Clinical and occult testicular leukemia in long-term survivors of acute lymphoblastic leukemia

Testicular involvement of acute lymphoblastic leukemia in children and adolescents: Diagnosis, biology, and management

Acute lymphoblastic leukemia (ALL) in children and adolescents can involve the testes at diagnosis or upon relapse. The testes were long considered pharmacologic sanctuary sites, presumably because of the blood-testis barrier, which prevents the entry of large-molecular-weight compounds into the seminiferous tubule. Patients with testicular involvement were historically treated with testicular irradiation or orchiectomy. With the advent of contemporary intensive chemotherapy, including high-dose methotrexate, vincristine/glucocorticoid pulses, and cyclophosphamide, testicular leukemia present at diagnosis can be eradicated, with the risk of testicular relapse being 2% or lower. However, the management of testicular leukemia is not well described in the recent literature and remains relevant in low- and middle-income countries where testicular relapse is still experienced. Chemotherapy can effectively treat late, isolated testicular B-cell ALL relapses without the need for irradiation or orchiectomy in patients with an early response and thereby preserve testicular function. For refractory or early-relapse testicular leukemia, newer treatment approaches such as chimeric antigen receptor-modified T (CAR-T) cell therapy are under investigation. The control of testicular relapse with CAR-T cells and their penetration of the blood-testis barrier have been reported. The outcome of pediatric ALL has been improved remarkably by controlling the disease in the bone marrow, central nervous system, and testes, and such success should be extended globally. LAY SUMMARY: Acute lymphoblastic leukemia (ALL) in children and adolescents can involve the testes at diagnosis or upon relapse. Modern intensive chemotherapy has largely eradicated testicular relapse in high-income countries. Consequently, most current clinicians are not familiar with how to manage it if it does occur, and testicular relapse continues to be a significant problem in low- and middle-income countries that have not had access to modern intensive chemotherapy. The authors review the historical progress made in eradicating testicular ALL and use the lessons learned to make recommendations for treatment.

Mechanisms of extramedullary relapse in acute lymphoblastic leukemia: Reconciling biological concepts and clinical issues

Long-term survival rates in childhood acute lymphoblastic leukemia (ALL) are currently above 85% due to huge improvements in treatment. However, 15-20% of children still experience relapses. Relapses can either occur in the bone marrow or at extramedullary sites, such as gonads or the central nervous system (CNS), formerly referred to as ALL-blast sanctuaries. The reason why ALL cells migrate to and stay in these sites is still unclear. In this review, we have attempted to assemble the evidence concerning the microenvironmental factors that could explain why ALL cells reside in such sites. We present criteria that make extramedullary leukemia niches and solid tumor metastatic niches comparable. Indeed, considering extramedullary leukemias as metastases could be a useful approach for proposing more effective treatments. In this context, we conclude with several examples of potential niche-based therapies which could be successfully added to current treatments of ALL.

Preferential survival of acute lymphoblastic leukemia cells at 33°C is associated with up-regulation of bcl-2

An important feature of childhood acute lymphoblastic leukemia (ALL) is the risk of testicular relapse in affected males, which may occur months or years after induction of remission. However, little is known about the factors that regulate leukemic cell survival and resistance to chemotherapy in the testis. In the present study, incubating ALL cell lines and primary cells from ALL patients at 33 degrees C resulted in increased survival, resistance to chemotherapeutic agents and upregulation of bcl-2. Acute myeloid leukemia cell lines incubated at 33 degrees C also showed increased survival and resistance to chemotherapeutic agents, but did not demonstrate upregulation of bcl-2. This may be important in determining survival of ALL cells at lower temperatures in the testis.

[Testicular biopsy at the stopping of the treatment in acute lymphoblastic leukemia: value of the immunohistochemical detection of residual blasts]

BACKGROUND

The prognostic value of clinical and histological detection of testicular leukemia after completion of therapy is still debated. Immunohistochemical study could improve the results of this detection.

PATIENTS AND METHODS

Between 1982 and 1992, 70 consecutive boys with acute lymphoblastic leukemia (ALL) and treated with the same therapeutic regimen were included in the study. Testicular biopsy (TB) was surgical and bilateral. One piece of tissue was fixed and analysed by conventional microscopy. An immunohistochemical study was performed on the other sample with a panel of anti-T and anti-B Mc Ab, including JCB 117 (anti-CD79a) which stains early pre B lymphoblasts.

