Predictors of spermatogenesis in radical orchiectomy specimen and potential implications for patients with testicular cancer

The Status of Spermatogenesis in Germ Cell Tumor Bearing Testis and Its Association with Metastatic Disease

INTRODUCTION

We aimed to evaluate the status of spermatogenesis detected by histological examination of non-tumoral testicular tissues in tumor bearing testis and its association with advanced stage disease.

PATIENTS AND METHODS

We retrospectively reviewed patients with testicular germ cell tumors (TGCTs) that undergone radical orchiectomy. All non-tumoral areas of the orchiectomy specimens were examined for the status of spermatogenesis. Patients were divided into two groups as localized (stage I) and metastatic (stage II-III) disease and analyzed separately for seminomatous (SGCT) and nonseminomatous germ cell tumors (NSGCT).

RESULTS

Four hundred fifty-four patients were included in our final analysis. Of those, 195 patients had SGCT, and 259 patients had NSGCT. Three hundred and six patients had localized disease at the time of diagnosis. Median (Q1-Q3) age was 31 (26 - 38) years and 102 (22.5%) patients had normal spermatogenesis, 177 (39.0%) patients had hypospermatogenesis and 175 (38.5%) patients had no mature spermatozoa. On multivariate logistic regression analysis, embryonal carcinoma >50% (1.944, 95 %CI 1.054-3.585, P = .033) and spermatogenesis status (2.796 95% CI 1.251-6.250, P = .012 for hypospermatogenesis, and 3.907, 95% CI 1.692-9.021, P = .001 for absence of mature spermatozoa) were independently associated with metastatic NSGCT. However, there was not any variables significantly associated with metastatic SGCT on multivariate logistic regression analysis.

CONCLUSION

Our study demonstrated that only 22.5% of patients with TGCTs had normal spermatogenesis in tumor bearing testis. Impaired spermatogenesis (hypospermatogenesis or no mature spermatozoa) and predominant embryonal carcinoma are associated with advanced stage NSGCT.

Case report: remedial microdissection testicular sperm extraction after onco-microdissection testicular sperm extraction failure

BACKGROUND

Testicular cancer (TC) mostly occurs in men aged 14 to 44. Studies have shown that TC seriously damages male fertility, and 6% to 24% of patients with TC were even found to suffer from azoospermia when they are diagnosed. At present, some studies have pointed out that onco-microdissection testicular sperm extraction (mTESE) can extract sperm from tumor testicles. However, there are almost no reports on remedial measures after onco-mTESE failure. Given the valuable opportunity for fertility preservation in patients with TC and azoospermia, it is necessary to provide effective remedial methods for patients with failed onco-mTESE.

METHODS

Two young men, who were diagnosed with TC and also found to have azoospermia, tried onco-mTESE while undergoing radical orchiectomy for fertility preservation. However, sperm extraction failed in both patients. Subsequently, the isolated testicular tissue of the patient in case 1 suffered from TC again, and the patient in case 2 was scheduled to receive multiple cycles of gonadotoxic chemotherapy. Because both had a plan to have a birth in the future, we performed remedial mTESE.

RESULTS

Sperm was successfully extracted from both patients. The patient recovered well, without complications. The patient couple in case 1 underwent 1 intracytoplasmic sperm injection (ICSI) cycle but did not achieve clinical pregnancy.

CONCLUSIONS

There is still an opportunity to extract sperm successfully using onco-mTESE, despite the difficulty of fertility preservation in TC patients with azoospermia. If sperm extraction from the tumor testis fails, implementing remedial mTESE as early as possible would likely preserve the last chance of fertility for these patients.

Semen parameters in testicular tumor patients before orchiectomy: What is the impact of testicular tumor stage and histology?

PURPOSE

To evaluate the influence of testicular cancer histology and stage on sperm parameters in cryopreserved samples collected prior to orchiectomy.

