Part I: testicular cancer--management of early disease

Adjuvant Therapy in Stage I Testicular Cancer: Surveillance for All

Given the remarkably high cure rates for clinical stage (CS) I testicular cancer, the toxicities and risks of adjuvant treatments, the cost effectiveness of surveillance, and the lack of reliable biomarkers to predict relapse, surveillance should be recommended for all patients with CS I testicular cancer.

The burden of testicular cancer from 1990 to 2019 in the Middle East and North Africa region

Background

The incidence rate of testicular cancer has risen in many countries during recent decades. This study aimed to outline the impact of testicular cancer on the Middle East and North Africa (MENA) region from 1990 to 2019, examining its burden by age group and according to the socio-demographic index (SDI).

Methods

Data on the incidence, death, and disability-adjusted life-years (DALYs) due to testicular cancer were retrieved from the Global Burden of Disease study 2019. The counts and age-standardized rates (per 100,000) were reported, and all rates were accompanied by 95% uncertainty intervals (UIs).

Results

In MENA, the age-standardized incidence rate of testicular cancer was 1.4 per 100,000 in 2019, showing a 244.0% increase since 1990. Similarly, the annual death rate, at 0.1, experienced a 2.6% rise during the same period. In 2019, testicular cancer accounted for 31.1 thousand DALYs, marking an age-standardized rate of 5.0, which was 2.8% higher than in 1990. The 1-4 age group exhibited the largest incidence rate in 2019. In addition, in both 1990 and 2019 the MENA/Global DALY ratio was higher than one in the 1-14 year age groups. During the period 1990 to 2019, the age-standardized DALY rate of testicular cancer steadily rose with higher SDI values, except for a decrease observed at an SDI of 0.8.

Conclusion

Over the last thirty years, there has been a notable rise in the burden of testicular cancer in the MENA region.

Reprint of: Updates in 2022 on the staging of testicular germ cell tumors

Testicular cancer is the most common solid neoplasm of adult men between the ages of 20 and 40 years. Germ cell tumors account for 95% of all testicular tumors. The assessment of staging is essential to guide further management of patients with testicular cancer and to prognosticate cancer-related outcomes. Postradical orchiectomy treatment options, including adjuvant therapy and active surveillance, vary based on the anatomical extent of disease, serum tumor markers, pathologic diagnosis, and imaging. This review provides an update on the germ cell tumor staging system adopted by the 8th edition of the American Joint Commission on Cancer (AJCC) Staging Manual, treatment implications, risk factors, and predictors of outcomes.

Radiological features characterising indeterminate testes masses: a systematic review and meta-analysis

CONTEXT

The use of scrotal ultrasonography (SUS) has increased the detection rate of indeterminate testicular masses. Defining radiological characteristics that identify malignancy may reduce the number of men undergoing unnecessary radical orchidectomy.

OBJECTIVE

To define which SUS or scrotal magnetic resonance imaging (MRI) characteristics can predict benign or malignant disease in pre- or post-pubertal males with indeterminate testicular masses.

EVIDENCE ACQUISITION

This systematic review was conducted in accordance with Cochrane Collaboration guidance. Medline, Embase, Cochrane controlled trials and systematic reviews databases were searched from (1970 to 26 March 2021). Benign and malignant masses were classified using the reported reference test: i.e., histopathology, or 12 months progression-free radiological surveillance. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool (QUADAS-2).

EVIDENCE SYNTHESIS

A total of 32 studies were identified, including 1692 masses of which 28 studies and 1550 masses reported SUS features, four studies and 142 masses reported MRI features. Meta-analysis of different SUS (B-mode) values in post-pubertal men demonstrated that a size of ≤0.5 cm had a significantly lower odds ratio (OR) of malignancy compared to masses of >0.5 cm (P < 0.001). Comparison of masses of 0.6-1.0 cm and masses of >1.5 cm also demonstrated a significantly lower OR of malignancy (P = 0.04). There was no significant difference between masses of 0.6-1.0 and 1.1-1.5 cm. SUS in post-pubertal men also had a statistically significantly lower OR of malignancy for heterogenous masses vs homogenous masses (P = 0.04), hyperechogenic vs hypoechogenic masses (P < 0.01), normal vs increased enhancement (P < 0.01), and peripheral vs central vascularity (P < 0.01), respectively. There were limited data on pre-pubertal SUS, pre-pubertal MRI and post-pubertal MRI.

