Testicular cancer: The usage of central review for pathology diagnosis of orchiectomy specimens

Multifocality in Testicular Cancer: Clinicopathological Correlations and Prognostic Implications

There are limited data regarding the significance of multifocality in testicular cancer patients. This study evaluated the relationship between multifocality and clinicopathological features determined at the time of radical orchiectomy. The study involved 280 consecutive patients who underwent radical orchiectomy between 2018 and 2023. Multifocality was defined as a distinct tumor focus characterized by a group of malignant cells > 1 mm, clearly differentiated from the primary tumor mass. Uni- and multivariate logistic regression analyses were employed to investigate the association between multifocality and histopathological parameters along with potential risk factors for clinical stages II + III. Multifocality was identified in 44 (15.7%) patients. Significantly smaller primary tumors were observed in subjects with multifocality (20.0 mm vs. 30.0 mm, p = 0.0001), while those exhibiting monofocality presented a markedly elevated rate of tumors exceeding 4 cm (40.3% vs. 18.2%, p = 0.005). Furthermore, multifocality was associated with a significantly higher rate of primary tumors < 2 cm (52.3% vs. 29.2%, p = 0.003). Univariate logistic regression analysis revealed a substantial decrease in the likelihood of multifocality occurrence in seminoma patients with tumors > 4 cm (OR = 0.38, p = 0.017). Meanwhile, in multivariate logistic regression, multifocality did not emerge as a significant risk factor for clinical stages II + III in either seminoma (p = 0.381) or non-seminoma (p = 0.672) cases. Our study suggests that multifocality holds no substantial prognostic relevance for clinically advanced disease in testicular cancer patients. The findings indicate that multifocality is associated with smaller primary tumors, particularly those measuring less than 2 cm.

No evidence for seasonal variations of the incidence of testicular germ cell tumours in Germany

The pathogenesis of testicular germ cell tumours (GCTs) is still incompletely understood. Any progress in its understanding must derive from observational studies. Recently, it has been suggested that the incidence of GCTs may follow a seasonal pattern based on circannual changes in the Vitamin D serum levels, with maximum incidence rates in winter months. To examine this promising hypothesis, we studied monthly incidence rates of testicular GCTs in Germany by analysing 30,988 GCT cases aged 15-69 years, diagnosed during 2009-2019. Monthly incident case numbers with data regarding histology and patient age were obtained from the Robert Koch Institut, Berlin, along with annual male population counts. We used precision weighting for deriving pooled monthly incidence rates for GCTs of the period 2009-2019. We stratified pooled rates by histology (seminoma and nonseminoma) and age (15-39 and 40-69 years). By assuming a cyclical effect, we used an estimator of the intensity of seasonal occurrence and report seasonal relative risks (RR). The mean monthly incidence rate was 11.93/105 person-months. The seasonal RR for testicular cancer over-all is 1.022 (95% CI 1.000-1.054). The highest seasonal RR was found in the subgroup of nonseminoma aged 15-39 years, with a RR 1.044 (95% CI 1.000-1.112). The comparison of the pooled monthly rates of the winter months (October-March) with the summer months (April-September) revealed a maximum relative difference of 5% (95% CI 1-10%) for nonseminoma, aged 15-39 years. We conclude that there is no evidence of a seasonal variation of incidence rates of testicular cancer. Our results are at odds with an Austrian study, but the present data appear sound because the results were obtained with precision weighted monthly incidence rates in a large population of GCT cases.

Clinical characteristics and treatment outcomes of germ cell tumor in Jordan: A tertiary center experience

Objective

In the Middle East, there is a paucity of data regarding germ cell tumor characteristics and treatment outcomes. Herein, we aim to present the largest series in Jordan reporting our cancer center experience managing GCT.

Methods

Between 2010 and 2020, a total of 241 patients with a pathological diagnosis of GCT were treated at our cancer center. Demographic, epidemiologic, and pathological data were retrospectively collected. In addition, survival and relapse outcomes based on tumor stage and adjuvant treatment were collected.

