Prepubertal yolk sac testicular tumors--report of the testicular tumor registry

Rare pediatric synchronous bilateral testicular germ cell tumors of different pathological types: a case report

The occurrence of synchronous bilateral testicular germ cell tumors (BTGCTs) of different pathologic histologic types in pediatric patients is rare. We reported a case of a left testicular yolk sac tumor (YST) combined with a right testicular mature teratoma. Left orchiectomy and right testis-sparing surgery were performed. Retroperitoneal recurrence was noted 6 months after surgery. The patient underwent reoperation for the resection of a retroperitoneal mass, which was pathologically diagnosed as a recurrent YST. A full cycle of chemotherapy was then administered. No tumor metastasis or recurrence has yet been detected. We present this new case, and we review the previous literature on synchronous BTGCTs to explore the clinicopathologic features and summarize the diagnostic and therapeutic experience. Radical orchiectomy, as the standard treatment for YSTs, should be considered with caution in patients with bilateral testicular tumors. Rapid intraoperative frozen pathology provides support for timely surgical planning. In patients with intraoperative frozen pathologic specimens suggestive of benign lesions, testis-sparing surgery is the preferred treatment option.

Trends of testis-sparing surgery for pediatric testicular tumors in South China

BACKGROUND

Testis-sparing surgery is not popular in South China. This study aimed to investigate this procedure for pediatric testicular tumors.

METHODS

Children with testicular benign tumors were retrospectively analyzed from January 2001 to June 2015 in the Sun Yat-sen University Cancer Center (SYSUCC) and the First Affiliated Hospital (SYSU-1st). Follow-up was performed until June 2016, and the proportions of TSS in the two hospitals during the different periods were compared.

RESULTS

Forty-seven children with testicular benign tumors were enrolled, and 16 cases underwent testis-sparing surgery. All patients were cured and discharged, which included mature teratoma (n = 37), testicular adrenal rest tumors (n = 4), epidermal cysts (n = 3), granulomatous inflammation (n = 2) and adenomatoid tumors (n = 1). Inguinal testis-sparing surgery was performed in 16 children, and no recurrence was detected during follow-up. It was performed more frequently in SYSUCC than in SYSU-1st (P = 0.031), and the tumor size of these patients was smaller than those of patients who underwent radical orchiectomy (P = 0.044). Moreover, testis-sparing surgery has become more common in the past 5 years, although differences over time have not reached significance (P = 0.051).

CONCLUSIONS

Testis-sparing surgery is reliable, and tumor size and special hospitals affect its success. Additionally, its use has become more popular in recent years. However, advocacy is still needed for the use of this technique in pediatric testicular benign tumors that are small sized.

Surveillance after initial surgery for Stage I pediatric and adolescent boys with malignant testicular germ cell tumors: Report from the Children's Oncology Group

PURPOSE

The purpose of this study was to determine prognostic factors correlating with outcome in boys with Stage I malignant testicular germ cell tumors (MTGCT) initially managed with surveillance after surgical resection.

METHODS

Between November 2003 and July 2011, 80 boys 0-15 years with Stage I MTGCT were enrolled in Children's Oncology Group Study AGCT0132. Those with residual or recurrent disease were treated with chemotherapy.

RESULTS

Characteristics include: age (65, 0-5 years and 15, 11+years), pure YST (93.9%, 0-5 years and 0%, 11+years); and lymphovascular invasion (LVI) (50.6% present vs. 49.4% absent). At median follow-up of 4.94 years, 19 had persistent or recurrent disease, all detected by elevated AFP at a median of 87 days after study enrollment. The outcome from enrollment was 4-year EFS 74% (95% CI: 63%-83%) and 4-year OS 100%. 4-year EFS was improved with younger age (<11 years, 80% vs. 11+years, 48%, p<0.01); pure YST vs. mixed histology (81% vs. 45%, p<0.01), and lack of LVI (84% vs. 62%, p=0.03).

CONCLUSIONS

Boys with Stage I MTGCT have excellent overall survival when treated with surgery alone. Age greater than 10 years, mixed histology and presence of LVI are each associated with relapse and may allow identification of high risk boys at time of enrollment.

Overview of pediatric testicular tumors in Korea

Prepubertal testicular tumors are rare compared with postpubertal testicular tumors. The incidence of prepubertal testicular tumors peaks at 2 years of age, tapers off after 4 years of age, and then begins to rise again at puberty. Prepubertal and postpubertal testicular tumors show many differences, including the typical tumor histology, molecular biological differences, and the malignant potential of tumors at different ages. Pediatric testicular tumors are classified as benign or malignant on the basis of their clinical behavior and histologically are divided into germ cell and gonadal stromal (nongerm cell) tumors. Many histological and biological studies have further confirmed the distinct nature of prepubertal and postpubertal testicular tumors. These differences have led to various management strategies for prepubertal and postpubertal tumors. Because overall about 75% of prepubertal testicular tumors are benign, a testis-sparing approach is becoming more common in children. Orchiectomy and observation with very selective use of chemotherapy has become the standard approach when a malignant tumor is identified. Retroperitoneal lymph node dissection and radiation therapy play very limited roles.

