Association of Down's Syndrome and Testicular Cancer

Current surgical approach: Extracranial malignant germ cell tumors

Germ cell tumors (GCT) are a complex, heterogeneous collection of tumors that may present in either gonadal or extragonadal sites. They consist of a variety of benign and malignant histologies that can occur at several locations throughout the body. An important component of treatment is surgical resection, and while the key components of resection are site specific, the universal goals of GCT resection include the complete resection of tumor without violating the tumor capsule, while preserving function of surrounding organs, minimizing morbidity, and assessing for regional spread.

Testicular cancer mortality in Latin America and the Caribbean: trend analysis from 1997 to 2019

BACKGROUND

In the last decades, an increasing incidence of testicular cancer has been observed in several countries worldwide. Although mortality rates have been variable in many countries, little information is available from Latin America and the Caribbean (LAC). Therefore, we examined mortality trends of testicular cancer in the last two decades.

METHODS

Age-standardized mortality rates (ASMR) of testicular cancer per 100,000 men-years were estimated using the World Health Organization mortality database from 1997 to 2019. We examined the mortality trends and computed annual percent change (APC) for all ages and the following age groups, 15-29, 30-44, 15-44, and ≥ 45 years.

RESULTS

Ten countries had mortality rates greater than 0.43 per 100,000 men, with the highest rates for Chile, Mexico, and Argentina. Significant increases in mortality rates were observed in Argentina, Brazil Colombia, and Mexico in all ages, and < 45 years, while Colombia, Ecuador, Mexico, and Peru reported significant downward trends in males aged ≥ 45 years. Only Chile showed significant decreases for all ages and age groups studied.

CONCLUSION

Mortality by testicular cancer increased among LAC countries in males of all ages and across age groups. A reduction in mortality rates was observed only in Chilean males of all ages and in men ≥ 45 years in several countries. Strengthening of early detection among symptomatic males may decrease the mortality by this neoplasm.

Metastatic Testicular Seminoma in a Patient With Down Syndrome Presenting As Extensive Deep Venous Thrombosis

Testicular cancer, particularly seminoma, is associated with Down syndrome. In cognitively impaired patients, the typical presenting signs of testicular cancer may be missed, and atypical presenting features may be the only clue to the diagnosis. In this report, we present the case of a 38-year-old male who presented with extensive deep vein thrombosis in the setting of seminoma.

Mental Health in Urologic Oncology

This article is a systematic review of mental health in urologic oncology patients with prostate cancer (PCa), bladder cancer (BC), renal cell carcinoma (RCC), testicular cancer (TC), or penile cancer (PeCa). For all pathologies, a focus on increasing quality of life post-treatment demonstrated a positive impact in reducing Mental Health Illness (MHI) prevalence. Cancer specific mental health care may be given to patients to reduce suicide risk in BC patients and sexual identify and masculinity counseling may improve mental health for TC or PeCa patients. In order to better accommodate patient’s mental health needs when undergoing GU cancer treatment, we recommend incorporation of mental health metrics such as questionnaires to assess early treatment of MHI, a greater emphasis on psychosocial support with the patient’s loved ones, peers, and healthcare team, alongside advising healthy habits such as exercise which has been shown to drastically reduce MHI incidence across all pathologies. We hope that these measures conducted by urologists and oncologists, alongside possible coordination with psychiatrists and psychologists for psychotherapy, psychopharmacology, and neuro-stimulation treatment modems may be helpful in the long term to reduce MHI incidence in urology oncology patients. Given the higher incidence of MHI in oncology patients and in the patient population after the Covid-19 pandemic, MHI awareness in the sphere of urologic oncologic treatment continues to be crucial when creating a collaborative treatment platform for patients.

Between a Rock and a Hard Place: An Epigenetic-Centric View of Testicular Germ Cell Tumors

Simple Summary

This minireview focuses on the role of epigenetics in testicular cancer. A working model is developed that postulates that epigenetic features that drive testicular cancer malignancy also enable these tumors to be cured at a high rate with chemotherapy. Chemoresistance may occur by epigenetic uncoupling of malignancy and chemosensitivity, a scenario that may be amenable to epigenetic-based therapies.