RESULTS

Twenty-five children relapsed while on treatment and did not undergo TB. Among the 45 boys who underwent routine TB, one had a diffuse infiltration seen in conventional histology. Thirty-nine had normal morphological and immunohistochemical study: among them, six relapsed subsequently in bone marrow; in this group, event free survival (EFS) was 85 +/- 10% with a median follow-up of 80 months after the biopsy. In the five remaining boys, anti-CD79a was found positive on blasts in four cases and anti-CD3 in one case; four of those relapsed, including two in the testes during the year following the biopsy; EFS was 20 +/- 36% (P = 0.001).

CONCLUSIONS

New Mc Ab such as JCB 117 (anti-CD79a) might detect a minimal residual disease in the testes of children treated for ALL, particularly on routine histological material. These results, if confirmed in larger series, might influence further therapeutic strategy.

Fine-needle aspiration cytology as a tool for the early detection of testicular relapse of acute lymphoblastic leukemia in children

Fine-needle aspiration cytology (FNAC) of the testis was done in 31 children (33 aspirates) with acute lymphoblastic leukemia (ALL) either as part of an end-therapy protocol (Group I, n = 20) or because of clinical suspicion of testicular relapse (Group II, n = 13). In Group I, none of the smears showed evidence of leukemic cells. However, two of these patients developed subsequent testicular relapse within 1 yr and were considered false-negative cases. Blast cells were present in nine patients of Group II; in the remaining four patients no neoplastic cells were observed in the smears and none experienced a relapse after a mean follow-up of 18 mo. Our findings indicate that FNAC can be a valuable method to evaluate clinically suspected testicular infiltration in children with ALL, and can be considered as an alternative procedure to surgical biopsy for screening testicular recurrence of childhood ALL.

Primary testicular and paratesticular tumors of childhood

Testicular and paratesticular neoplasms are uncommon tumors of childhood. Consequently, the experience gained with regard to their optimal management is limited in any given children's cancer centre. Here we review the classification, diagnosis, and staging of testicular and paratesticular neoplasms and subsequently discuss the more frequently occurring ones: germ cell tumors, gonadal stromal tumors, gonadoblastoma, tumors of the supporting tissue, lymphomas and leukemias, tumor-like lesions, secondary tumors, and tumors of the adnexa.

An immunohistochemical study of testicular biopsies in childhood acute lymphoblastic leukemia: reactivity of normal testicular components and leukemic infiltrates

We performed an immunohistochemical analysis of frozen sections from testicular biopsies from 23 children with acute lymphoblastic leukemia. Eleven cases were infiltrated by leukemia. Tumor cells were immunostained by a panel of antibodies that identified CD10, CD43, CD19, CD3, CD7, and MHC class I and II. The immunoreactivity of normal testicular components was also studied. Normal testis showed no CD10 reactivity. Wide variation in the number of stromal macrophages identified by CD11c was found. Transferrin receptor (CD71) was expressed by some stromal macrophages, by seminiferous tubules, and by Leydig cells. B lymphocytes were absent from the testicular stroma but small numbers of T lymphocytes were consistently present. MHC class I and II were expressed by most stromal cells but not by seminiferous tubules.

Testicular relapse in children with acute nonlymphoblastic leukemia

The clinical course and other distinctive features of five children who developed a testicular relapse 4 months to 25 months after the diagnosis of acute nonlymphoblastic leukemia (ANLL) are described. The chief presenting feature at relapse was painless testicular enlargement, as is also seen in children with acute lymphoblastic leukemia who relapse in the testes. By French-American-British convention, the malignant cells were classified as M4 (myelomonoblastic) in four cases and M2 (myeloblastic) in one. All children received a course of multiagent reinduction chemotherapy and all but one received local irradiation to the testes. Only one of these children, whose relapse was a late event after elective cessation of therapy, is a long-term survivor. A comparison with six previously published cases shows similar clinical characteristics and outcome. Given the poor responses of such patients to conventional treatment, it seems worthwhile to consider the use of intensive reinduction chemotherapy with concomitant bilateral testicular irradiation followed by remission intensification and an autologous or allogenic marrow transplant.

