Incidence and clinical pattern of contralateral synchronous and metachronous germ cell testicular cancer

Testicular ultrasonographic features predict future risk for bilateral testicular germ cell tumour: A long-term single centre follow-up study

BACKGROUND

Bilateral testicular germ cell tumours (B-GCT) are rare, with an incidence of 2-5%, and can be classified as synchronous (sB-GCT) or metachronous (mB-GCT). Our study aimed to identify clinical, biochemical, and radiological risk factors for mB-GCT in a cohort of patients with GCT at a single tertiary referral centre.

METHODS

This retrospective case-control study included patients with GCT referred to Policlinico Umberto I-Sapienza University of Rome, from 2005 to 2023. We evaluated clinical history, testicular ultrasound features, hormone levels, semen analysis, histological characteristics, staging, and treatments. mB-GCTs were compared with unilateral GCT patients with a follow-up longer than the median time-to-onset of the second tumour.

RESULTS

Of 319 patients, 52 experienced B-GCT, with a median time-to-onset of the second tumour of 62 months (range: 8-229). The mB-GCT group showed higher gonadotropin levels (FSH 13.6mUI/mL vs. 7.4mUI/mL, p < 0.001; LH 6.6mUI/mL vs. 3.9mUI/mL, p = 0.004), lower sperm concentration (27 × 106/ejaculate vs. 78 × 106/ejaculate, p = 0.009), smaller residual testis volume (10.4 mL vs. 16.3 mL, p < 0.001), more inhomogeneous echotexture [57.5% vs. 14%, p < 0.001], and presence of microlithiasis (75% vs. 19.5%, p < 0.001). Kaplan-Meier curves confirmed that ultrasound features of the residual testis increased the cumulative risk of developing a second tumour. Microlithiasis was a strong independent predictor (OR 30.712, 95% CI 3.357-280.942, p = 0.002).

CONCLUSIONS

Histological features of the first tumour or its treatment do not influence the onset of a second tumour. However, low residual testis volume, inhomogeneous echotexture, and microlithiasis significantly increase this risk. A comprehensive evaluation of the residual testis at baseline is essential for developing a personalised surveillance programme in GCT survivors, with regular ultrasound follow-up recommended beyond the conventional 5-year limit.

Effects of epidemiological risk factors on prognosis in testicular cancer

PURPOSE

Testicular cancer is frequently seen, especially in young males, and constitutes 1% of all male cancers. Family history, testicular dysgenesis syndrome, and the presence of tumour in the contralateral testis are each well-defined epidemiological risk factors. The aim of the current study was to determine the distribution of these risk factors according to tumour stage and to evaluate the effects on progression.

MATERIALS AND METHODS

A total of 71 patients diagnosed with testicular cancer in our clinic between January 2018 and December 2021 were classified according to tumour stage (Group 1: Early, n = 29; Group 2: Advanced, n = 42). The presence of risk factors, and demographic and pathological data were recorded.

RESULTS

No significant difference was determined between the groups in respect of age, comorbidities, and tumour type (p > 0.05). There was no difference between Group 1 and Group 2 in terms of median follow-up time [15.5 (17.5), 16.5(26.5) months, respectively, p = 0.4]. Epidemiological risk factors were seen more in Group 2 than in Group 1 (p = 0.03). Progression-free survival was determined to be shorter in patients with risk factors compared to those without (7.95 ± 1.3 vs. 29.4 ± 2.06 months, p < 0.001, respectively). Family history and testicular dysgenesis syndrome were determined to be independent risk factors for progression [HR:0.046 (0.004-0.485); HR:0.101 (0.03-0.347), p < 0.05, respectively].

CONCLUSIONS

More advanced-stage tumours are seen in patients with testicular cancer when epidemiological risk factors are also present. Of these risk factors, family history and testicular dysgenesis syndrome have a negative effect on progression.

Optimized detection of germ cell neoplasia in situ in contralateral biopsy reduces the risk of second testis cancer

OBJECTIVE

To evaluate whether optimized and standardized diagnostic procedures would improve detection of germ cell neoplasia in situ (GCNIS) in the contralateral testis of patients with testicular germ cell tumour (TGCT) and decrease the rate of metachronous tumours, which in a nationwide Danish study was estimated to be 1.9%.

PATIENTS AND METHODS

This was a retrospective analysis of outcomes in 655 patients with TGCT who underwent contralateral biopsies (1996-2007) compared with those in 459 non-biopsied TGCT controls (1984-1988). The biopsies were performed using a standardized procedure with immunohistochemical GCNIS markers and assessed by experienced evaluators. Initial histopathology reports were reviewed, and pathology and survival data were retrieved from national Danish registers. In 604/608 patients diagnosed as GCNIS-negative (four were lost to follow-up), the cumulative incidence of metachronous TGCT was estimated in a competing risk setting using the Grey method. All cases of metachronous TGCT were re-examined using immunohistochemistry.

RESULTS

Germ cell neoplasia in situ was found in 47/655 biopsied patients (7.2%, 95% confidence interval [CI] 5.4-9.5%). During the follow-up period (median 17.3 years) five of the 604 GCNIS-negative patients developed a TGCT. In 1/5 false-negative biopsies, GCNIS was found on histological revision using immunohistochemistry and 2/5 biopsies were inadequate because of too small size. The estimated cumulative incidence rate of second tumour after 20 years of follow-up was 0.95% (95% CI 0.10%-1.8%) compared with 2.9% (95% CI 1.3%-4.4%) among the non-biopsied TGCT patients (P = 0.012). The estimates should be viewed with caution due to the small number of patients with metachronous TGCT.

CONCLUSIONS

Optimized diagnostic procedures improved the detection rate of GCNIS in patients with TGCT and minimized their risk of developing metachronous bilateral cancer. Urologists should be aware of the importance of careful tissue excision (to avoid mechanical compression) and the need of adequate biopsy size. Performing contralateral biopsies is beneficial for patients' care and should be offered as a part of their management.

Intricacies of retroperitoneal lymph node dissection for testis cancer

PURPOSE OF REVIEW

Retroperitoneal lymph node dissection (RPLND) and retroperitoneal tumor resection for germ cell cancer are complex operations requiring experience and expertise in surgical techniques necessary to achieve complete resection while minimizing morbidity. This article reviews the intricacies of RPLND for testis cancer.

RECENT FINDINGS

Surgical management of advanced testis cancer begins with an intimate understanding of retroperitoneal anatomy and the various techniques necessary to safely extirpate tumors. Preoperatively patients should undergo comprehensive counseling and obtain up-to-date imaging along with tumor markers to assist in surgical planning and evaluation of extraretroperitoneal (ERP) disease. Surgeons must be well versed in nerve-sparing techniques to maintain ejaculatory function. Newer techniques using a midline extraperitoneal technique minimizes morbidity and length of hospital stay. Special consideration should be given to the possibility of encountering ERP disease in advanced germ cell tumors, with management of these cases in tertiary care centers with multidisciplinary teams.

SUMMARY

The perioperative care of the testis cancer patient undergoing RPLND is complex. The goal is to achieve complete resection to render patients disease free while minimizing surgical and long-term morbidity. Advanced testis cancer patients should be managed at tertiary care facilities with surgical expertise and access to multidisciplinary care.