Abstract

Compared to many common solid tumors, the main genetic drivers of most testicular germ cell tumors (TGCTs) are unknown. Decades of focus on genomic alterations in TGCTs including awareness of a near universal increase in copies of chromosome 12p have failed to uncover exceptional driver genes, especially in genes that can be targeted therapeutically. Thus far, TGCT patients have missed out on the benefits of targeted therapies available to treat most other malignancies. In the past decade there has been a greater appreciation that epigenetics may play an especially prominent role in TGCT etiology, progression, and hypersensitivity to conventional chemotherapy. While genetics undoubtedly plays a role in TGCT biology, this mini-review will focus on the epigenetic “states” or features of testicular cancer, with an emphasis on DNA methylation, histone modifications, and miRNAs associated with TGCT susceptibility, initiation, progression, and response to chemotherapy. In addition, we comment on the current status of epigenetic-based therapy and epigenetic biomarker development for TGCTs. Finally, we suggest a unifying “rock and a hard place” or “differentiate or die” model where the tumorigenicity and curability of TGCTs are both dependent on common but still ill-defined epigenetic states.

Efficacy of Ifosfamide-Cisplatin-Etoposide (ICE) Chemotherapy for a CNS Germinoma in a Child With Down Syndrome

Intracranial germ cell tumor is sometimes associated with Down syndrome; however, no optimal treatment has been developed due to the high risk of recurrence and treatment-related mortality. Here, we report on a patient with an intracranial germinoma in the bilateral basal ganglia. The patient received 3 courses of ifosfamide-cisplatin-etoposide in combination with whole-brain irradiation (24 Gy), with no serious complications. The patient is alive and disease free 16 months after the initial diagnosis. This regimen is a feasible treatment for intracranial germ cell tumor associated with Down syndrome, although careful attention must be paid to the increased risk for severe infection.

Hypermethylation of genes in testicular embryonal carcinomas

BACKGROUND

Testicular embryonal carcinoma (EC) is a major subtype of non-seminomatous germ cell tumours in males. Embryonal carcinomas are pluripotent, undifferentiated germ cell tumours believed to originate from primordial germ cells. Epigenetic changes during testicular EC tumorigenesis require better elucidation.

METHODS

To identify epigenetic changes during testicular neoplastic transformation, we profiled DNA methylation of six ECs. These samples represent different stages (stage I and stage III) of divergent invasiveness. Non-cancerous testicular tissues were included. Expression of a number of hypermethylated genes were examined by quantitative RT-PCR and immunohistochemistry (IHC).

RESULTS

A total of 1167 tumour-hypermethylated differentially methylated regions (DMRs) were identified across the genome. Among them, 40 genes/ncRNAs were found to have hypermethylated promoters. Quantitative RT-PCR confirmed downregulation of 8 out of 9 of the genes. Among the confirmed genes, five were sex-linked genes, including X-linked genes STAG2, SPANXD/E and MIR1184, and Y-linked genes RBMY1A1/1B/1D and FAM197Y2P. RBMY1A is a testis-specific gene for spermatogenesis. RNF168 and USP13 are potential tumour suppressors. Expression of RBMY1A was lost in EC and seminoma as documented in the Protein Atlas. We confirmed downregulation of USP13 in EC by IHC.

CONCLUSIONS

Our genome-wide analysis of testicular EC identified methylation changes in several previously unknown genes. This may provide insight of crosstalk between normal germ cell development and carcinogenesis.

Exploration of the treatment challenges in men with intellectual difficulties and testicular cancer as seen in Down syndrome: single centre experience

Down syndrome is the most common chromosomal disorder in humans as well as the most common cause of inherited intellectual disability. A spectrum of physical and functional disability is associated with the syndrome as well as a predisposition to developing particular malignancies, including testicular cancers. These tumours ordinarily have a high cure rate even in widely disseminated disease. However, individuals with Down syndrome may have learning difficulties, behavioural problems, and multiple systemic complications that have the potential to make standard treatment more risky and necessitates individualized approach in order to avoid unacceptable harm. There is also suggestion that tumours may have a different natural history. Further, people with learning disabilities have often experienced poorer healthcare than the general population. In order to address these inequalities, legislation, professional bodies, and charities provide guidance; however, ultimately, consideration of the person in the context of their own psychosocial issues, comorbidities, and possible treatment strategies is vital in delivering optimal care. We aim to present a review of our own experience of delivering individualized care to this group of patients in order to close the existing health inequality gap.

