Testis tumors: review of 125 cases at the Cleveland Clinic

Retroperitoneal lymphocele formation after selective laparoscopic retroperitoneal lymph node sampling

Laparoscopic retroperitoneal lymph node sampling is being evaluated at several institutions as a minimally invasive alternative to evaluate pathologically retroperitoneal lymph nodes in cases of clinical stage A testis tumor. We report on the development of a symptomatic lymphocele after selective laparoscopic retroperitoneal lymph node sampling.

Metastatic pure choriocarcinoma of the testis in an elderly man

The case described of pure choriocarcinoma of the testis is rare because of the histological type and patient age at presentation. A 63-year-old man had a 160 gm. tumor, with a necrotic, hemorrhagic appearance and sparse bright areas that consisted exclusively of syncytial and cytotrophoblastic cells. Immunocytochemical analysis revealed strong staining for human chorionic gonadotropin in the syncytiotrophoblastic cells. The specimen was moderately positive for keratin and negative for alpha-fetoprotein.

Lymphocele after retroperitoneal node dissection for testis tumor

A patient is presented in whom a lymphocele developed after a retroperitoneal lymph node dissection for Stage II embryonal carcinoma of the testicle. The benign nature of this lymphocele has been confirmed not only by the diagnostic procedures outlined, but by its stability over a 42-month follow-up period with no further antitumor therapy. We conclude from reviewing the literature that while aggressive measures are necessary to confirm the diagnosis of a lymphocele, its management should be expectant. If significant obstruction of neighboring structures occurs, an attempt at percutaneous drainage (and possibly sclerosis) seems appropriate despite potential risks of interventional treatment such as hemorrhage and introduction of infection. Open procedures for marsupialization and drainage should be reserved for cases in which more conservative measures fail.

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.

Nonlymphomatous metastatic tumor to the testis

A patient with pancreatic carcinoma presented with an initial left testicular mass that proved to be metastatic adenocarcinoma of the pancreas. Regional spread of the pancreatic carcinoma may have created venous and lymphatic obstruction with inferior passage of tumor emboli to the testis. A summary of nonlymphomatous secondary tumors of the testis also is presented.

Testicular germ cell tumors. Prognostic factors

A retrospective analysis of clinical and pathologic data of 100 patients with germ cell testicular tumors is presented. The presenting symptoms and their duration prior to orchiectomy are analyzed and categorized. The duration of symptoms correlated with the stage of disease for each tumor. Seventy-five per cent of locally invasive lesions were found in patients with Stage II or III disease.

The management of disseminated testicular cancer

Fourteen patients with disseminated non-seminomatous germ cell tumours of the testis were treated with a 3-drug combination of vinblastine, bleomycin and cis-diamminedichloroplatinum. Of 13 patients with measurable disease, 9 (69%) had complete and 3 (23%) partial remission. One patient with a solitary metastasis failed to respond but is disease-free following surgical excision. Toxicity was significant but no drug-related deaths occurred and there were no apparent lasting side effects. No patient attaining complete remission has relapsed. Eleven (79%) of the 14 patients are without evidence of disease from 3+ to 36+ months, 6 of these for 2 years or more. Of the patients in partial remission one died at 16 months and one is undergoing further treatment for relapse with liver metastases. One patient remains in partial remission at 30 months. These results demonstrate the efficacy of this drug combination in testicular cancer.

Combination chemotherapy with cis-diammine-dichloro-platinum, vinblastine, and bleomycin in advanced testicular non-seminoma

40 patients with disseminated testicular non-seminoma were treated with cis-diammine-dichloro-platinum, vinblastine, and bleomycin. Complete remission was achieved in 24 (60%) patients and partial remission in 11 (28%). 22 of the 24 complete responders, who have been followed-up for a median of 11 months, have been tumour-free for 5--30 months. There were 3 drug-related deaths. This regimen is the most effective remission-induction treatment available for disseminated testicular non-seminoma. Patients should be treated in centres experienced in the specialised management of this potentia-ly curable disease.

Management of advanced testicular seminoma

The treatment of seminoma (stages A, B1 and B2) with conventional x-ray therapy can be expected to give satisfactory cure rates. However, the cure rate for patients with advanced stages of B3 and C disease, treated with conventional radiation therapy, is unacceptable (22 per cent). It appears that with a pre-radiation/chemotherapeutic plan consisting of actinomycin D, vincristine and cyclophosphamide survival can be improved dramatically in these patients. After a rest period of 2 to 4 weeks radiation therapy is given to the retroperitoneal, mediastinal and supraclavicular lymph nodes as per standard therapy. If evidence of bulk disease persists or if positive alpha-fetoprotein or beta-human chorionic gonadotropin has been detected then retroperitoneal lymph-adenectomy should be done after completion of the radiation therapy. With adjuvant chemotherapy 5 of 5 patients survive free of disease 18 months to 5 years after therapy.

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

Prolactin (PRL), human placental lactogen (hPL), the beta-subunit of human chorionic gonadotropin (betahCG), testosterone (T), estrone (E1), and estradiol (E2) were measured in blood samples from 45 patients with testicular tumors, 27 of whom had gynecomastia at some stage of their disease. Forty-two of the 45 patients had at least one abnormal hormone level. The most common abnormality was that of plasma estrone: it was elevated in 32 out of 42 (76%) patients in whom it was measured, suggesting a useful role for E1 as a testicular tumor marker. Prognosis was notably worse in patients with embryonal carcinoma, teratocarcinoma, and choriocarcinoma, in those with gynecomastia and, particularly, galactorrhea. Such patients also had the highest incidence of hormonal abnormalities as well as the most extreme absolute values. Hormonal mechanisms were implicated in the development of gynecomastia and galactorrhea. Prolactin, betahCG, E1, and E2 levels in all permutations correlated significantly among patients with gynecomastia, but not among those without, while estrogen to testosterone ratios were elevated in patients with galactorrhea.

Improved chemotherapy in disseminated testicular cancer

Two combination chemotherapy regimens for disseminated testicular cancer are described. Our present regimen of platinum vinblastine and bleomycin has been highly successful, producing 16 complete (80 per cent) and 4 partial (20 per cent) remissions. Furthermore, 2 patients have been rendered free of disease by the surgical removal of residual disease, making the effective complete remission rate in these 20 patients 90 per cent. Of these patients 16 are alive and 14 are free of disease for more than 8 to more than 20 months. Despite the significant toxicity during the first 12 weeks of this therapeutic regimen it usually was manageable and maintenance therapy produced minimal toxicity. We believe that this regimen is a major advance in the management of patients with disseminated testicular cancer.