Yolk sac tumour of the cryptorchid testis, with an unusual presentation - diagnosed by fine needle aspiration cytology

Yolk sac tumour is the most common germ cell tumour in infants and children, with a majority of them arising in the gonads. Rare cases of extra - gonadal germ cell tumours have been described in the literature. We are presenting here, a case of a yolk sac tumour of the cryptorchid testis in a 2 year old child, who initially presented with a mass in the left lobe of the liver, with huge ascites and which posed diagnostic difficulties. The mass was diagnosed as hepatoblastoma on Computed Tomography (CT). Subsequently, CT guided Fine Needle Aspiration Cytology (FNAC) of the liver mass showed the features of a yolk sac tumour. The raised serum Alfa Foetoprotein (AFP) levels corroborated with the cytological diagnosis.

Pediatric germ cell tumors

Pediatric germ cell tumors represent a diverse group of tumors that present from in utero through adolescence at many nongonadal locations, from the neck to the sacrococcygeal region. Surgical resection remains the central element of management, and accurate surgical staging is essential to properly ascertain the correct risk-based treatment. The management for all benign tumors (mature and immature teratomas) and select completely resectable malignant tumors is surgery alone. Modern-day chemotherapy is extremely effective in infants and children with unresectable and metastatic disease and these children have a very high survival rate. The use of neoadjuvant chemotherapy allows vital organ preservation and there is no role for resection of vital structures at the time of initial presentation.

Metastasis of testicular yolk sac tumor to cauda equina

Primary germ cell tumors may spread to the lung, liver, brain, and bone hematogenously. However, spinal metastasis is extremely rare. A case with yolk sac tumor (YST) and cauda equina metastasis was presented in a 2-year-old boy. Two months prior to admisssion, he underwent left radical orchiectomy for testicular YST. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed spinal and cauda equina involvement. This is the first report of metastasis of testicular YST to cauda equina in a child.

Prepubertal testicular germ cell tumors: 25-year experience in Taipei Veterans General Hospital

BACKGROUND

Due to the rarity of testicular tumors in the prepubertal population, adequate information about their biological course is difficult to document well in a single institution. The purpose of this study was to focus on prepubertal males in an attempt to evaluate clinical features and optimal management among various testicular germ cell tumors with long-term follow-up.

METHODS

We retrospectively reviewed the records of children younger than 12 years of age with primary testicular germ cell tumors between February 1981 and December 2005 at Taipei Veterans General Hospital. Thirty-four children were diagnosed with adequate clinical and pathologic data. The stage of the disease was determined according to the staging system used by the Children's Oncology Group. Mean follow-up time was 139 months (range, 2-283 months).

RESULTS

All of the 34 prepubertal patients were diagnosed initially with a painless scrotal mass. The mean age of the patients at diagnosis ranged from 6 months to 84 months (mean, 20.5 months). All patients underwent radical orchiectomy as an initial treatment. Twenty-nine (85.3%) patients had yolk sac tumors, and 5 (14.7%) had mature teratomas. Of the 29 patients with yolk sac tumor, 26 (89.7%) were diagnosed as stage I, 1 (3.4%) as stage III, and 2 (7.0%) as stage IV. Five (19.2%) of the 26 stage I yolk sac tumors progressed to metastasis after radical orchiectomy, and all of these 5 patients later received chemotherapy. One patient initially with stage III yolk sac tumor and 2 patients with stage IV yolk sac tumor were also treated with chemotherapy. Eventually, 1 patient with stage IV yolk sac tumor died due to tumor progression; the remaining 28 patients with yolk sac tumor all survived without tumor relapse after appropriate treatment. In the 5 patients with teratomas, there was no tumor relapse after radical orchiectomy with a mean follow-up time of 139.1 months. The 5-year survival rates for yolk sac tumor and teratomas were 96.5% and 100%, respectively.

CONCLUSION

The most common prepubertal malignant testicular tumor is yolk sac tumor, and the most common benign testicular tumor is teratoma. Children with testicular germ cell tumors have excellent long-term survival rates after appropriate treatment.

Pathology of germ cell tumors of the testis

BACKGROUND

An increasing incidence of testis tumors has been noted over the second half of the 20th century. Congenital malformation of the male genitalia, prenatal risk factors, nonspecific and specific exposures in adulthood, and male infertility have all been associated with the etiology of germ cell tumors.