Health conditions associated with aging and end of life of adults with Down syndrome

Expectations for the life course of individuals with Down syndrome (DS) have changed, with life expectancy estimates increasing from 12 in 1949 to nearly 60 years of age today (Bittles & Glasson, 2004; Penrose, 1949). Along with this longer life expectancy comes a larger population of adults with DS who display premature age-related changes in their health. There is thus a need to provide specialized health care to this aging population of adults with DS who are at high risk for some conditions and at lower risk for others. This review focuses on the rates and contributing factors to medical conditions that are common in adults with DS or that show changes with age. The review of medical conditions includes the increased risk for skin and hair changes, early onset menopause, visual and hearing impairments, adult onset seizure disorder, thyroid dysfunction, diabetes, obesity, sleep apnea and musculoskeletal problems. The different pattern of conditions associated with the mortality of adults with DS is also reviewed.

Challenges in treating patients with Down's syndrome and testicular cancer with chemotherapy and radiotherapy: The Royal Marsden experience

AIMS

With a life expectancy similar to the general population, greater numbers of patients with Down's syndrome are being diagnosed with testicular cancer. Learning difficulties and medical co-morbidity are common in this patient population and may lead to non-standard oncological treatment. We aimed to identify and discuss management challenges in the treatment of these patients with chemotherapy and radiotherapy and report their clinical outcome.

MATERIALS AND METHODS

The Royal Marsden Hospital urology database was searched from 1982 to 2005 to identify all cases of patients with Down's syndrome and histologically confirmed testicular cancer who were referred for consideration of chemotherapy or radiotherapy.

RESULTS

Nine patients were identified, of whom eight received chemotherapy or radiotherapy. Two patients had bilateral tumours and four had crypto-orchidism. At the time of diagnosis, the patients were 21-50 years of age. Of the 11 tumours identified, nine were seminomas and two were malignant teratoma undifferentiated. Five patients presented with stage I disease, of whom three received carboplatin and one received para-aortic radiotherapy as adjuvant treatment. Three patients presented with stage II disease, of whom two were treated with carboplatin and one received combination chemotherapy followed by radiotherapy. One patient with stage IV disease was treated with carboplatin. Five of nine patients relapsed within 30 months, of whom three were successfully salvaged with radiotherapy and one with combination chemotherapy.

CONCLUSION

After standard and non-standard therapy for seminoma, the relapse rate for patients in our cohort was high. Since relapsed disease is much more difficult to manage with combination chemotherapy on account of respiratory, cardiac and renal co-morbidity, adequate initial treatment is advised. Consideration of psycho-social issues and the multiple treatment strategies available is vital in delivering optimal care to patients with Down's syndrome and testicular cancer.

Down syndrome and esophageal cancer

We present two cases of Down syndrome with inoperable esophageal cancer at a relatively young age. The first patient had a locally advanced squamous cell carcinoma of the distal esophagus. The second had a short circular adenocarcinoma of the distal esophagus with peritoneal and liver metastases. The cases are discussed with regard to the current literature on Down syndrome and esophageal cancer.

Evaluation of residual tissues after adjuvant therapy in germ cell tumors

OBJECTIVE

Germ cell tumors are the tumors sensitive for adjuvant therapy such as radiotherapy and chemotherapy. We evaluated the pathological findings of these heterogeneous tumors to determine the persistence of residual viable tumor cells after adjuvant therapy.

PATIENTS AND METHODS

Between 1988 and 2005, we treated 31 patients with germinoma or germinoma with syncytiotrophoblastic giant cells (STGC) and 15 patients with non-germinomatous malignant germ cell tumors (NGMGCTs). All 46 patients received a combination of chemo- and radiotherapy. A second-look operation was performed in 3 of 31 patients with germinomas or germinomas with STGC and 12 of 15 patients with NGMGCTs. The follow-up period was 2-139 months (median 95) in patients with germinomas or germinomas with STGC (group 1) and 10-202 months (median 65) in NGMGCT patients (group 2).