Results

A total of 241 patients were diagnosed with GCT, of whom 108 (44.8%) had seminoma and 133 (55.2%) had non-seminoma tumors (NSGCT). Median age (interquartile range) at diagnosis was 31 years (25-36). Patients with seminoma (68.5%) had pT1 disease post orchiectomy, while only 37.5% of patients with NSGCT had pT1 on final pathology. Elevated tumor markers such as beta-human chorionic gonadotropin were present in 10% of seminomas. Following radical orchiectomy and staging, 88 (36.5%) went for active surveillance while 153 patients (63.5%) received adjuvant treatment. With regard to pathology slides read outside, rereading by our genitourinary pathologist yielded a discrepancy on GCT type in 41 (19.3%) out of 212 patients. The median follow-up was 36 (24-48) months. Twenty-two patients relapsed after an average follow-up time of 39 months. The 5-year overall survival for stage I, II, and III was 98%, 94%, and 87%, respectively, and 3-year recurrence-free survival for stage I, II, and III was 94.8%, 78%, and 67%, respectively.

Conclusion

Our data on testicular GCT including demographic, histological, and treatment outcomes were comparable to that of developed countries. In light of the pathology discrepancy rate revealed in our study, authors recommend a second review by expert genitourinary pathologists to ensure proper classification and management of GCT.

Prognostic factors in patients with clinical stage I nonseminoma-beyond lymphovascular invasion: a systematic review

OBJECTIVE

To systematically evaluate evidence on prognostic factors for tumor recurrence in clinical stage I nonseminoma patients other than lymphovascular invasion (LVI).

METHODS

We performed a systematic literature search in the biomedical databases Medline (via Ovid) and Cochrane Central Register of Controlled Trials (search period January 2010 to February 2021) for full text publications in English and German language, reporting on retro- or prospectively assessed prognostic factors for tumor recurrence in patients with stage I nonseminomatous germ cell tumors.

RESULTS

Our literature search yielded eleven studies reporting on 20 potential prognostic factors. Results are based on cohort studies of mostly moderate to low quality. Five out of eight studies found a significant association of embryonal carcinoma (EC) in the primary tumor with relapse. Among the different risk definitions of embryonal carcinoma (presence, predominance, pure), presence of EC alone seems to be sufficient for prognostification. Interesting results were found for rete testis invasion, predominant yolk sac tumor, T-stage and history of cryptorchidism, but the sparse data situation does not justify their clinical use.

CONCLUSIONS

No additional factors that meet the prognostic value of LVI, especially when determined by immunohistochemistry, could be identified through our systematic search. The presence of EC might serve as a second, subordinate prognostic factor for clinical use as the data situation is less abundant than the one of LVI. Further efforts are necessary to optimize the use of these two prognostic factors and to evaluate and validate further potential factors with promising preliminary data.

Discrepancy in pathology reports upon second review of radical orchiectomy specimens for testicular germ cell tumors

INTRODUCTION

We sought to evaluate the discrepancies between primary pathology report and second pathology review of radical orchiectomy (RO) specimens.

METHODS

A retrospective review was performed of RO specimens from the Ontario Cancer Registry. All cases required both a primary pathology report and a second pathology review from another institution. Histopathological variables assessed included histological subtype and components of mixed germ cell tumor (GCT), pathological tumor (pT) stage, lymphovascular invasion (LVI), spermatic cord invasion, and surgical margin.

RESULTS

Between 1994 and 2015, 5048 ROs were performed with 2719 (53.9%) seminoma and 2029 (40.2%) non-seminoma. Of these, 519 (10.3%) received a second pathology review. There was concordance between primary pathology report and second pathology review in 326 (62.8%) cases. The most common discrepancies involved a change in pT stage (n=148, 28.5%), with upstaging in 83 (16%) and downstaging in 65 (12.5%) cases relative to the original pT stage. The second most common discrepancy regarded the reporting of LVI (n=121, 23.3%), with 62 (11.9%) reporting presence of LVI when the primary pathology report did not. Other discrepancies included a change in the histological subtype in 28 (5.4%) cases and spermatic cord margin status in five (9.6%) cases.