METHODS

The histologic classification, pathology, and current concepts of testicular germ cell tumors are reviewed.

RESULTS

Germ cell tumors occur at all ages. The tumors are identified as pure form (those of one histologic type) and mixed form (more than one histologic type). Over half of germ cell tumors consist of more than one cell type, requiring appropriate sampling for the correct diagnosis and correlation with the serum tumor markers. Burned-out germ cell tumors may occur in patients with metastatic disease with no gross evidence of a testicular tumor.

CONCLUSIONS

Appropriate management of testis tumors relies on accurate pathology and classification of these tumors.

An overview of testicular germ cell tumors

CONTEXT

More than 90% of testicular neoplasms originate from germ cells. Testicular germ cell tumors (GCTs) are a heterogeneous group of neoplasms with diverse histopathology and clinical behavior.

OBJECTIVE

To help the readers distinguish various subtypes of GCTs, to highlight the clinical manifestations and pathologic features of these tumors, and to review several newly developed immunohistochemical markers for GCTs.

DATA SOURCES

Review of the pertinent literature and our experience.

CONCLUSIONS

The etiology of GCTs is largely unknown. Cytogenetic studies suggest a different pathogenesis for each group of infantile/prepubertal GCTs, postpubertal GCTs, and spermatocytic seminoma. Unclassified intratubular germ cell neoplasia is the precursor of all GCTs, excluding spermatocytic seminoma and infantile/prepubertal GCTs. Seminoma, the most common GCT in adults, does not occur before 5 years of age. Spermatocytic seminoma, a tumor of elderly men, typically has an indolent clinical behavior, but rarely it undergoes sarcomatous transformation associated with an aggressive behavior. Embryonal carcinoma is the most common component in mixed GCTs. Eighty percent or more of embryonal carcinoma component and vascular invasion are recognized predictors of occult metastasis for clinical stage I mixed GCTs. Most patients with prepubertal yolk sac tumor, the most common pediatric GCT, have stage I disease at presentation. Most choriocarcinomas present with metastatic symptoms because of the propensity for rapid hematogenous dissemination. Teratomas in children regardless of maturity and dermoid cysts in adults are benign; in contrast, teratomas in adults have a malignant behavior. With appropriate therapy, the majority of testicular GCTs are curable.

Sonographic appearance of a testicular yolk sac tumor in a 2-year-old boy

Yolk sac tumor (YST) of testis is the most common of all childhood testicular malignancies. We report a case of testicular YST in a 2-year-old boy. The tumor appeared sonographically as an ovoid, homogeneous, well-circumscribed, isoechoic, solid testicular mass with good sound-through transmission and increased internal vascularity on color Doppler imaging. The serum alpha-fetoprotein level was 4,396 ng/ml. Pathological examination confirmed YST at at stage I. Although the sonographic appearance of YST of the testis is nonspecific, the diagnosis is achievable in clinical practice on the combination of elevated serum alpha-fetoprotein level and sonograms depicting a solid testicular hypervascular mass.

PREPUBERTAL TESTIS TUMORS: ACTUAL PREVALENCE RATE OF HISTOLOGICAL TYPES

PURPOSE

Tumor registries, urological textbooks and literature surveys all assert that yolk sac tumors are the most common primary testicular tumors in boys 12 years and younger. In contrast, several individual institutions have reported that benign tumors are more common than malignant tumors. To clarify these discordant findings, we surveyed the primary pathology records from 4 major pediatric centers.

MATERIALS AND METHODS

The pathology records of the contributing centers were culled for primary testicular masses in boys 12 years and younger. Older boys and those with either paratesticular tumors or leukemia were excluded. The prevalence of each histological subtype was calculated from the pooled cases.

RESULTS

A total of 98 patients met our criteria. Only 15% had yolk sac tumors. Teratomas comprised 48% of the tumors (mature 44%, immature 4%). Epidermoid cysts were found in another 14% of patients. Gonadal stromal cell tumors represented 13% of the total, divided among granulosa cell (5%), Leydig cell (4%), Sertoli cell (3%) and mixed gonadal stromal cell (1%). Other pathology, including cystic dysplasia (2), lymphoma (4), inflammatory pseudotumor (1) and gonadoblastoma (2), made up 9% of the total number of cases.

CONCLUSIONS

We found that benign lesions represent the majority of primary testis tumors (74%), with the most common histological type being teratoma (48%). The reported high prevalence rates of prepubertal yolk sac tumors probably results from a reporting bias, since benign tumors are less likely to be submitted to tumor registries. Therefore, the primary operative approach to the majority of testis tumors in boys 12 years and younger should entail testis sparing surgery. Orchiectomy should be reserved for histologically confirmed malignancy based on increased preoperative alpha-fetoprotein and/or frozen section analysis of the tumor.