RESULTS

Post-treatment, 3 group 1 and 12 group 2 patients manifested residual tumors. The pathological diagnosis in group 1 patients was mature teratoma, pineal cyst, and fibrous tissue with calcification; in group 2 it was yolk sac tumor (n = 1), immature teratoma (n = 3), mature teratoma (n = 4), and necrosis or fibrous tissue (n = 4). While no group 1 patients manifested tumor cells, MIB-1-positive viable tumor cells were present in resected tissues from one-third of the group 2 patients (3 immature teratomas and 1 yolk sac tumor).

CONCLUSION

The absence of viable tumor cells in residual tissue indicates that the combination of cisplatin-based chemo- and radiotherapy was effective in our germinoma patients. On the other hand, in patients with NGMGCTs, these cells persisted despite this combination therapy.

Testicular microlithiasis in patients with Down syndrome

OBJECTIVES

Testicular microlithiasis (TM) occurs with benign as well as with pathological conditions, such as testicular cancer. Since Down syndrome (DS) may be associated with increased frequency of testicular cancer, we determined the prevalence of TM in DS in patients from a DS clinic and evaluated the prevalence by age group.

STUDY DESIGN

We compared results of research scrotal ultrasounds obtained from 1998 to 2001 from 92 Latino patients with DS (ages newborn to 29.7 years) and clinical ultrasounds obtained from 1998 to 2004 from 200 Latino patients without DS (ages newborn to 18.3 years). We also reviewed the medical records.

RESULTS

The prevalence of TM in DS was 29%, significantly higher than the 7% found in patients without DS (P < .0001). Twenty of the 27 patients with DS and TM had no testicular pathology clinically or by history. The TM prevalence in the entire group of patients with and without DS increased with advancing age.

CONCLUSIONS

We found a significantly increased prevalence of TM in DS. The clinical significance of TM needs to be investigated further.

An ovarian dysgerminoma in Down syndrome. Hypothesis about the association

An 11-year-old girl with Down syndrome (DS) was operated for a stage I right ovary dysgerminoma. She is in good health 33 years later. Some data in the literature suggest that ovarian cancers could be slightly overrepresented in DS. Despite the rarity of ovarian dysgerminoma, our case is the fifth reported in DS. This case is the second one associated with a family history suggesting the possibility of a familial predisposition to cancer. A hypothesis explaining the development of dysgerminoma in DS is proposed.

A 2-year-old baby with Downs syndrome, cryptorchidism and testicular tumour

Seminomas are rare germ cell tumours. It occurs usually in men aged over 50 years. Seminomas differ genetically and clinically from germ cell tumours. They have a late age of onset and rarely metastasise. The incidence of testicular carcinoma (seminoma) in patients of Down syndrome has recently been emphasised. One of the predisposing factors for seminoma is undescended testis which not only results in spermatogenic arrest but also in carcinoma in situ. This triad of abnormalities that is cryptorchidism, oligozoospermia and testicular cancer is known as testicular dysgenesis syndrome (TDS). Since there is an increased incidence of tumourogenesis in Down syndrome cases the cryptorchid condition may result in an increased risk for testicular carcinogenesis and its early onset and poor prognosis. Therefore all Down syndrome cases with cryptorchidism should be counselled to go in for surgical descent of testis at the earliest age and also to come for regular follow up for early detection for any foci of malignancy. This is the youngest testicular seminoma ever reported in human. This tumour occurred in a 2-year-old child and it is possible that Trisomy 21 may predispose to early onset of seminoma and such cases should be under regular follow up. Thus improved understanding and identification of various urogenital anomalies associated with Down syndrome will aid in better management of these cases. This case report and review of literature all suggest that Down syndrome is associated with an increased risk of development of seminoma and that too at an early age. This advocates a need for thorough gonadal examination in all cases of Down syndrome.