CONCLUSIONS

This meta-analysis identifies radiological characteristics that have a lower OR of malignancy and may be of value in the management of the indeterminate testis mass.

Stage I seminoma: Outcome of different treatment modalities and changes in patterns of care. A single institution experience

BACKGROUND

The mainstay for management of stage I seminoma is high inguinal orchiectomy with post-orchiectomy therapeutic options including active surveillance, chemotherapy or radiation therapy.

OBJECTIVES

To analyze different post-orchiectomy treatment modalities outcomes of stage I seminoma patients presented to NCI, Cairo University in the period from 2005-2019.

PATIENTS AND METHODS

A retrospective review of all patients' records with clinical stage I seminoma who presented to our institute in the period from 2005-2019 was done. Adjuvant treatment details were extracted and we compared overall survival (OS) and disease free survival (DFS) for different modalities and changes in patterns of care over this period.

RESULTS

Thirty five patients were identified with thirty three patients eligible for analysis. Median age was 35 years (range, 19-52). Fourteen patients were kept under active surveillance, eleven patients received adjuvant carboplatin and eight patients received adjuvant radiation to para-aortic chain. Five-year OS was 100% for all patients regardless post-operative approach. Five-year DFS was 100% for patients who received adjuvant chemotherapy or radiotherapy versus 93% for patients who were kept under active surveillance (p=0.03).

CONCLUSION

Clinical stage I seminoma is a favorable disease entity with favorable disease related outcomes regardless post-operative approach. Active surveillance is reasonable and safe given equal survival to active treatment.

Clinical features and prognostic factors in patients diagnosed with lymphovascular invasion of testicular germ-cell tumors: Analysis based on the SEER database

Background

Lymphovascular invasion (LVI) is a high-risk factor for testicular germ-cell tumors (TGCT), but a prognostic model for TGCT-LVI patients is lacking. This study aimed to develop a nomogram for predicting the overall survival (OS) of TGCT-LVI patients.

Methods

A complete cohort of 3288 eligible TGCG-LVI patients (training cohort, 2300 cases; validation cohort, 988 cases) were obtained from the Surveillance, Epidemiology, and End Results database. Variables screened by multivariate Cox regression analysis were used to construct a nomogram, which was subsequently evaluated using the consistency index (C-index), time-dependent receiver operating characteristic curve (ROC), and calibration plots. The advantages and disadvantages of the American Joint Committee on Cancer (AJCC) staging system and the nomogram were assessed by integrated discrimination improvement (IDI) and net reclassification improvement (NRI). Decision-analysis curve (DCA) was used to measure the net clinical benefit of the nomogram versus the AJCC staging system. Finally, Kaplan-Meier curves were used to evaluate the ability to identify different risk groups between the traditional AJCC staging system and the new risk-stratification system built on the nomogram.

Results

Nine variables were screened by multivariate Cox regression analysis to construct the nomogram. The C-index (training cohort, 0.821; validation cohort, 0.819) and time-dependent ROC of 3-, 5-, and 9-year OS between the two cohorts suggested that the nomogram had good discriminatory ability. Calibration curves showed good consistency of the nomogram. The NRI values of 3-, 5-, and 9-year OS were 0.308, 0.274, and 0.295, respectively, and the corresponding values for the validation cohort were 0.093, 0.093, and 0.099, respectively (P<0.01). Additionally, the nomogram had more net clinical benefit as shown by the DCA curves, and the new risk-stratification system provided better differentiation than the AJCC staging system.

Conclusions

A prognostic nomogram and new risk-stratification system were developed and validated to assist clinicians in assessing TGCT-LVI patients.