EPIDEMIOLOGICAL AND CLINICAL BEHAVIOR OF PREPUBERTAL TESTICULAR TUMORS IN KOREA

PURPOSE

To our knowledge there is no multi-institutional report on prepubertal testicular tumors in Korea to date. We obtained demographic data for a better understanding of the biological behavior and optimal management of these tumors.

MATERIALS AND METHODS

The prepubertal testicular tumor registry form was mailed to all 87 hospitals registered in the Korean Urology Association. We retrospectively reviewed recent 5-year medical records.

RESULTS

A total of 209 patients were enrolled in this registry. The incidence was 0.98/100,000 children. Age was 1 to 142 months (median 18). Most patients were diagnosed with a scrotal mass before age 4 years. Serum alpha-fetoprotein and beta-human chorionic gonadotropin increased in as many as 62.9% and 2.7% of patients, including 94.7% and 2.2% in those with yolk sac tumor and 30.4% and 2.7% in those with teratoma, respectively. While potentially malignant tumors accounted for 52.5% of patients, the remainder were benign. Germ cell tumors were the most common (89.4% of cases), mainly with yolk sac tumor (47.8%) or teratoma (39.7%). Management after surgery included surveillance in 71.8% of cases, chemotherapy in 9.1%, combination therapy in 1.4% and other in 17.7%. Of the total patients 10.5% (5.9% of stage I yolk sac tumors) had progression to metastasis. The final results of treatment were complete remission (64.6% of cases), incomplete remission (2.9%), no response or disease progression (1.4%) and unknown (31.1%). Outcomes at the last followup (average 23.5 months) were 76.1% of patients alive, 0.9% dead and 23.0% of unknown status.

CONCLUSIONS

Demographic data on pediatric testicular tumors in Korea will lead to a better understanding of these rare tumors and to optimal therapy in these children.

HISTOLOGY IN MIXED GERM CELL TUMORS. IS THERE A FAVORITE PAIRING?

PURPOSE

Mixed germ cell tumors account for approximately 30% to 50% of testicular tumors. To our knowledge a systematic review with statistical analysis of the associations of histological subtypes in mixed germ cell tumors has not been done previously. It was our impression that such associations exist. Delineating concordant histological types may provide insight into the ontogeny of testicular tumors and also have important clinical implications.

MATERIALS AND METHODS

We retrospectively reviewed the testis cancer data base at our institution. The primary tumor of orchiectomy specimens was examined in 2589 patients. Of these patients mixed histology was noted in 1765 (68.2%). ORs were calculated for all possible combinations of teratoma, embryonal carcinoma, yolk sac tumor, choriocarcinoma and seminoma. In addition, we evaluated the association of various histological types with teratoma at post-chemotherapy retroperitoneal lymph node dissection.

RESULTS

Of 10 possible combinations of histological types in the primary tumor, positive correlations were noted in 4. The strongest correlation was found between teratoma and yolk sac tumor (OR 2.58, p <0.001). Teratoma or yolk sac tumor in the testis was associated with teratoma in the pathology specimen at post-chemotherapy retroperitoneal lymph node dissection.

CONCLUSIONS

The strongest associations of histological subtypes in mixed germ cell tumors were seen between yolk sac tumor and teratoma. Similar associations are seen in late relapse and in some cases of prepubertal tumors. Further study of these associations may prove valuable in understanding the biology and clinical behavior of germ cell tumors.

Testicular tumors in children

PURPOSE

The aim of this study was to present an updated picture of surgical management of pediatric testicular tumors based on our 30 years' experience, which consisted of one of the largest noncollected series treated in a single medical center.

METHODS

Records of children who were treated for testicular tumor in our unit from 1970 to 1999, inclusive, were reviewed retrospectively. Information recorded for each patient included age, sex, past medical history, clinical characteristics, diagnostic procedures, treatment methods, histopathologic findings, and outcome.