MATERIALS AND METHODS

We conducted a retrospective analysis of tumor histology, stage and sperm parameters of patients who underwent pre-orchiectomy sperm cryopreservation for testicular cancer between March 2010 and March 2023. The World Health Organization (WHO) 2010 sperm reference values were used to identify patients with subnormal semen parameters and to further categorize patients by sperm alteration. Localized disease was classified as Stage I, while metastatic disease encompassed Stages II and III. Continuous variables were compared using t-test or Mann Whitney U test, and categorical variables using Chi-square and Fishers exact test.

RESULTS

A total of 64 patients was identified, 48 (75%) classified as stage I and 16 (25%) classified as stage II/III. No difference was found in semen parameters between patients with seminoma and patients with non-seminoma germ cell tumor (NSGCT). Patients with stage II/III disease had significantly lower percentages of progressive motility (36% vs 53%, p=0.021) and total motility (60% vs 69%, p=0.015) than stage I patients. When categorizing by sperm alterations according to WHO 2010 reference values, patients with stage II/III disease had significantly higher proportions of asthenozoospermia (38% vs 15%, p=0.048) and teratozoospermia (63% vs 31%, p=0.027) than stage I patients. Elevated tumor markers were not associated with sperm abnormalities.

CONCLUSIONS

Patients with metastatic testicular cancer present with worse sperm quality than patients with localized disease. Sperm cryopreservation should be offered to all patients with testicular cancer, and especially emphasized in patients with metastatic disease.

Ex vivo microscopic testicular sperm extraction at the time of radical orchiectomy in men with nonobstructive azoospermia (NOA): a scoping review

Testicular tumor is the most common solid malignancy in males under 40 years of age. This malignancy is known to have a negative impact on male fertility. Therefore, several techniques for sperm retrieval have been proposed, including microdissection testicular sperm extraction (mTESE). The objective of this study was to review the literature on the outcomes of oncological (Onco)-mTESE at the time of radical orchiectomy. We conducted a comprehensive literature search through PubMed, Scopus, and Cochrane Central Controlled Register of Trials. Only studies reporting ex vivo mTESE in patients with testicular tumor were considered. Twelve papers met the inclusion criteria and were included in this review. Tumor size was identified as the sole preoperative factor influencing spermatogenesis. The considered studies demonstrated a satisfactory success rate for Onco-mTESE, associated with a similarly valid percentage of live healthy births through assisted reproductive technology. Currently, no comparison has been made between Onco-mTESE and conventional Onco-TESE, hence further assessment is required. In cases where the tumor completely replaces the cancer-bearing testicle, a contralateral micro-TESE may be a viable alternative. However, the surgeon should evaluate associated risks and benefits preoperatively. In conclusion, Onco-mTESE at the time of radical orchiectomy appears to be a promising therapeutic option for young patients with testicular tumors. Nevertheless, additional studies are necessary to achieve a definitive conclusion.

Testicular Dysfunction Among Cancer Survivors

In parallel with increased survival rates, quality of life (QoL) has become of growing importance in the management of young cancer survivors. Several surveys have indicated that in those subjects, the issue of reproductive function is considered as one of the main QoL aspects. In this article, we summarize the current evidence, as well as gaps of knowledge and research needs, regarding the impact of cancer and cancer treatment on testicular function-including fertility and androgen production. Also, pre and posttherapy clinical management of reproductive issues in male cancer survivors, are given.

Microdissection oncoTESE (micro-oncoTESE) in azoospermic men with suspected testicular cancer: Analysis of outcomes from a specialist centre

Objective:

The main aim of this study was to report the outcomes of azoospermic men with suspicious testicular lesions, undergoing microsurgical sperm retrieval (micro-oncoTESE) at the time of radical/partial orchidectomy.

Patients and methods:

Testicular lesions suspicious for cancer were confirmed on ultrasound scanning. In patients undergoing radical inguinal orchidectomy, ex vivo microdissection of the unaffected testicular parenchyma was performed. Microdissection was performed in vivo for partial orchidectomy. The primary outcome measure was surgical sperm retrieval (SSR) rate.