Immunophenotyping to detect and characterize acute lymphocytic leukemia in testicular biopsies

This study establishes the utility of immunophenotyping testicular biopsy specimens in patients with acute lymphoid leukemia. The value of immunophenotyping in detecting or excluding leukemic testicular infiltration is demonstrated in six children with acute lymphocytic leukemia. A panel of monoclonal antibodies was employed on snap-frozen testicular biopsies, allowing both detection and immunologic characterization of four neoplastic lymphocytic infiltrates. Two samples were proven both histologically and phenotypically negative for leukemic infiltration. One of the four leukemic cases was clinically silent and might have escaped detection except for phenotyping. One leukemic infiltrate was also suspected to possess a multidrug-resistant phenotype (p-glycoprotein +); the latter possibility was excluded by an absence of reactivity with anti-p-glycoprotein monoclonal antibody. Thus, three clinically useful applications are demonstrated: (1) confirmation of testicular leukemic relapse, gaining assertion in histologically uncertain cases; (2) exclusion of clinically suspected disease relevant to cessation of therapy, and (3) detection/exclusion of drug-resistant phenotypes. Unexpectedly, we found expression of plasma cell-associated antigen in testicular germ cells, which may prove to be diagnostically useful in the future evaluation of germ cell tumors.

Testicular relapse in adult acute lymphocytic leukemia: a case report and literature review

In the pediatric age group, acute lymphocytic leukemia (ALL) may involve the testicles during complete remission of the disease in the marrow. We report a case of testicular involvement with ALL in an adult and review 11 cases of this phenomenon reported previously, to draw attention to the fact that it can occur at any age. Recognition of this fact is important, because testicular involvement may be the first manifestation of systemic relapse. The treatment of choice is irradiation to both testicles and combination chemotherapy.

Immunohistochemical detection of post-therapy residual testicular lymphoblasts in childhood acute lymphoblastic leukemia (ALL)

The aim of this study was to evaluate the diagnostic value of immunohistochemistry with monoclonal antibodies (MoAbs) in detecting residual blast cells in testicular biopsies from children with acute lymphoblastic leukemia (ALL). In a prospective study of 26 patients, testicular biopsies were performed after completion of therapy, and the average follow-up after biopsies was 29 months. After immunostaining, seven patients with negative biopsies on routine histology showed scattered, strongly calla-positive cells as well as cells reacting with anti-B (CD22) MoAb. Among these seven patients with residual blast cells, four had relapsed either in testes (n = 1), bone marrow and testes (n = 1), or in the bone marrow (n = 2). In contrast, among the 15 patients without residual blast cells, all but 1 remained in complete remission. In four other cases no definite conclusion was possible after immunohistochemical study. Four testicular biopsies from patients with occult infiltration were used as positive controls. Negative controls consisted of testicular biopsies from children with testicular ectopia and postmortem testicular tissue specimens. Results suggest that the risk of relapse is significantly higher in patients with positive immunohistochemical findings indicating persistent residual blast cells. However, the predictive value of these findings requires confirmation on a larger number of cases to have therapeutic implications.

Testicular adhesion: a potential complication from wedge testicular biopsy in childhood leukemia

Elective bilateral wedge testicular biopsy is frequently performed in childhood acute lymphoblastic leukemia. Acute and delayed complications of this procedure are rarely encountered. We report on two children with testicular adhesions 16 and 20 months postsurgery. In each instance there were resultant diagnostic and management difficulties. The possible cause and potential side effects of testicular adhesions are discussed.

Fine needle aspiration cytology (FNAC) of the testes in childhood acute lymphoblastic leukemia and non-Hodgkin's lymphoma: preliminary report

Eighteen patients with childhood acute lymphoblastic (ALL) or non-Hodgkin's lymphoma (NHL) in remission and 2 patients with ALL in suspected testicular relapses were studied by testicular fine needle aspiration cytology (FNAC). Well-preserved testicular cells, both singly and in small clusters, were considered indicative of an adequate aspiration. Of 18 patients in remission, 17 had at least one adequate sample from each testis and one showed evidence of leukemic infiltrate. None of these patients experienced a relapse during a median follow up of 4 years. In 2 other patients with clinically suspected testicular relapses, the smears from fine needle aspirates contained numerous malignant lymphoid cells that could be readily distinguished from seminiferous tubular cells. The observations indicate that FNAC is a promising new approach to study testicular conditions in childhood ALL and NHL. A larger prospective study and accumulation of additional follow-up data is required before a definitive evaluation of the technique can be made.