RESULTS

Fifty-one patients with a mean age of 3.8 +/- 0.5 years were treated for testicular tumors. Of these, 35 (69%) had germ cell testis tumor (GCT) and 16 (31%) had non-germ cell testis tumor (NGCT). Endodermal sinus tumor and paratesticular rhabdomyosarcoma were the dominant histologic subtypes in each group, respectively. The most common mode of presentation was painless scrotal mass. At initial presentation, retroperitoneal (n = 5), both retroperitoneal and lung (n = 2), and retroperitoneal and liver (n = 3) metastases were recorded in 10 (19%) patients. Initial operative procedures were radical inguinal orchiectomy (RIO) (n = 29), scrotal orchiectomy (SO; n = 9), bilateral RIO (n = 2), both RIO and unilateral retroperitoneal lymph node (RPLN) excision (n = 6), testis-sparing enucleation of the tumor (n = 5). SOs were performed elsewhere, and these patients underwent high ligation (n = 4) and both high ligation plus RPLN excision (n = 5) in our unit. Histopathologically, spermatic cord invasion and RPLN involvement were present in 10 patients. Scrotal recurrences were encountered in 2 patients who had scrotal orchiectomy initially. Retroperitoneal recurrences were noted in a patient presenting with stage I embryonal carcinoma and in 2 patients presenting with group IV paratesticular rhabdomyosarcoma. The mean follow-up period was 89 +/- 10 months. Four patients with stage IV embryonal carcinoma (n = 2) and group IV paratesticular rhabdomyosarcoma (n = 2) died of progression of the disease. All remaining patients were alive and disease free at their last outpatient appointment. No significant difference was noted with regard to 5-year survival rates between (1) malignant GCT and paratesticular rhabdomyosarcoma patients (91% v 80%) and (2) patients treated by RIO (88%), SO plus high ligation (87%), and RIO plus RPLN excision (80%). Five-year survival rates were 100% for stage I, II, III patients and 33.3% for stage IV and group IV patients presenting with malignant testicular tumors (P <.05).

CONCLUSIONS

Childhood testicular tumors deserve special attention from the therapeutic point of the view. A solid scrotal mass should be considered malignant until proved otherwise. Any suspicion of the testicular tumor warrants an inguinal approach to prevent scrotal violation by the tumor. Current trends emphasize that testis-sparing surgery should be performed for benign lesions such as teratoma, leydig cell tumor, and epidermoid cyst based on frozen biopsy findings. Literature findings and our experience suggest that RIO is the accurate treatment for stage I malignant GCT and group I and IIa paratesticular rhabdomyosarcoma. RPLN excision is not of benefit either as a staging or therapeutic procedure in stage I and group I and IIa diseases of these tumors. RPLN excision should be reserved for (1) malignant GCT patients who have persistent elevation of alpha-fetoprotein after orchiectomy in the presence of normal total body CT scan, and for patients presenting with stage II and III disease with definitive abnormality on CT scans, and (2) group IIb, IIc, and III paratesticular rhabdomyosarcoma patients with radiologic evidence of retroperitoneal involvement on CT scans. High ligation should be done as a complementary procedure after SO to increase the survival rates. J Pediatr Surg 36:1796-1801.

Diagnosis and management of teratomas and epidermoid cysts

One can strongly suspect a benign lesion in a prepubertal child on the basis of preoperative sonographic, biochemical, and clinical evaluation; however, when considering a testis-sparing enucleation, the definitive diagnosis must be established by pathologic frozen section of the tumor. The high incidence of benign testicular lesions in the prepubertal patient, the absence of associated carcinoma in situ in prepubertal germ cell tumors, and the universally benign behavior of the specific tumors described in this article are supportive evidence for testis-sparing surgery versus orchiectomy, for these benign lesions.

Paratesticular rhabdomyosarcoma in a neonate

A 13-day-old boy presented with left scrotal tumor and coronary hypospadias. Left radical orchiectomy was performed. Histological diagnosis was embryonal-type paratesticular rhabdomyosarcoma. To the authors' knowledge, this is the first reported case of paratesticular rhabdomyosarcoma in a neonate in English-language literature. Also, the association of a testicular tumor with hypospadias has not been noted.

Pediatric germ cell tumors

Malignant germ cell tumors are relatively uncommon, accounting for approximately 3% of all childhood malignancies. Occurring with an incidence of approximately 4 per million among children less than 15 years of age, they account for approximately 225 new cases per year in the United States. Germ cell tumors occur in both gonadal and extragonadal sites, with extragonadal and testicular tumors predominating in children less than 3 years of age and with the gonads being the main location of tumors during and after puberty. They occur more frequently in girls than boys. Germ cell tumors are interesting for several reasons: (1) abnormal migration of primordial germ cells account for many of the childhood germ cell tumors; (2) markers exist to allow evaluation of the extent of resection and the development of recurrence for many of the tumors; and (3) the introduction of platinum-based chemotherapy has markedly improved the survival rate for germ cell tumors, as well as the salvage rate for recurrent or metastatic disease.

Testicular simple cyst and teratoma: asynchronous bilateral occurrence within the first year of life

Benign and malignant testicular tumors are rare in infancy. Moreover, only a few cases of bilateral testicular tumors in children have been reported to date. To our knowledge, we report the first case of an asynchronous bilateral simple testicular cyst and testicular teratoma in an infant. This case demonstrates that although both lesions are benign in the prepubertal child, treatment decisions should be made carefully.