Cancer incidence of persons with down syndrome in Finland: A population-based study

Individuals with Down syndrome (DS) have a predisposition to leukaemia and testicular cancer, but data on the incidence of cancers are yet sparse. A cohort of 3,581 persons with DS was identified from a National Registry of Finnish persons with intellectual disability collected between 1978 and 1986 and followed-up for cancer incidence until 2002. Standardised incidence ratios (SIRs) were defined as ratios of observed number of cancer cases to those expected from the national cancer incidence rates, by age and sex. The overall cancer risk was equal to that of the general population, but a significantly high risk of leukaemia (SIR 10.5, CI 95% 6.6-15.8) and testicular cancer (SIR4.8, CI 95% 1.8-10.4) was found.

Maturation delay of germ cells in fetuses with trisomy 21 results in increased risk for the development of testicular germ cell tumors

Trisomy 21 is associated with an increased risk for the occurrence of germ cell tumors in males. The development of these tumors is thought to be related to events in fetal life. A delay in the maturation of germ cells is one of the mechanisms that have been proposed for the development of these tumors in high-risk groups such as intersex patients. To investigate whether a delay in germ cell development also occurs in trisomy 21, we examined the gonads of 30 fetuses, neonates, and infants with trisomy 21 (19 males and 11 females) for the expression of several immunohistochemical germ cell markers throughout pregnancy and compared them with a series of 46 age-matched controls. The results of our study reveal a significant delay in germ cell development in fetuses with trisomy 21, especially in males. Prolonged expression of octamer binding transcription factor 3/4, in combination with an increased expression of testis-specific protein, Y-encoded, might have pathogenetic relevance for the development of testicular germ cell tumors in this population.

Testicular microlithiasis: an unreported feature of McCune-Albright syndrome in males

OBJECTIVE

To ascertain the incidence of testicular microlithiasis (TM) in boys with McCune-Albright syndrome (MAS).

STUDY DESIGN

Study population consisted of 8 boys with MAS whose medical records were reviewed with emphasis on their past genitourinary histories. All of the boys underwent a clinical and ultrasonographic (US) scanning of the scrotal and inguinal regions. US results in boys with MAS were compared with those obtained in two control populations consisting of 20 healthy subjects and 12 boys with idiopathic and untreated central precocious puberty (CPP).

RESULTS

Clinical examination revealed urological abnormalities in no patients, whereas US showed a typical picture of TM in 5 of 8 boys. TM was observed in none of the subjects belonging to control populations (v=15.2 and 11.3, respectively; P <.001).

CONCLUSIONS

In a series of 8 boys with MAS we demonstrated a high prevalence (62%) of TM that was associated with neither malignant nor nonmalignant conditions. This finding is unlikely to be only occasional, considering the very low prevalence of TM reported until now in healthy children and young adults and in our results in control populations. TM may be another marker for MAS.

Incidence of cryptorchidism and ascending testes in trisomy 21: a 10 year retrospective review

Children with Down syndrome have an increased risk of cryptorchidism, but the reported incidence is unclear. In a proportion of these children, the testes are within the scrotum at birth but later appear to have ascended to an ectopic position. Records of patients diagnosed with trisomy 21 who had surgery for undescended testes in two tertiary paediatric centres over a 10-year period were examined. Information on liveborn males with Down syndrome was obtained from the Victorian Genetic Registry, and then the incidence of congenital and acquired undescended testes was determined. The incidence of undescended testes in Down syndrome was found to be 6.52% (24/368), with 4.35% (16/368) being acquired undescended or ascending testes. In conclusion, there is an increased incidence of cryptorchidism in Down syndrome; in particular, there is a significant proportion of acquired undescended testes.

Urological Manifestations of Down Syndrome

PURPOSE

We identified the urological anomalies seen in patients with Down syndrome.

MATERIALS AND METHODS

We reviewed the literature on Down syndrome and its associated genitourinary pathology.

RESULTS

Associated defects have been reported throughout the genitourinary tract. The most common renal anomalies seen are renal hypoplasia, obstructive uropathy and glomerular microcysts. Decreased creatinine clearance has also been noted. Developmental anomalies, such as megaureter and vesicoureteral reflux, have been reported. Dysfunctional voiding and urinary retention have been found in these patients. Posterior urethral valves and hypospadias have also been seen. The testicular abnormalities most frequently reported are cryptorchidism, testicular cancer and infertility.