Results:

A total of 33 patients (median age 33 years, interquartile range (IQR) 22) with suspected testicular cancer (TCa) underwent micro-oncoTESE. Histological analysis confirmed TCa in 26 patients and benign pathology in 7 patients. The overall SSR rate was 39%. Sub-analysis of patients with TCa and benign histology found that the SSR was 46% and 14%, respectively. There was no significant difference in maximum tumour length between successful and unsuccessful SSR groups 33.9 mm ± 23 (SD) versus 29.8 mm ± 17.5 (SD) ( p = 0.62).

Conclusion:

Based on our cohort, micro-oncoTESE provides an option for sperm retrieval in azoospermic men with testicular lesions.

Onco-Testicular Sperm Extraction (oncoTESE): A Contemporary Concept Review and Report of Australian Sperm Retrieval Rates and Fertility Outcomes

OBJECTIVE

To assess sperm retrieval rates of Onco-Testicular Sperm Extraction (oncoTESE) in men with testicular tumors and coexisting severe spermatogenic impairment.

METHODS

Multi-centre Australian wide retrospective review of oncoTESE procedures performed within the last 10 years. Patients were postpubertal adults having a testicular tumor requiring orchidectomy, with severe oligozoospermia or nonobstructive azoospermia. Ipsilateral testicular sperm extraction was performed following radical inguinal orchidectomy. A contralateral micro-testicular sperm extraction was performed if no sperm or insufficient amounts were initially achieved. Surgical sperm retrieval rates, live birth rates and post operative serum testosterone were recorded.

RESULTS

Four surgeons compiled a total 13 patients. The mean age was 34.9 years. Seven of 13 were germ cell tumor (GCT), 4 of 13 had non-GCT and 2 of 13 contained benign lesions. Twelve of 13 patients were azoospermic and 1 was severely oligozoospermic. Sperm was found in 6 of 7 GCT patients; 3 of 7 were found in the ipsilateral testis whilst the remaining 4 underwent contralateral micro-testicular sperm extraction; sperm was retrieved in 3 of 4. The respective mean pre and post orchidectomy testosterone was 12.0 vs 14.1nmol/L (GCT cohort). Cryopreserved sperm has been used in assisted reproduction in 2 of 13 patients, with median follow up of 38.7 months. Including use of both cryopreserved and fresh sperm, 6 pregnancies were achieved, including 5 healthy live births and 1 miscarriage.

CONCLUSION

OncoTESE appears feasible, with acceptable sperm retrieval and subsequent live birth rates, following assisted reproduction. Despite significant underutilisation in the Australian population, oncoTESE should be considered in the management for TC patients with severe oligozoospermia, or nonobstructive azoospermia.

The absence of spermatogenesis in radical orchiectomy specimen is associated with advanced-stage nonseminomatous testicular cancer

BACKGROUND

To assess if clinical, pathological, and spermatogenesis factors are associated with clinical staging in patients with testicular germ cell tumors.

PATIENTS AND METHODS

We retrospectively reviewed the pathology reports and slides from 267 men who underwent radical orchiectomy for testicular cancer at our institution during 1998-2019. Histologic slides were reviewed and the presence of mature spermatozoa was documented. Clinical, laboratory and radiographic characteristics were recorded. Logistic regression analyses were used to identify factors associated with advanced disease stage at diagnosis.

RESULTS

Of 267 male patients, 115 (43%) patients had testicular non-seminomatous germ cell tumors (NSGCT) and 152 (57%) seminomatous germ cell tumors (SGCT). Among NSGCT patients, those presenting with metastatic disease had a higher proportion of predominant (>50%) embryonal carcinoma (64% vs. 43%, respectively, P = 0.03), and lymphovascular invasion (45.8% vs. 26.6%, respectively, P = 0.03) than non-metastatic patients. Spermatogenesis was observed in 56/65 (86.2%) and 36/49 (73.5%) of non-metastatic and metastatic NSGCT patients, respectively (P = 0.09). On semen analysis, severe oligospermia (<5 million/ml) was more common in metastatic than in non-metastatic NSGCT (26.5% vs. 8.3%, respectively, P = 0.04). On multivariate analysis, predominant embryonal carcinoma and lack of spermatogenesis in pathological specimens were associated with metastatic disease.