Seminoma in an adult with acute lymphocytic leukemia

We present a unique case of a seminoma in an adult with acute lymphocytic leukemia in clinical remission. As survival improves with modern multimodal chemotherapy testicular relapse of acute lymphocytic leukemia is becoming more common. A histopathological diagnosis is needed to initiate appropriate local and systemic therapy. In children a transscrotal approach for testis biopsy is used. However, the approach in adults with presumed testicular relapse has not been addressed. The risk factors of testicular relapse, the use of ultrasound in the diagnosis and the need to consider the classic differential diagnosis of a testicular mass are discussed.

Noninvasive testicular screening in childhood leukemia

To evaluate the potential of transscrotal ultrasound and magnetic resonance imaging as noninvasive screening methods we studied 8 boys with acute lymphocytic leukemia before testicular biopsy. Ultrasonic images of the testes were performed in 4 patients, including 2 with negative and 2 with positive biopsies, and all images were interpreted as normal. Magnetic resonance images of the testes also were interpreted as normal in 4 patients, including 2 with negative and 2 with positive biopsies, and they were technically inadequate in the remaining 4. The results suggest that neither transscrotal ultrasonography nor magnetic resonance imaging as currently applied may substitute reliably for testicular biopsy as a screen for occult testicular leukemia.

Intermediate dose methotrexate in childhood acute lymphoblastic leukemia resulting in decreased incidence of testicular relapse

Six hundred thirty-four children with acute lymphoblastic leukemia (ALL) were randomized to receive sanctuary therapy consisting of either cranial irradiation (CRT) plus intrathecal (IT) methotrexate (MTX) or three courses of intermediate-dose methotrexate (IDM) plus intrathecal methotrexate. Two hundred sixty-six male patients achieved a complete response and were evaluable for the effects of prophylactic therapy on the duration of remission. There was one isolated testicular relapse (0.8%) in the IDM group compared with 14 (10%) in the CRT group. The incidence of testicular relapse was significantly lower in the patients treated with IDM (P less than 0.001). High plasma levels of MTX achieved during the 24-hour infusions may result in increased penetration of MTX into the interstitium of the testes, thus allowing for the eradication of sequestered leukemic cells and preventing the emergence of drug resistance resulting from exposure to sublethal concentration of MTX.

Radiation treatment of testicular relapse in acute lymphoblastic leukemia

Ten patients with testicular relapse among 128 cases of acute lymphoblastic leukemia are reported. At the time of the initial diagnosis of leukemia all patients with later testicular relapse showed one or more risk factors as predictive for leukemic infiltration of the testicles. All patients except one, who underwent orchiectomy and died 11 weeks after surgical intervention, received radiation therapy with doses ranging from 12 to 20 Gy and chemotherapy. The local control was excellent. Average survival time from testicular relapse to death was 68 weeks in 8 of 9 patients treated by irradiation and chemotherapy. One patient is still alive without signs of disease after 6 years.

Ultrasound evaluation of scrotum in pediatrics

Scrotal abnormalities are difficult to assess using clinical criteria alone. Ultrasound provides an accurate means of demonstrating the scrotal contents so that appropriate therapy may be instituted. In a retrospective study, 119 ultrasound examinations of 96 patients (aged 4 days to 23 years) have been compared with the clinical diagnosis, surgical/pathologic findings, and other imaging modalities. The gamut of disease identified included congenital anomalies, neoplasm, trauma, torsion, varicocele, hydrocele, epididymo-orchitis, epididymal cyst/spermatocele, and post-radiation fibrosis. The ultrasound findings correlated well in 93/96 patients. In inconclusive cases, sequential imaging helps differentiate traumatic and inflammatory lesions from neoplastic processes.