CONCLUSIONS

Improved understanding and identification of the various urological anomalies associated with Down syndrome will aid in the care of these patients. In addition, an awareness of perioperative issues will further facilitate a smooth clinical course.

Three cases of advanced seminoma and Down's syndrome: a possible association

This is a report of three cases of classic seminoma in Down's syndrome patients treated at our institution. Review of literature shows an observation of increased occurrence of testicular cancer in patients with DS, however, with no definitive association documented. A brief discussion of the possible pathogenesis is presented.

Syndromic aspects of testicular carcinoma

BACKGROUND

In patients with hereditary or constitutional chromosomal anomalies, testicular carcinoma can develop sporadically or on the basis of an underlying hereditary genetic defect. Greater knowledge of these genetic defects would provide more insight into the molecular pathways that lead to testicular carcinoma. To the authors' knowledge, little attention has been paid to date to the comorbid occurrence of testicular carcinoma in patients with hereditary disorders or constitutional chromosomal anomalies.

METHODS

The authors performed a review of the literature.

RESULTS

Twenty-five different hereditary disorders or constitutional chromosomal anomalies have been reported in patients who developed seminomatous or nonseminomatous testicular carcinoma.

CONCLUSIONS

Although most of these malignancies were too rare to enable the detection of statistically significant correlations between the chromosomal/hereditary disorder and the testicular tumor, it was striking that many of the patients had also other urogenital abnormalities. Susceptibility to urogenital abnormalities seems to disrupt normal urogenital differentiation and suggests a correlation with testicular dysgenesis and, thus, also with testicular carcinoma. Other evidence of causal involvement has been found in the field of tumor cytogenetics. Some of the genes responsible for hereditary disorders have been mapped to regions that are of interest in the development of sporadic testicular carcinoma. Molecular studies on candidate genes will be required to provide definite answers. Completion of the human gene map and the availability of advanced gene arrays and bioinformatics are expected to greatly facilitate further exploration of the role of hereditary genetic defects in testicular carcinoma.

The palliative care needs of people with intellectual disabilities: a literature review

People with intellectual disabilities are among the most disadvantaged groups in society. A literature review was conducted aiming to answer the following question: What are the palliative care needs of people with intellectual disabilities? The literature review covers case histories, morbidity and mortality patterns for people with intellectual disabilities, their healthcare needs and primary care provision, the way they may present symptoms, their conceptualization of illness and death and issues around education and training. While the literature review reveals a lack of empirical data around the palliative care needs of people with intellectual disabilities, a number of potential problem areas are highlighted. These include late presentation of illness, difficulties in assessing symptoms, difficulties in understanding the illness and its implications and ethical issues around decision making and consent to treatment. It is suggested that future studies will need to include the views and experiences of people with intellectual disabilities themselves. Areas for possible future development include symptom assessment, evaluation of current practice and access to services and the development of information and training materials.

Evaluation of constitutional chromosome aberrations in hematologic disorders

We have reviewed 4164 patients with various hematologic disorders cytogenetically studied in our laboratory during the last 25 years to analyze the frequency of constitutional chromosome aberrations (CCA) and to evaluate their association with hematologic malignancies. Our population of patients included 1133 pediatric patients and 3031 adults. Twenty-four (0.58%) cases showed CCA. They included four patients with Robertsonian translocations, one patient with a balanced translocation, two patients with sex chromosome abnormalities, and 17 cases with Down syndrome (DS). Nonsignificant differences among the frequency of patients with CCA from our hematologic series and those observed in the two largest combined surveys of livebirth published (0.65-0.84%) were found. The incidence of DS patients in our population (0.41%) was approximately three times higher than of that observed at birth (0.12-0.17%; P<0.001). The total incidence of constitutional chromosome abnormalities in the non-DS hematologic patients was 0.168% (7 of 4164) lower than of that observed in the newborn population (0.51-0.67%; P<0.001). Nonsignificant differences were found when the incidences of structural aberrations and sex chromosome anomalies were individually compared with the data of the overall population. Our results suggest that the presence of a CCA, other than DS, would not predispose patients to hematologic malignancies.

