Special Problems in Managing Patients with Testicular Cancer

An enormous testicular sex cord/gonadal stromal tumor

Testicular sex cord/gonadal stromal tumors are relatively rare non-germ cell neoplasms. The authors describe an unusual case of an enormous unclassified sex cord/gonadal stromal tumor, which histologically appeared benign. The implications of the pathological findings and the surgical management are discussed.

Transscrotal approach to testicular tumors: an anatomical approach

Performing a conventional radical inguinal orchiectomy for suspected testicular cancer has three important deficiencies: 1) A benign lesion can unnecessarily and unknowingly be treated by orchiectomy. 2) Alternate routes of tumor dissemination (superficial external pudendal veins) are not clamped or destroyed before the tumor-bearing testis is brought up through the external inguinal ring. 3) The act of squeezing the testis through the external inguinal ring may be an important cause of tumor spread. Presented in this paper is a transscrotal approach that eliminates these three deficiencies. It is advocated for critical clinical evaluation.

Aspiration cytology of palpable lesions of the scrotal content

To date, we have studied 89 palpable lesions of the scrotum, testicle, and epididymis using fine-needle aspiration cytology (FNAC). Cystic lesions (48.3%) and inflammatory pathology (25.8%) were the most frequent findings. Tumors accounted for 11.2% of results, with a slight predominance of the malignant varieties. In this article, we describe the cytopathology of the main entities and discuss the principal problems of differential diagnosis, especially among inflammatory processes, seminomas, and embryonal carcinomas. The cytopathological pattern of the neoplasias is highly characteristic, and this permits their diagnosis with great precision. FNAC is essentially nontraumatic and easy to carry out, but it requires considerable practice in its execution and in the interpretation of the aspirates. We believe FNAC to be the technique of choice for the study of the pathology of the scrotal content, and we think that it should be employed on the patient's very first visit. The main advantage of FNAC is avoiding delays in diagnosis.

Malignant Leydig-cell tumour of testis

A rare case of a malignant Leydig-cell tumour of the testis in a 26-year-old patient, with radical orchiectomy from an inguinal incision is described. Although the results of AFP, HCG, biochemical, X-ray, lymphographic and scintigraphic examinations were negative, the first metastases into the lungs appeared one year after the operation. Combined cytostatic treatment, polychemotherapy and X-ray therapy proved ineffective. The patient died of multiple metastases 28 months after the surgical intervention.

Testis tumors: the clinical significance of the tumor-contaminated scrotum

Between 1977 and 1979 we evaluated 224 patients with testicular cancer. Of these patients 32 had undergone inadequate primary procedures, such as transscrotal orchiectomy, transcrotal exploration, biopsy or aspiration. These 32 patients were compared to a cohort population who had undergone radical inguinal orchiectomy. Differences in management, nodal metastases, local recurrences, intervals free of disease and survival by stage of disease were determined. Patients with seminoma and a contaminated scrotum received radiation therapy to the involved hemiscrotum . Partial scrotectomy without ilioinguinal node dissection was performed on most patients with nonseminomatous disease. An inguinal node metastasis developed before radiation therapy in a patient with seminoma. There were no local recurrences. No statistically significant difference in either intervals free of disease or survival between contaminated and cohort populations was found. We conclude that with prompt adequate management there is no adverse effect on prognosis due solely to scrotal tumor contamination, contrary to what has been implied in the literature.

Current concepts in the management of testicular germ cell tumours in adults. A review

Due to a combination of aggressive chemotherapy and radical surgery today most cases of advanced non-seminomatous germ cell tumours of the testicle can be cured. The most active chemotherapeutic regimen is a combination of cis-platinum, velban, and bleomycin: the epipodophyllotoxin VP-16-213 still being a second hand alternative. Surgery is applied for definite cure in low-stage disease and for debulking of remaining tumour after initial chemotherapy in advanced stages. Survival figures today are given as 100% in stage I, 90% in stage II, and 60% in stage III. Low-stage seminoma is still routinely treated with radiotherapy, however, chemotherapy seems to markedly improve survival also in advanced stages of this disease. The use of highly toxic chemotherapy and advanced surgery necessitates a concentration of these cases to few centres with experienced staff. The article also briefly discusses classification, symptoms, diagnostic aids, and follow-up procedures.

Bilateral testicular germ cell malignancy

The other testicle was involved in 6 of 235 patients (2.69 per cent) with a history of testicular germ cell tumor. It occurred more often following seminoma (4 of 113, 3.5 per cent cases). The mean age at occurrence of the first tumor (twenty-five years) was earlier than expected, and the mean interval between tumors was 8.8 years. Accurate clinical staging of second tumors is impeded by alteration in the routes of metastatic dissemination, and treatment options are limited by previous therapy for the first tumor.

Treatment of testicular tumors arising in patients with previous inguinal and/or scrotal surgery

Of 20 patients with testicular tumors that occurred after previous inguinal and/or scrotal surgery 6 with seminomas were treated with traditional radiation therapy that included the ipsilateral groin, while 14 with nonseminomatous tumors were treated with retroperitoneal lymph node dissection with or without chemotherapy. No patient suffered inguinal lymph node metastases. Based on the satisfactory results in these patients to date and the lack of subsequent detectable recurrence of tumor we do not advocate additional treatment to the superficial inguinal lymph nodes and scrotum.

Retroperitoneal block dissection in the treatment of nonseminomatous tumors of the testis

Fifteen patients with nonseminomatous tumors of the testis, stages I and II, underwent a retroperitoneal block dissection as part of their treatment regimen. Nonseminomatous germ cell and paratesticular tumours were reported. The preoperative measures and operative technique of the anterior transabdominal approach are described. There were no deaths or major postoperative complications encountered, in spite of the magnitude of the surgery involved. In two patients the tumor had occurred in an undescended testis. No patient had normal ejaculatory function after the operation. Special attention is drawn to the proper management of patients having undergone a transscrotal biopsy or orchiectomy. Five patients with a relatively long-term follow-up, are free of disease and doing well.