The enigma of testicular leukemia: a critical review

Isolated testicular relapse (T.R.) in acute lymphoblastic leukemia (ALL) has an overall incidence of 10% and affects mainly patients off therapy. Multivariate analysis of pretreatment characteristics has shown that lymphadenopathy and splenomegaly are independently associated with increased risk of T.R. during maintenance and off therapy, respectively. Sequential biopsy studies have demonstrated that testicular biopsies are unable to detect scanty infiltrates and have no practical utility. Prophylactic gonadal irradiation produced equivocal results and should not be used because of its sterilizing effect. Intensive multi-drug regimens or prolonged maintenance were unable to substantially reduce T.R. rate. On the contrary, intermediate-dose methotrexate (IDM) early in remission has almost abolished T.R. These findings strongly support the hypothesis that testicular interstitium is a very peculiar site where blasts are partially protected from the drug action; high drug concentrations are required for the optimal cytocidal effect. There are sufficient clues of a link between the excess of late marrow relapse in male sex and the capacity of testes of harboring blasts. Therefore IDM early in remission should be routinely adopted for prevention of testicular leukemia and its potential of late spread.

The impact of induction anthracycline on long-term failure-free survival in childhood acute lymphoblastic leukemia

Early intensive therapy might be critical in improving failure-free survival for children with acute lymphoblastic leukemia. Between 1973 and 1977, 107 children received vincristine and prednisone (VP) induction and 30 received the same two agents plus an anthracycline (VPA). Ninety-nine of the VP-treated group and all 30 of the VPA-treated patients achieved complete remission. At a median observation time of 10 years, 59 of 137 children remain in continuous complete remission. Failure-free survival was 37% for the VP group and 63% for the VPA group (p = 0.02). Failure-free survival for boys who received VP was 28%, compared with 68% for boys who received VPA (p = 0.007). All 11 extramedullary relapses and all seven relapses occurring beyond 3.8 years from diagnosis (three testicular and four bone marrow) were observed among the VP group. We conclude that use of an anthracycline during remission induction therapy influenced failure-free survival and that early results of successful antileukemic therapy in children must be confirmed by follow-up progress reports.

Ultrastructural criteria in evaluating leukemic infiltration in prepubertal testicular biopsies

The diagnosis of leukemic infiltration in the testis by routine histology is not always possible. During the past 5 years, 46 bilateral testicular biopsies from prepubertal boys were examined by electron microscopy for the purpose of establishing the presence or absence of leukemic infiltration. The ultrastructure of the cells of acute lymphoblastic leukemia is described from the positive cases and compared with cases from the literature. Variations in ultrastructure between the T-cell, B-cell, and "null cell" types are discussed. The ultrastructure of the normal prepubertal cellular elements, which include immature Leydig cells, primitive fibroblastic cells (intertubular), and attenuated peritubular fibroblasts, is described. Ultrastructural criteria are summarized that enable a definitive evaluation of cases that are equivocal by histologic examination.

Metastatic neuroblastoma and testicular involvement

Neuroblastoma metastatic to the testes is thought to be an extremely rare event and is therefore not routinely considered in the evaluation of neuroblastoma patients. A review of metastatic sites in a series of neuroblastoma patients, however, revealed 11 cases with testicular involvement. Analysis of these cases suggests that the phenomenon may not be uncommon in a subset of neuroblastoma patients, namely, male patients with infra-diaphragmatic primaries and advanced-stage disease. Because the testes constitute a sanctuary site for tumor cells, occult testicular involvement may play a role in the relapse of patients judged to be in complete remission. Accordingly, it is proposed that in the above group of patients special diagnostic attention should be directed at the scrotal contents and, if testicular involvement is detected, orchiectomy or local irradiation should be considered.

Elective testicular biopsy during chemotherapy for childhood leukaemia is of no clinical value

The clinical value of early detection of testicular leukaemia was assessed by elective wedge biopsy during the 12th or 18th month of therapy in children with acute lymphoblastic leukaemia. Biopsy samples were taken in 106 of 238 consecutively treated boys who attained complete remission; only 1 had occult disease. Samples were also taken in 2 boys with testicular leukaemia at diagnosis as soon as they achieved complete remission, and in 14 others at the end of therapy; none showed evidence of leukaemic infiltration. 13 boys, including the 1 with biopsy-confirmed occult disease, had a testicular relapse; 6 of these patients had had negative biopsy findings 12-28 months before relapse. These results indicate that elective testicular biopsy during therapy for childhood leukaemia is of no benefit clinically. They also suggest that routine use of end-of-therapy testicular biopsy should be re-evaluated, since frequency of testicular relapse is low, therapy is effective, and negative biopsy findings do not preclude eventual relapse.

