atrophic and/or indurated in 14 (54%) patients, enlarged in one (4%) and unremarkable in 11 (42%). Ultrasound examination of the testes in 20 patients showed pathological findings in all of them. Histology of the testis was available in 25 of 26 patients and revealed active tumor in three, intratubular germ cell neoplasia in four, scar tissue in 12, sclerosis in three, sclerosis and fibrosis in one, and fibrosis alone in two.

CONCLUSIONS

So-called primary extragonadal germ cell tumors in the retroperitoneum are very likely a rare or non-existing entity and should be considered as metastases of a viable or burned-out testicular cancer until proven otherwise. All of our patients with histologically examined testes had pathological finding, 76% of which were either viable tumor or scars.

Fertility issues and their management in men with testis cancer

Although a curable malignancy, testis cancer and its treatment have unique associated morbidities that largely affect reproductive dysfunction. In this focused review, the factors that contribute to infertility in men with testis cancer are outlined. The treatment-specific risks to fertility that accompany cancer management are also discussed. Contemporary methods of overcoming infertility in testis cancer patients are addressed, and several exciting and promising experimental approaches to the preservation or restoration of fertility for men with testis cancer are presented.

Effect of cryopreservation on semen quality in patients with testicular cancer

OBJECTIVES

Current techniques in cryopreservation of human semen substantially decrease sperm quality. In addition, the pregnancy rate using cryopreserved sperm obtained from testicular cancer patients is lower than when sperm from normal fertile men is used. However, it is still unclear whether cryopreserved sperm from these patients is inherently defective or if the sperm loses its motility after thawing. This study was undertaken to assess the effect of cryopreservation on the quality and motion characteristics of semen from patients with testicular cancer before definitive therapy compared with semen from normal volunteers.

METHODS

We compared the sperm quality before and after cryopreservation in samples from 34 patients with testicular cancer and 30 normal volunteers who were referred for sperm banking over a 7-year period. The effects of cancer stage and histologic type on various semen parameters were also examined. A computer-assisted semen analysis was performed before and after cryopreservation on each specimen. The nitrogen vapor technique using Test yolk buffer with glycerol as a cryoprotective agent was used for cryopreservation. The motile sperm count and motion characteristics (motility, velocity, linearity, amplitude of the lateral head movement, motility index) were analyzed before and after cryopreservation and compared between the groups.

RESULTS

Semen quality did not significantly differ among patients with Stage I, II, or III cancer. However, semen quality tended to be poorer at higher cancer stages. In general, semen quality was better among patients with pure seminomas than with pure embryonal tumors; quality was worst among patients with mixed germ cell tumors. However, 71.4% of patients with mixed tumors presented with Stage III disease, whereas all patients with seminomas presented with Stage I disease. Significant differences were also seen in prefreeze motility (median, 42% [interquartile range, 24 to 51] versus 60.5% [range, 49 to 73]; P = 0.0004) and motile sperm count (6.7 x 10(6)/mL [range, 3.4 to 14.4] versus 50.0 [range, 24.6 to 72.0]; P = 0.0001) in patients compared with controls, respectively. The motile sperm count and percent motility significantly decreased in both patients and controls after cryopreservation (P = 0.0001). However, the percentage decline in motile sperm count and motion characteristics after cryopreservation did not differ significantly between patients and controls (P > 0.01).

CONCLUSIONS

We conclude that the effect of cryopreservation on sperm quality in patients with testicular cancer is identical to its effect on sperm from normal fertile men. Differences in values after preservation are explained by poor semen characteristics before freezing; semen quality declines with more extensive disease. Stage I patients also had poorer quality than control subjects. Thus, we recommend that routine sperm banking be encouraged among all patients with testicular cancer before the initiation of specific medical treatment. We also recommend that future efforts be focused on improving the technique of sperm banking.

Late sequelae of gonadal, mediastinal and oral teratomas in childhood

Thirty-two patients with gonadal or non-sacrococcygeal extragonadal teratomas who underwent operation in childhood were evaluated for different late sequelae. Follow-up times ranged from 5.0 to 40 years. Physical abnormalities resulting from surgery were seen in eight patients who had had oral or mediastinal primary teratomas. Radiographs revealed multiple spina bifida occulta lesions in three patients. The males, but not the females, showed signs of gonadal dysfunction. Impaired semen quality or abnormal serum concentrations of testosterone or gonadotrophins were found in five of 10 adult men who had had testicular or mediastinal teratomas. Thus, some late sequelae may be predicted from the site of the primary teratoma, but gonadal dysfunction in males and vertebral anomalies may occur irrespective of where the teratoma is situated.

Germ cell function and hormonal status in patients with testicular cancer

Sperm counts, serum gonadotropins, and androgen levels were investigated in 39 seminoma patients and 58 patients with a nonseminomatous germ cell tumor of the testis after unilateral orchiectomy. In 58% of the patients, the total sperm count was below the lower reference value (80 million). A multiregression analysis demonstrated a correlation between a decreased total sperm count and the following three explanatory variables: (1) an elevated serum alpha-fetoprotein (AFP), (2) a history of chryptorchidism, or (3) a seminomatous tumor. In 42% of the patients, the sperm concentration and the sperm motility met criteria considered sufficient for cryopreservation. Serum follicle-stimulating hormone (FSH) was elevated in 33% of the patients. Androgens (serum testosterone [T] or urine 17-oxy-steroids [17-OS]) were subnormal in 5% of the patients, whereas serum luteinizing hormone (LH) was elevated in 14% of the patients without human chorionic gonadotropin beta-subunit (beta-HCG) in serum.