Classification and pathology of testicular germ cell and sex cord-stromal tumors

Germ cell tumors of the testis are the most frequent testicular neoplasms, with seminoma predominating. The pathologist must be able to discriminate between seminoma and nonseminomatous germ cell tumors as well as sex cord-stromal tumors and metastatic lesions. Appropriate therapy and accurate prognostic information are dependent on the proper classification of testicular neoplasia. Characteristic histologic features, serum markers, and immunohistochemistry are helpful in this regard. Sex cord-stromal tumors comprise a small minority of testicular neoplasms. It remains critically important not to confuse these neoplasms with testicular germ cell or metastatic tumors, and, again, recognition of the characteristic histologic features, immunohistochemical findings, and clinical information is diagnostic. The urologist can provide the pathologist with key clinical information in the attempt to make a correct diagnosis.

Pediatric germ cell tumors: protocol update for pathologists

The therapy for pediatric germ cell tumors has historically been widely variable and institution dependent. The efforts to provide consistent, biology-driven therapy through Intergroup protocols has been a relatively recent phenomenon that has provided the framework for future protocol designs. The first Intergroup protocols confirmed that stage I malignant testicular germ cell tumors and immature teratomas at all sites in children could be treated with surgery alone followed by close observation. Future protocols currently in the planning stages may extend this low-risk category to stage I ovarian germ cell tumors of all histologic types. Low-stage extragonadal germ cell tumors may be placed in a new intermediate risk category. Particular pathologic issues that were raised and reported during the first protocols and that may impact on future protocol design include the presence and size of foci of endodermal sinus tumors within low-stage immature teratomas at all sites. Accurate staging will grow more critical in future protocols. The ability to recruit international cooperative groups will determine the success of chemotherapy tailored to specific subgroups that now must be lumped for statistical purposes. Lastly, companion biologic studies will be critical to defining the different subtypes of germ cell tumors and to determining predictors of biologic behavior.

Testis sparing surgery for epidermoid cyst of the testis: a case report

A rare tumour of a prepubertal child, an epidermoid cyst, was excised with testicular preservation. Childhood testicular tumours are usually benign. Although epidermoid cysts of the testis may have teratomatous component, testicular teratomas are generally benign in the prepubertal child. For these reasons testis sparing surgery seems applicable in childhood epidermoid cysts.

Benign and malignant pediatric scrotal masses

Pediatric patients presenting with painless scrotal masses can be perplexing because of the long differential diagnosis. A careful plan based on the physical examination and sonogram findings localizes the mass to the testis or an extratesticular location. Sonography distinguishes solid from cystic lesions. Subsequent management is based on the location and nature of the mass. Intratesticular masses are assumed to be malignant, but testis-sparing surgery is possible in pediatric patients. Extratesticular cystic lesions are likely benign and are managed according to the specific diagnosis. Solid extratesticular lesions require exploration to establish the correct diagnosis.

Testis sparing surgery for epidermoid cyst of the testis: a case report

A rare tumour of the prepubertal child, an epidermoid cyst was excised with testicular preservation. Childhood testis tumours are usually benign. Although epidermoid cysts of the testis may have teratomatous component, testicular teratomas are generally benign in the prepubertal child. For these reasons testis sparing surgery seems applicable in childhood epidermoid cysts.

Indications for hemiscrotectomy in the management of genitourinary tumors in children

In the last 30 years at St Jude Children's Research Hospital, 10 boys have undergone hemiscrotectomy for primary testicular tumors or paratesticular rhabdomyosarcoma. Indications for this procedure were scrotal contamination and positive or uncertain surgical margins. Residual tumor was found in only one specimen. There were four complications in the study group. Two patients had complications directly attributable to the hemiscrotectomy, and in one patient this caused a delay in treatment. Preoperative imaging was performed in three patients. This has not been helpful in evaluating residual masses and is not indicated. Based on the authors' experience and a review of the literature, there are a number of indications for hemiscrotectomy in the management of genitourinary tumors in children. Controversies regarding some of these indications should be discussed with the families of these patients during preoperative counseling.

Treatment of a stage I testicular yolk sac tumor with vascular invasion

There is controversy concerning the treatment of stage I yolk sac tumor of the testis, particularly of those with histological factors that indicate a high risk of relapse. Usually orchiectomy alone is sufficient and adjuvant chemotherapy is unnecessary. Retroperitoneal lymphadenectomy is indicated for patients with persistently high alpha-fetoprotein. Once recurred, treatment at that time is thought to be curative. However, postoperative chemotherapy may be necessary for patients with a tumor expressing histological factors that predict possible relapse. In this paper we report on a case of a 2 year old boy whose tumor invaded the testicular veins. The patient suffered from recurrent disease but was successfully treated by chemotherapeutic regimens including cisplatin and retroperitoneal lymphadenectomy. The importance of the histological factors in making a decision on the treatment strategy for stage I testicular yolk sac tumor is discussed.