CONCLUSION

The absence of spermatogenesis and a high proportion of embryonal carcinoma was associated with advanced disease in patients with NSGCT. Whether it may also translate as a predictor of oncologic outcome needs further evaluation.

Incidental discovery of azoospermia on work-up of testicular tumour: a practice changing discovery

Testicular tumours are increasing in incidence, especially in developed countries. This incidence increases specifically in the subpopulation of infertile men. This case highlights a young man incidentally diagnosed with a subcentimetric testicular lesion, who was discovered to have concomitant azoospermia. The authors review management strategies in this challenging case, as treatment options for men with infertility and concomitant testicular tumours vary from men who are fertile.

Level of evidence: Not applicable for this multicentre audit.

[Onco-TESE and testicular cancer]

INTRODUCTION

Fertility preservation is essential before cancer treatment. When ejaculated sperm preservation is not possible, testicular tissue can be surgically collected by Onco-TESE technic (Oncological Testicular Sperm Extraction) to isolate sperm. We report on our experience with Onco-TESE in testicular cancer patients at the Rouen University Hospital.

MATERIAL AND METHOD

Retrospective study including all pubescent men, treated for testicular cancer, uni- or bilateral, before any carcinological therapy, who have undergone Onco-TESE at the Rouen University Hospital. Fragment weight, detection of sperm or its precursors were analysed. A histological interpretation of the testicular tumor was carried out. For each positive sample, straws were kept at the French Sperm Bank.

RESULTS

Twenty-four patients had an Onco-TESE: 58.34% severe sperm alteration (SSA) and 41.36% sperm collection failure (SCF), between 1996 and 2019. The mean age was 26.6 (±5.29) years. The mean procedure and length of stay were 71minutes (±30.7) and 3.75 days (±2.83), respectively. The rate of positive testicular biopsies (TB) was 58.33% overall and 66,67% in the case of TB on tumour testis. One patient had a Clavian-Dindo III complication. The mean number of straws preserved per patient was 14.28 (±15.34) for 7.14% use.

CONCLUSION

Our results seem to confirm that Onco-TESE is an effective solution for preserving fertility in men with testicular cancer in cases of SSA or SCF.

LEVEL OF EVIDENCE

III.

Relevance of testicular histopathology on prediction of sperm retrieval rates in case of non-obstructive and obstructive azoospermia

Introduction:

The aim of our research was to establish the relevance of testicular histopathology on sperm retrieval after testicular sperm extraction in patients with non-obstructive azoospermia and in patients with obstructive azoospermia, who already underwent a previous failure testicular fine needle aspiration.

Methods:

We evaluated a total of 82 azoospermic men, underwent testicular sperm extraction, referring to the Assisted Reproductive Technology Centre of the University of Florence, Italy between January 2008 and March 2017. A general and genital physical examination, scrotal and trans-rectal ultrasound, semen analysis, hormone measurements, including follicle-stimulating hormone, luteinizing hormone and total testosterone, were collected.

Results:

Successful sperm retrieval was obtained in 36 men of total (43.9%). Successful sperm retrieval was 29.5% in non-obstructive azoospermia patients, while men with obstructive azoospermia, who, underwent a previous failure testicular fine needle aspiration, had sperm retrieval in 86% of cases. Mean luteinizing hormone was 6.55 IU/L, total testosterone 4.70 ng/mL, right testicular volume 13.7 mL and left testicular volume 13.6 mL. Mean Follicle-stimulating hormone was 13.45 IU/L in patients with negative sperm retrieval and 8.18 IU/L in men with successful sperm retrieval. According to histology, 20.7% had normal spermatogenesis, 35.3% hypospermatogenesis, 35.3% maturation arrest and 8.5% Sertoli cell-only syndrome. Successful sperm retrieval was 88.2% in patients with normal spermatogenesis, 24.1% in the maturation arrest group and 48.27% in patients with hypospermatogenesis, while negative sperm retrieval was reported in Sertoli cell-only syndrome patients. Seven cases with maturation arrest showed a successful sperm retrieval.

Conclusion:

Testicular histopathology after testicular sperm extraction offers important information on prediction of sperm retrieval and can guide the surgeon in choosing the more suitable therapeutic practice.