Cancer incidence among people with intellectual disability

The aim of the present study was to address the unresolved question of the risk of neoplasms among people with intellectual disability (ID). A total of 2173 individuals with ID from a large, representative, nation-wide population study conducted in Finland in 1962 were followed-up for cancer incidence between 1967 and 1997. Standardized incidence ratios (SIRs) were defined as ratios of observed to expected numbers of cancer cases. Expected rates were based on national incidence rates. The observed number of cancers in the cohort (173) was close to what was expected [SIR = 0.9, 95% confidence interval (95% CI) = 0.8-1.0]. There was a significantly reduced risk of cancers of the prostate (SIR = 0.2, 95% CI = 0.0-0.5), urinary tract (SIR = 0.3, 95% CI = 0.1-0.7) and lung (SIR = 0.6, 95% CI = 0.4-1.0). The risk was increased in cancers of the gallbladder (SIR = 2.8, 95% CI = 1.1-5.8) and thyroid gland (SIR = 2.1, 95% CI = 1.0-4.8). The risks of lung and gallbladder cancer were lowest and highest, respectively, in those subjects with profound and severe ID, a group who also had significantly elevated SIRs for brain cancer (SIR = 3.46, 95% CI = 1.5-14.4) and testicular cancer (SIR = 9.9, 95% CI = 1.2-35.6). The incidence of cancer among people with ID was comparable with the general population, despite their low prevalence of smoking and apparently decreased diagnostic screening activity. Nevertheless, a few types of cancer carry a higher risk in the population with ID, possibly because of conditions typical among this group, such as gallstones or oesophageal reflux.

Trisomy 21 associated with ovarian dysgerminoma

A 13-year-old G(0)P(0) white female with trisomy 21 presented with a complex pelvic mass. She underwent resection of the mass and complete staging for what was found to be a stage IIIC completely resected dysgerminoma. She was treated with three cycles of bleomycin, etoposide, and cisplatin chemotherapy and remains free of disease 1 year later. This association is presented as a rare case that may illustrate the relative increase in germ cell neoplasms in female patients with Down's syndrome. While the association of seminoma with Down's syndrome has been documented in a number of cases in males, the female counterpart of this tumor, dysgerminoma, in trisomy 21 has been reported quite infrequently. The potential for germ cell tumors in both male and female trisomy 21 is therefore illustrated.

Seminoma associated with bilateral cryptorchidism in Down's syndrome: a case report

BACKGROUND

A case of testicular typical seminoma associated with bilateral undescended testes in Down's syndrome is reported. A 42-year-old institutionalized male patient developed left testicular seminoma with retroperitoneal metastasis.

METHODS/RESULTS

Neither adjuvant chemotherapy nor radiotherapy were performed due to his severe mental retardation. He died as a result of the cancer 2 years after a left radical orchiectomy and an autopsy was carried out.

DISCUSSION

Recently an increase in the incidence of the association of testicular tumors and Down's syndrome has been repeatedly documented. Thirty-six cases of testicular tumors associated with Down's syndrome have been reported and of these 17.1% had cryptorchidism. This is a much lower percentage considering the high risk of cryptorchidism in males with Down's syndrome. The relationship between testicular germ cell tumors associated with cryptorchidism and Down's syndrome is discussed.

Mechanisms of neuronal death in Down's syndrome

There is growing evidence that neuronal death in Down's syndrome is due to apoptotic mechanisms. The phenomena, however, that trigger and regulate programmed cell death in the Down's syndrome-related neurodegeneration are still much debated. In vitro evidence has suggested that the main factor responsible for neuronal death in this condition is the accumulation of beta-amyloid, due to the overexpression of its precursor protein. Another hypothesis argues for the importance of reactive oxygen species in neuronal death. However, the in vivo findings do not entirely support either theories. We propose that neuronal apoptosis, as well as the formation of Alzheimer-type pathology, in Down's syndrome is due to an aberrant re-entry of neurones into the cell division cycle. Due to the simultaneous overexpression of conflicting cell cycle regulatory signals the mitogenic amyloid precursor and the differentiation factor S100, the cell cycle is abandoned. Subsequently the cell cycle arrest may lead to either the formation of Alzheimer-related pathology or to apoptotic cell death.