Management of children with isolated testicular leukemia

Since 1975, nine children with testicular leukemia were treated at the University of Kansas Medical Center on a standard protocol. Six patients presented with overt testicular leukemia and three patients had microscopic testicular leukemia detected on a biopsy done after 3 years of continuous complete remission. All patients had an M1 bone marrow at the time of testicular relapse and one patient had a concomitant central nervous system (CNS) relapse. Therapy consisted of testicular irradiation, CNS chemoprophylaxis, and systemic reinduction chemotherapy. Systemic maintenance therapy after the testicular relapse consisted of 6-mercaptopurine and methotrexate with vincristine/prednisone pulses administered in the same basic dose and schedule as the patient's original maintenance regimen. These nine patients had a mean duration of first remission of 33 months and a mean duration of second remission of 45+ months. Four patients have relapsed (two bone marrow, one CNS, one CNS + bone marrow), but five patients remain in their second complete remission for 33+ to 94+ months from the time of testicular relapse. These results demonstrate that, in some children, testicular leukemia represents a site of temporary drug resistance and long-term second remissions can be obtained (once local disease is controlled) by using the initial maintenance chemotherapy regimen.

Hypothalamo-hypophyseal-testicular function in prepubertal boys with acute lymphoblastic leukemia following chemotherapy and testicular radiotherapy

Hypothalamo-hypophyseal-testicular function was studied in twenty-eight prepubertal boys with ALL in clinical and haematological remission. Eighteen were treated with combined systemic chemotherapy (24-36 months) and the other ten, who had testicular leukemic infiltrates, received chemotherapy (38-60 months) and testicular radiotherapy (2 000 rad). Plasma levels of LH and FSH were measured before and after stimulation with LHRH (100 micrograms i.v.) and plasma levels of testosterone before and after stimulation with hCG (1 500 IU/48 h/7 doses). In patients treated with chemotherapy alone, mean basal LH and FSH, mean responses to LHRH stimulation and mean testosterone levels after stimulation with hCG did not significantly differ from those of the controls. Five of these patients who had normal testosterone values after three doses of hCG had testosterone values below the normal range after seven doses. In patients treated with chemotherapy and testicular radiotherapy, mean basal FSH and mean responses to LHRH stimulation were significantly higher than those of the controls. Testosterone values after stimulation with hCG were low in three and very low in the other seven. In both groups of patients data from testicular biopsies were consistent with functional results. We conclude that chemotherapy causes slight testicular damage, but chemotherapy and testicular radiotherapy produce severe testicular damage in patients with testicular leukemic infiltrates.

Testicular relapse in childhood acute lymphoblastic leukaemia in Malaysia, 1967-82

From 1967-82, 9 children with testicular relapse (TR) of acute lymphoblastic leukaemia (ALL) were diagnosed out of 99 boys treated, an incidence of 9.1%. The median time from the onset of ALL until diagnosis was 28 months (range 3-41 months). All were asymptomatic; six were detected on routine examination while three were diagnosed only on biopsy. Routine biopsy prior to stopping chemotherapy is useful in detecting occult TR. Biopsies should be done on both the testes regardless of the clinical findings. The age, leucocyte count and hepatosplenomegaly at diagnosis of ALL were not found to be significant factors in influencing relapse. Eight children were in bone marrow remission at the time of TR, but three had preceding or concurrent meningeal leukaemia while in the other five the testis was the first and only site of relapse. Radiotherapy was effective in local disease control but failed to prevent bone marrow relapse in all except two patients despite continuation of chemotherapy. The median time from onset of TR until bone marrow relapse was 7 months (range 3-13 months) and the median time until death, was 11 months (range 6-18 months). The frequency of testicular relapse may be related to the intensity of either the initial induction therapy or the consolidation chemotherapy. Further studies are required to determine whether the incidence of testicular relapse will decline with more intensive early treatment.

Hypopyon in acute lymphoblastic leukemia

A child with acute lymphoblastic leukemia had central nervous system relapse 23 months after diagnosis while in bone marrow remission. This was followed by leukemic involvement of the eye as the only site of relapse 7 months later. Leukemic cells layered out in the anterior chamber and cytologic examination was the only way to make a definitive diagnosis of leukemic hypopyon. Topical treatment is generally ineffective and radiotherapy is the treatment of choice. The prognosis with this complication depends on whether it occurs during therapy or after therapy has been discontinued.

