Testicular tumors in subfertile men: report of 4 cases with implications for management of patients presenting with infertility

Microinvasive germ cell tumor of the testis

Microinvasive germ cell tumor (MGCT) consists of a limited number of malignant germ cells in the intertubular tissue of the testis. The cells have large nuclei, prominent nucleoli, abundant clear cytoplasm, and distinct cellular borders in hematoxylin and eosin staining. MGCT can be the first stage of malignancy in the development of testicular germ cell tumor (TGCT). Biopsies from men with maldescended testes have been reported to contain intratubular germ cell neoplasia, unclassified (IGCN) and MGCT in 1.8% of the examined cases (95% CI 0.5-4.6%). MGCT has also been found in testes of subfertile men and in the contralateral testis of patients with TGCT. MGCT is a frequent finding (19%) in the testicular tissue adjacent to an overt TGCT. Men with a high risk of TGCT may gain from screening for precursor lesions of TGCT with ultrasonography of the testes followed by a testicular biopsy if suspicious abnormalities are found: Treatment is high-voltage radiotherapy for intratubular germ cell neoplasia (IGCN), and orchidectomy for MGCT and germ cell tumor in situ, either intratubular seminoma or intratubular embryonal carcinoma. After local treatment, patients with precursor lesions can be followed with a surveillance program. The mRNA levels of invasion-related genes were evaluated based on a DNA microarray data set, and we found two gene abnormalities most relevant for the invasion of malignant germ cells: matrix metalloproteinase 9 (MMP9) and plasminogen activator, urokinase (PLAU) genes were up-regulated in a study comparing tissue samples of TGCT and IGCN.

Microinvasive germ cell tumour (MGCT) adjacent to testicular germ cell tumours

AIMS

To examine the occurrence and prognostic significance of intratubular germ cell neoplasia (IGCN) and microinvasive germ cell tumour (MGCT) in tissue adjacent to testicular germ cell tumours (TGCT) in adults.

METHODS AND RESULTS

The study was based on two Danish studies of adult patients with stage I TGCT and included 255 patients. Of 106 patients with seminoma, 75 [71%, 95% confidence interval (CI) 61, 79] had IGCN without MGCT and nine (8%, CI 4, 15) had both IGCN and MGCT. Of 149 patients with non-seminoma, 62 (42%, CI 34, 50) had IGCN without MGCT, and 32 (22%, CI 15, 29) had both IGCN and MGCT. Non-seminomas with a seminoma component were more often associated with MGCT (23 of 54 testes, 43%, CI 29, 57) than were non-seminomas without this component (nine of 95 testes, 10%, CI 4, 17) (P < 0.000 05, Fisher's exact test). Relapse-free survival was not influenced by the concomitant presence of the two precursor stages in the testes (P = 0.36, and P = 0.19, log rank test, respectively).

CONCLUSIONS

MGCT was a relatively frequent finding in testes adjacent to a macroscopic TGCT. However, neither IGCN nor MGCT predicted relapse for patients with stage I TGCT.

False-negative biopsies for the diagnosis of testicular intraepithelial neoplasia (TIN)--an update

PURPOSE

Testicular intraepithelial neoplasia (TIN; or carcinoma in situ of the testis) is the precursor of testicular germ-cell tumours (GCT). It is detected by conventional surgical biopsy of the testis. To date, only little information is available in regard to the accuracy of the biopsy. False-negative biopsies have been reported only sporadically.

PATIENTS AND METHODS

Twenty-one patients who developed a testicular GCT despite a testicular biopsy negative for TIN were analysed clinically and histologically. The median age of the patients is 34 years. The median interval from biopsy to the clinical appearance of GCT is 39 months. Four of the 21 patients had their biopsy done within a previously reported multicentric study (n=1859 cases with negative biopsy including five cases with false-negative biopsy hitherto known). All of the biopsy specimens were re-examined immunohistologically. In 15 cases, the orchiectomy specimens were re-examined for the presence of TIN in the tumour-surrounding tissue.