CONCLUSIONS

Only 10% of orchiectomy specimens underwent a second pathology review, with nearly 40% of reviews leading to a meaningful change in parameters. Such variation could lead to incorrect tumor staging, estimate of relapse risk, and inappropriate treatment decisions. Expert pathology review of RO specimens should be considered, as it has significant implications for decision-making.

Clinical dilemmas in local and regional testis cancer

At the Canadian Testis Cancer Workshop, the multidisciplinary management of testis cancer care was discussed. The two-day workshop involved urologists, medical and radiation oncologists, pathologists, radiologists, physician's assistants, residents, fellows, nurses, patients, and patient advocacy group members.This review summarizes the discussion regarding clinical dilemmas in local and regional testis cancer. We present cases that highlight the need for a coordinated approach to individualize care. Overarching themes include the importance of a multidisciplinary approach to testis cancer, willingness to involve a high-volume experienced center, and given that the oncological outcomes are excellent, a reminder that clinical decisions need to prioritize selecting a strategy with the least treatment-related morbidity when safe.

Prospective molecular and morphological assessment of testicular prepubertal-type teratomas in postpubertal men

In 2016, the World Health Organization classification system of testicular tumors included the new entity prepubertal-type teratoma based on its morphological and molecular profile, and the realization that these tumors may occur in postpubertal men. For treatment and prognostic purposes, it is important to distinguish prepubertal-type teratoma from the usual postpubertal-type teratoma, because the former is benign unlike the latter. The distinction may be challenging. In this study, we investigated clinical, morphological, and molecular criteria for distinguishing prepubertal-type teratoma from postpubertal-type teratoma in a prospective series of pure testicular teratomas. All cases of pure teratoma in postpubertal men assessed at Barts Health NHS Trust or in consultation since the introduction of routine investigation of chromosome 12p status in 2010 were reviewed. Morphological features suggestive of prepubertal-type teratoma were observed in 14 out of 35 cases. All underwent molecular testing and none displayed 12p amplification. Mean tumor size was 16 mm (range 7-28 mm). None had associated germ cell neoplasia in situ or significant atrophy. Four incorporated a well-differentiated neuroendocrine tumor, 1-2 mm in size. Of the ten patients with follow-up information, none have recurred or metastasized. Twenty-one of the 35 cases were diagnosed as postpubertal-type teratoma, mean tumor size 40 mm (range 6-90 mm). One case underwent molecular testing: a tumor of pure skeletal muscle differentiation and possessed 12p amplification. Three cases presented with clinical metastases. Eight cases contained immature areas, ten cases had associated germ cell neoplasia in situ, and 17 cases had severe atrophy of the parenchyma. One case with neither germ cell neoplasia in situ nor atrophy showed necrosis. We conclude that both morphological and molecular features are of help in differentiating prepubertal-type teratoma from postpubertal-type teratoma. In nearly all postpubertal-type teratomas, molecular testing was unnecessary, and merely confirmed the morphological impression in the prepubertal-type teratomas. Our study confirmed the high incidence of well-differentiated neuroendocrine tumors in the prepubertal-type.

Lymphovascular invasion and presence of embryonal carcinoma as risk factors for occult metastatic disease in clinical stage I nonseminomatous germ cell tumour: a systematic review and meta-analysis

Objective

To systematically review the literature on the prognostic value of lymphovascular invasion (LVI) and embryonal carcinoma (EC) for occult metastatic disease in clinical stage I nonseminomatous germ cell tumour (CS I NSGCT).

Materials and methods

The PubMed, Embase (OVID) and SCOPUS databases were searched up to March 2019. Studies reporting on the association between LVI and/or EC and occult metastatic disease were considered for inclusion. The quality and risk of bias were evaluated by the Quality in Prognosis Studies tool.