Testicular biopsy and occult tumor in acute lymphocytic leukemia

Testicular biopsy has become a routine procedure before discontinuing chemotherapy in male children being treated for acute lymphocytic leukemia (ALL). Before a decision can be made to discontinue multiple drug therapy, all possible sites of occult tumor such as the testis, cerebrospinal fluid, and bone marrow must be sampled. Between December, 1978, and November, 1981, 25 male children underwent testicular biopsies after two or more years of combination chemotherapy at the Babies Hospital, Columbia-Presbyterian Medical Center. Only 3 of the 25 patients (12%) were found to have leukemic infiltrates on histologic sections. Two of 3 patients, however, were noted preoperatively to have either irregular testicular contours or testicular enlargement and induration. Occult testicular infiltration discovered after two or more years of chemotherapy is rare. Most children with a histologically positive biopsy result were at least suspected preoperatively to have testicular involvement.

Chemotherapy does not affect the development of inter-Sertoli junctions in childhood leukaemia

The inter-Sertoli junctions of children aged between 5 and 12 years, affected by acute lymphoblastic leukaemia, were analyzed in sections and freeze-fracture replicas. The testicular biopsies were performed at the end of therapy, when patients were in continuous remission for over 30 months. Chemotherapy does not seem to affect the development of junctions that were studied in sections and freeze fracture. Two age groups were considered (I, 5 to 8 years; II, 9 to 12 years). In age group I, oval Sertoli cells were connected by occasionally focal points of fusion, which in replicas appeared as scattered, interrupted ridges on the P face and grooves on the corresponding E face. In age group II Sertoli cells presented cytoplasmic extensions and interdigitations. Tight junctions appeared close to one another in conventional sections. Freeze fracture evidenced extensive although isolated areas formed by intervining strands. Lanthanum penetrated freely the intercellular spaces and gap junctions were observed in both age groups. The results suggest that tight junctions formation is initiated long before puberty; a progression in the complexity of the strand organization is present as the tubules mature; the strands reorganize in parallel and continuous rows only at puberty.

Proceedings of the tumor board of the Children's Hospital of Philadelphia. Testicular leukemia: incidence and management results

The patient was an eight-year-old black male who presented to the Children's Hospital of Philadelphia (CHP) in June 1977 with foot pain. Abnormal findings on physical examination were diffuse shotty lymphadenopathy without hepatosplenomegaly. Examination of the extremities was normal. There was no evidence of increased bruising or bleeding. Laboratory data revealed a hemoglobin of 11.2 gm/dl, white blood cell count of 26,200/cu mm, and platelet count of 21,000/cu mm. Serum uric acid level was 4.2 mg/dl. The remainder of the laboratory findings were within normal limits. Bone marrow examination revealed a hypercellular marrow replaced with lymphoblasts. Immunologic evaluation showed these cells to have no surface immunoglobin and no rosette formation with sheep red blood cells. The patient received vincristine 1.5 mg/M2 daily, oral prednisone at 40 mg/M2 daily, L-asparaginase 6,000 IU/M2 for nine intramuscular doses, and methotrexate 12 mg intrathecally. After 28 days, bone marrow aspiration showed that the leukemia was in remission. He then received 2,400 rad cranial irradiation over three weeks, along with four more doses of intrathecal methotrexate, given once weekly. Maintenance consisted of monthly pulses of vincristine (1.5 mg/M2), prednisone (40 mg/M2 for five days), daily oral 6-mercaptopurine (75 mg/M2), and weekly oral methotrexate (20 mg/M2). After six months of maintenance, the patient was given a scheduled course of reinduction therapy with vincristine, prednisone, and L-asparaginase. Eleven months after diagnosis both testes were noted to be enlarged on physical examination. Wedge biopsy of both testes revealed leukemic infiltration. Examination of the bone marrow and cerebrospinal fluid (CSF) at that time were unremarkable. The patient was treated with vincristine, prednisone, and L-asparaginase again for four weeks and received intrathecal methotrexate as central-nervous-system (CNS) prophylaxis. Twenty-four hundred rad were given to both testes at 200 rad/day with decrease in testicular size. Maintenance consisted of monthly pulses of vincristine and prednisone with oral methotrexate and 6-mercaptopurine. Seven months after his testicular relapse the patient had a bone marrow relapse. He expired eight months later with disseminated leukemia.