A case of metastatic yolk sac tumor of testis in a child

We report a case of testicular yolk sac tumor in a child aged 3 years and 6 months with multiple bulky metastases to lung and retroperitoneum (stage IIIB2). After three courses of chemotherapy with a PVB regimen (cisplatin, vinblastine and bleomycin), complete and partial responses were obtained for lung and retroperitoneal lymph node metastases, respectively. The patient was followed-up closely. However, on the basis of a re-elevated alpha-fetoprotein (AFP) after 4 months' follow-up, he was treated with three courses of salvage chemotherapy with a modified VAB-6 regimen (cyclophosphamide, etoposide, actinomycin D, bleomycin and cisplatin), followed by retroperitoneal lymph node dissection. Histologically, only necrotic tissue was found. There is no evidence of recurrence 24 months after lymphadenectomy. There is very little information in the literature on the appropriate management of postchemotherapy residual mass in pediatric testicular tumors.

Testicular germ cell tumours of childhood in Denmark, 1943-1989: incidence and evaluation of histology using immunohistochemical techniques

In the Danish Cancer Registry, 72 testicular tumours in boys younger than 15 years of age were recorded during the period 1943-1989 and material from 34 of these was retrieved from Danish departments of pathology. The histological types were evaluated and the role of immunohistochemical staining was analysed. The survival of the patients was correlated with the histological diagnoses, and changes in the incidence of testicular cancers in childhood were analysed. Twenty-nine of the 34 patients had germ cell tumours, which fell into two groups (infantile and pubertal) with distinct differences. The tumours of infancy usually presented before the age of 3 years and were either pure yolk sac tumours or teratomas. The tumours of puberty showed no morphological or immunohistochemical differences from adult germ cell tumours. In the infantile group, immunohistochemical staining confirmed the morphological evaluation but was not necessary for diagnosis. Patients in the infantile group seemed to have a better prognosis than adult patients, only one patient dying from his disease, whereas the pubertal patients seemed to have a prognosis similar to that of adult patients. The incidence of infantile testicular cancer in Denmark appears to have increased at almost the same rate as that observed in adult men, but due to the small numbers in infancy, this cannot be statistically substantiated. We conclude that the testicular germ cell tumours of infancy and puberty may arise from different precursor cells, but both groups seem to arise prenatally.

Clinical experience with yolk sac tumors and teratoma in children

Between 1971 and 1993, 12 children with testicular germ cell tumors were treated at the Department of Urology, Faculty of Medicine, Kyoto University. Seven patients had yolk sac tumors and 5 had mature teratoma. Of the 7 patients with yolk sac tumors 6 had stage I and 1 had stage III tumors. Initial management of the stage I tumors consisted of high orchiectomy in 5 patients and high orchiectomy plus retroperitoneal lymph node dissection in 1 patient. Of these 6 patients, 4 were cured by surgery alone but lung metastases developed in the other 2 patients. One of them was salvaged with thoracotomy and chemotherapy but the other died of tumor. The patient with stage III tumor had bulky tumor spread to lung and retroperitoneum, but seems to have been cured by chemotherapy followed by resection of the residual mass although follow-up is still inadequate (14 months). Six of the 7 patients (85.7%) are alive 13 months to 21 years after diagnosis. Five patients with mature teratoma were treated by high orchiectomy or, more recently, enucleation and all are alive 4 months to 22 years after surgery.

Neonatal testis tumors: a review of the Prepubertal Testis Tumor Registry

Since 1980, 338 testis tumors have been registered in the Prepubertal Testis Tumor Registry of the American Academy of Pediatrics, Section on Urology. Of these tumors 22 occurred in neonates less than 1 month old, of which 7 (31%) were diagnosed at birth. The distribution of lesions in this group revealed 6 yolk sac tumors, 6 gonadal stromal tumors, 6 juvenile granulosa cell tumors, 2 gonadoblastomas, 1 teratoma and 1 hamartoma. Preoperative serum alpha-fetoprotein levels were available for 10 patients and ranged from 23 to 61,700 ng/ml., which is within normal limits. No patient had evidence of metastatic disease at presentation. Of the 18 children in whom follow up is available 17 have no evidence of disease and 1, who was diagnosed with a yolk sac tumor before the advent of chemotherapy, died of metastatic disease before reaching age 1 year. Although neonatal testis tumors are rare, they should be considered in the differential diagnosis and management of a newborn with a scrotal mass.