RESULTS

In five cases, TIN was found in the biopsy specimen upon re-examination. In all of the 15 orchiectomy specimens there was evidence of TIN in the tissue adjacent to the tumour. In three biopsy specimens there were microcalcifications in the seminiferous tubules. Severe impairment of the spermatogenesis was observed histologically in only 3 of the 21 patients. The relative proportion of false-negative biopsies is 0.5% (95% confidence intervals (CI): 0.22%; 0.92%). The sensitivity of the biopsy to detect TIN is 0.914 (95% CI: 0.842; 0.959) and the overall accuracy is 0.995 (95% CI: 0.991; 0.9979). A total of 44 false-negative biopsies are reported to date.

CONCLUSIONS

False-negative biopsies for TIN do occur but the proportion is only 0.5%. There is no clear-cut clinical nor histological feature associated with false-negative biopsies. However, young age (i.e. <18 years) and intratubular microcalcifications should increase the clinician's and pathologist's vigilance. The majority of false-negative biopsies are caused by the non-random distribution of TIN in the testis while some few cases are caused by technical problems. Two-site biopsies would probably increase the accuracy of the biopsy in high risk cases.

A percutaneous large-needle aspiration biopsy technique for histologic examination of the testis in infertile patients

OBJECTIVE

To describe a relatively new percutaneous large-needle aspiration biopsy technique for histologic examination of the testis in infertile patients.

DESIGN

Retrospective analysis of clinical and pathologic data.

SETTING

Clinical and academic research environment.

PATIENT(S)

Sixty-six infertile patients who underwent testicular biopsy.

INTERVENTION(S)

Local anesthesia was induced through spermatic cord block with lidocaine, and a relatively large needle (usually 18- or 20-gauge) was introduced percutaneously into the testicle without a scrotal incision.

MAIN OUTCOME MEASURE(S)

The number of seminiferous tubules per histologic section of each testicular biopsy sample.

RESULT(S)

A mean of 74 seminiferous tubules were obtained in the histologic sections of each biopsy sample. This number varied according to the size of the needle used; it was 24.7 when a 21-gauge needle was used, 56.2 when a 20-gauge needle was used, and 103 when an 18-gauge needle was used. The biopsies were performed in the office. No significant hematomas occurred, no antibiotic prophylaxis was prescribed, and no postbiopsy medical or pharmacologic interventions were required.

CONCLUSION(S)

Tissue specimens as large as those obtained with open surgical biopsy can be obtained from the testicles of infertile patients with the use of a percutaneous technique that is easier, less costly, and safer than any previously reported.

A comparison of open versus needle biopsy (Tru-cut R) of the testis

Testicular biopsy is an important investigation in the management of an infertile patient with azoospermia. The study is aimed at defining the role of needle biopsy (Tru-cut R) of the testes as an alternative to conventional open testicular biopsy in a prospective controlled trial of 45 consecutive patients. Our study shows that needle biospy of the testis is safe and effective, making it a reliable alternative to open biopsy of the testes.

Microinvasive germ cell neoplasia of the testis

BACKGROUND

The term microinvasive germ cell neoplasia denotes the presence of neoplastic germ cells in the tubuli and interstitium of the testis, unaccompanied by clinically detectable tumor.

METHODS

Testicular biopsy specimens from three patients (age range, 26-38 years) without clinical evidence of tumor showed microinvasive germ cell neoplasia. The indications for biopsy were gynecomastia and testicular atrophy in Patient 1, infertility in Patient 2, and nonseminomatous cancer in the contralateral testicle in Patient 3.

RESULTS

In all three cases, orchiectomy specimens disclosed multifocal intratubular and extratubular growth of neoplastic germ cells, occasionally confluent in seminoma-like infiltrates. In Cases 1 and 2, no malignant cells were found at biopsy of the contralateral testis.