Results

We screened 5287 abstracts and 207 full‐text articles. We included 35 studies in the narrative synthesis and 24 studies in a meta‐analysis. LVI showed the strongest effect. Pooled rates of occult metastasis were 47.5% and 16.9% for LVI‐positive and LVI‐negative patients, respectively (odds ratio [OR] 4.33, 95% confidence interval [CI] 3.55–5.30; P < 0.001). Pooled rates of occult metastasis were 33.2% for EC presence and 16.2% for EC absence (OR 2.49, 95% CI 1.64–3.77; P < 0.001). Pooled rates of occult metastasis were 40.0% for EC >50% and 20.0% for EC <50% (OR 2.62, 95% CI 1.93–3.56; P < 0.001).

Conclusions

LVI is the strongest risk factor for relapse. The prognostic value of EC is high, but there is no common agreement on how to define this risk factor. Both EC presence and EC >50% have similar ORs for occult metastasis. This shows that the assessment of EC presence is sufficient for the classification of EC.

Prognostic factors for relapse in patients with clinical stage I testicular cancer: protocol for a Danish nationwide cohort study

INTRODUCTION

Approximately one-fourth of patients with clinical stage I testicular germ cell cancer will relapse within 5 years of follow-up. Certain histopathological features in the primary tumour have been associated with an increased risk of relapse. The available evidence on the prognostic value of the risk factors, however, is hampered by heterogeneity of the study populations included and variable reporting of the histopathological features. The aim of this study is to identify pathological risk factors for relapse in an unselected large nationwide cohort of patients with stage I disease.

METHODS AND ANALYSIS

All incident cases of stage I testicular germ cell cancer diagnosed in Denmark between 2013 and 2018 will be identified using the nationwide prospective Danish Testicular Cancer (DaTeCa) database. Archived microscopic slides from the orchiectomy specimens will be retrieved through linkage to the Danish Pathology Data Bank and reviewed blinded to the clinical outcome. The DaTeCa database includes 960 stage I seminoma patients with expected 185 relapses and 480 patients with stage I non-seminoma with expected 150 relapses. A minimum follow-up period of 3 years of all patients will be ensured. Predefined prognostic variables will be investigated with regard to relapse in univariable and multivariable analysis using the Cox proportional hazards model.

ETHICS AND DISSEMINATION

This study protocol has been approved by the Regional Ethics Committee (Region Zealand, Denmark) and the Danish Data Protection Agency. All data will be managed confidentially according to legislation. Study results will be presented at international conferences and published in peer-review journals.

Oncologic Outcomes Following Surgical Management of Clinical Stage II Sex Cord Stromal Tumors

OBJECTIVE

To investigate the clinical history of patients with clinical stage II sex cord stromal tumors who underwent retroperitoneal lymph node dissection (RPLND) at our institution.

METHODS

Our prospectively maintained testicular cancer database was queried to identify patients who presented with or developed clinical stage II sex cord stromal tumors and underwent RPLND at our institution between 1980 and 2018. Demographic, clinical, and pathologic characteristics were reviewed. Kaplan-Meier curves were graphed to assess recurrence-free and overall survival.

RESULTS

Fourteen patients were included in the study with a median age of 44.2years. Four patients presented with clinical stage II disease and 10 patients developed metastatic disease during follow-up of initial clinical stage I disease with a median time to metastasis of 2.7years (range: 0.4-19.5 years). Of the 10 patients with orchiectomy pathology data available, all patients had at least 1 risk factor on testis pathology (mean: 2.9 risk factors). Nine patients received treatment prior to referral to our institution. All patients recurred post-RPLND at Indiana University. Median recurrence-free survival was 9.8 months. Twelve patients died of disease with a median overall survival of 14.4 months.

CONCLUSION

Metastatic sex cord stromal tumors are rare and are more resistant to standard treatment modalities than metastatic germ cell tumors. Patients presenting with sex cord stromal tumors should consider prophylactic primary RPLND in the setting of 1 or more pathologic predictor of malignancy.