Prepubertal Testicular Tumor Registry

The Prepubertal Testicular Tumor Registry has been in existence for 12 years. Information on 327 patients was collected and registered in the database. Demographic data have been analyzed, leading to a better understanding of these rare tumors. Information regarding the natural history and behavior of the tumors has also evolved from a retrospective review of the tumors. The registry will continue in an effort to collect centrally information on these unusual tumors and to attempt to aid in developing a better understanding of the natural history and behavior of the tumors to provide early detection, consistent treatment and improved survival.

Yolk sac tumors and alpha-fetoprotein in first year of life

Serum alpha-fetoprotein (AFP) levels are normally elevated in the first eight months of life. This is important information when using AFP as a tumor marker for patients in this age group. We report a case of a one-month-old boy with a yolk sac tumor of the testis. After radical orchiectomy and a negative workup for metastatic disease, his AFP level dropped, but remained mildly elevated over the normal range for six months. Using a half-life of five days it was predicted that it would fall into this range in eighty days. Although the elevated levels suggested residual tumor, they did continue to decline each month which led us to pursue some other explanation for this pattern. A literature search revealed the AFP levels are normally elevated in this age group. In retrospect, our patient's AFP was within this range less than sixty days after surgery. Dissemination of knowledge that the normal AFP ranges in young infants are higher than those in older patients will improve the clinical usefulness of AFP as a tumor marker in this age group.

Long-term follow-up of children with testicular tumours: surgical issues

Testicular tumours are rare in childhood. The clinical, pathological and follow-up details of 48 children are presented. The combined approach of surgery, chemotherapy and radiotherapy is confirmed as being extremely effective. Transcrotal orchiectomy is not an appropriate surgical procedure. Testicular biopsy is detrimental to prognosis.

Testicular sparing surgery for prepubertal teratoma of the testis: a clinical and pathological study

We report on 5 patients 14 months to 6 1/2 years old with prepubertal teratoma of the testis treated by testicular sparing tumor enucleation. All 5 patients had no evidence of recurrence at a mean followup of 96 months. Recognizing that this is not accepted therapy for testis tumors, 17 orchiectomy specimens containing teratoma from children were histologically analyzed in cooperation with the Armed Forces Institute of Pathology Tumor Registry. All patients were prepubertal at orchiectomy (3 months to 8 years old) and all are well with a mean followup of 174 months. Histological examination revealed no foci of teratoma separate from the main tumor in any specimens. Immunohistochemical studies with placental alkaline phosphatase, a marker for malignant germ cells, were done to detect carcinoma in situ in the seminiferous tubules of these testes. This test did not reveal any intratubular malignant germ cells (carcinoma in situ). Based on our clinical experience with testicular sparing tumor enucleation, the histological findings on Armed Forces Institute of Pathology review demonstrating no associated carcinoma in situ and the universally benign behavior of prepubertal testicular teratomas, we recommend a testicular sparing operation rather than orchiectomy for testicular teratoma in prepubertal patients.

New concepts in the treatment of genitourinary cancer in childhood

The treatment of Wilms' tumor is based on initial surgical removal followed by clinical and histologic staging. Chemotherapy provides the major adjunctive therapy in virtually all Wilms' tumors, radiotherapy being used in some situations. Exceptions to this are the treatment of bilateral Wilms' tumors and large intracaval extension. Bilateral Wilms' tumor is treated with initial biopsy and staging, adjunctive chemotherapy, and/or radiation therapy and bilateral partial nephrectomy after there is maximum resolution of tumor. Similarly, extensive caval extension of tumor may be treated preoperatively with chemotherapy and radiotherapy followed by resection. Nephroblastomatosis, a precursor of Wilms' tumor, is a common associated finding at exploration. It requires alteration in management and may change the prognosis. Sarcomas of the kidney and congenital mesoblastic nephroma represent the spectrum of severity of solid renal masses in children. Neuroblastoma is the most common solid tumor in children, and its prognosis is largely dependent on the age of the patient and the stage of disease. Chemotherapy and radiotherapy is adjunctive treatments have been disappointing. Immunotherapy holds some promise for the future. Testicular tumors are unusual in children. Those that occur in infancy are most often benign teratomas that require orchiectomy alone. Malignant germ cell tumors in children are most often yolk sac tumors and respond to surgery and chemotherapy. Lymph node dissection is indicated only in paratesticular rhabdomyasarcoma. Other genitourinary rhabdomyasarcomas occur in the bladder, prostate, vagina, and uterus. After maximum decrease in tumor volume with chemotherapy and radiotherapy, surgical exploration and resection of remaining tumor probably represent the best form of treatment. Organ-sparing procedures should be carefully selected in that they may worsen the prognosis.