CONCLUSIONS

In contrast to intratubular (in situ) germ cell neoplasia, microinvasion constitutes a definitive malignancy and the starting point of differentiation into seminoma or nonseminomatous tumor. Inguinal orchiectomy is recommended as primary therapy. The necessity of complementary therapy is an issue that must be investigated.

Carcinoma in situ in testicular biopsies

Carcinoma in situ of the testis is an abnormality of the seminiferous epithelium characterized by aneuploid cells with clear cytoplasm located along the tubular basement membrane or in the lumina of tubules. Morphological, cytogenetic, and histochemical features of this anomaly are presented. An adequate fixation of testicular tissue samples is necessary for correct diagnosis. The fact that approximately 50% of carcinoma in situ may develop into malignant germ cell tumours of the testis in 5 years and the investigations of the testicular tissue adjacent to these tumours support the malignant nature and invasive potential of testicular carcinoma in situ. The incidence of carcinoma in situ in persons at risk is reviewed.

Bilateral prepubertal carcinoma in situ of the testis and ambiguous external genitalia

A 10-year-old boy with bilateral carcinoma in situ in maldescended testes and concomitant ambiguous genitalia is presented.

Identification of testicular atypical germ cells by an immunohistochemical technique for placental alkaline phosphatase

The identification of atypical testicular germ cells is often difficult by by routine histologic examination. By immunohistochemical detection of placental alkaline phosphatase (PLAP) and by periodic acid Schiff staining of glycogen, atypical germ cells were easily identified in testicular samples. Forty-one fetal and adult testes were used for a preliminary study, and 121 testes from infants and adults with either cryptorchidism or germ cell tumors were studied for the presence of atypical germ cells. Two types of clear germ cells were differentiated histochemically, and one with PLAP-positive cell surfaces and glycogen-rich cytoplasm was considered to be atypical. The alkaline phosphatase of atypical germ cells appeared to be similar to that found in a few germ cells of early fetal testes. The atypical germ cells seemed to be multi-potential malignant cells capable of developing not only into seminoma but also into other germ cell tumors. Only in yolk sac tumor of infants were the atypical germ cells absent from tumor-adjacent seminiferous tubules.

Subfertility: an etiologic factor in development of testicular cancer?

Gonadal dysfunction with resultant subfertility has been implicated as a possible etiologic factor in testicular cancer. A survey of 57 men who had been married before testicular cancer developed revealed that only four marriages (9%) had problems with fertility. Our findings fail to support a premise that testicular carcinoma is associated with prior male infertility.

Testicular failure in patients with extragonadal germ cell tumors

Eight patients with mediastinal or retroperitoneal germ cell tumors who had undergone testicular biopsy or orchiectomy were retrospectively analyzed for primary testicular abnormalities, subfertility, and abnormal sex hormone levels. Testicular tissue was abnormal in all patients, revealing peritubular fibrosis (six), decreased spermatogenesis (eight), interstitial edema (five), Sertoli cells only (one), and Leydig cell hyperplasia (two). Detailed hormone analysis in five patients revealed elevations of luteinizing hormone in four, decreased serum testosterone in two, elevations of estradiol in two, and elevation of human chorionic gonadotropin in one patient. A history of infertility was documented 2 months to 13 years before presentation in four patients and suspected in another. Extragonadal germ cell tumors, like their testicular counterparts are associated with primary germ cell defects, some of which seem to be independent of gonadotropin production by the tumor. In addition, the rather high incidence of antecedent infertility suggests that either a congenital or acquired primary germ cell defect contributes to defective spermatogenesis and the development of cancer in incompletely migrated germ cells.

Needle biopsy of testes: a safe outpatient procedure

A total of 287 testes biopsies were performed in the office under local anesthesia, using a modified needle and technique to collect the tissue which was then fixed in Bouin's solution. Adequate tissue was obtained in all specimens for histopathologic diagnosis. In 3 patients small hematomas developed and were treated conservatively. Five patients complained of orchialgia, but none required narcotic analgesia. No sperm antibodies, extravasation, or serious complications were encountered. We believe this technique is safe, simple, and cost-effective.