Updates in 2022 on the Staging of Testicular Germ Cell Tumors

Testicular cancer is the most common solid neoplasm of adult men between the ages of 20 and 40 years. Germ cell tumors account for 95% of all testicular tumors. The assessment of staging is essential to guide further management of patients with testicular cancer and to prognosticate cancer-related outcomes. Postradical orchiectomy treatment options, including adjuvant therapy and active surveillance, vary based on the anatomical extent of disease, serum tumor markers, pathologic diagnosis, and imaging. This review provides an update on the germ cell tumor staging system adopted by the 8th edition of the American Joint Commission on Cancer (AJCC) Staging Manual, treatment implications, risk factors, and predictors of outcomes.

Testicular Germ-Cell Tumors with Spermatic Cord Involvement: A Retrospective International Multi-Institutional Experience

The 8th Edition of the American Joint Committee on Cancer (AJCC) Staging Manual designates discontinuous involvement of spermatic cord soft tissue by testicular germ cell tumors as a metastatic deposit. We conducted a retrospective international multi-institutional study to validate the current recommendations. Thirty-three (72%) nonseminomatous and 13 (28%) seminomatous testicular germ cell tumors were collected from 15 institutions in America, Europe, and Asia. Testicular tumor size ranged from 1.3 to 18.0 cm (mean: 6.1). Cases were classified as discontinuous involvement of spermatic cord soft tissue (n = 26), continuous cord involvement (n = 17), or cord lymphovascular invasion (n = 3). The mean follow-up was 39 months. Clinical stage for discontinuous involvement of spermatic cord soft-tissue patients was I (local disease) in 2/24 (8%), II (regional disease) in 6/24 (25%), and III (distant disease) in 16/24 (67%) cases; 16 (67%) patients presented with distant metastasis. Clinical stage for continuous cord involvement patients was I in 9/17 (53%), II in 4/17 (23%), and III in 4/17 (23%); 4 (23%) patients presented with distant metastasis. Disease progression was seen in 4 patients with discontinuous involvement of spermatic cord soft tissue and 5 with continuous cord-involvement (p = 0.699). When comparing discontinuous and continuous cord involvement, a significant difference was found in cord margin status (p = 0.044), spermatic cord tumor size (p = 0.016), lymph-node involvement (p = 0.037), distant metastasis (p = 0.010), individual clinical stage (p = 0.003), and nonadvanced vs. advanced disease (p = 0.003) at presentation. In multivariate analysis, after adjusting for age, histology, testicular tumor size, percent of embryonal carcinoma, lymphovascular invasion, and cord margin status, discontinuous involvement of spermatic cord soft tissue was significantly associated (p = 0.011) with advanced clinical stage at presentation. Our findings support the designation of metastatic disease for discontinuous involvement of spermatic cord soft tissue, as introduced by the 8th edition of the AJCC staging.

Testicular Cancer, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology

Testicular cancer is relatively uncommon and accounts for <1% of all male tumors. However, it is the most common solid tumor in men between the ages of 20 and 34 years, and the global incidence has been steadily rising over the past several decades. Several risk factors for testicular cancer have been identified, including personal or family history of testicular cancer and cryptorchidism. Testicular germ cell tumors (GCTs) comprise 95% of malignant tumors arising in the testes and are categorized into 2 main histologic subtypes: seminoma and nonseminoma. Although nonseminoma is the more clinically aggressive tumor subtype, 5-year survival rates exceed 70% with current treatment options, even in patients with advanced or metastatic disease. Radical inguinal orchiectomy is the primary treatment for most patients with testicular GCTs. Postorchiectomy management is dictated by stage, histology, and risk classification; treatment options for nonseminoma include surveillance, systemic therapy, and nerve-sparing retroperitoneal lymph node dissection. Although rarely occurring, prognosis for patients with brain metastases remains poor, with >50% of patients dying within 1 year of diagnosis. This selection from the NCCN Guidelines for Testicular Cancer focuses on recommendations for the management of adult patients with nonseminomatous GCTs.

miR-371a-3p, miR-373-3p and miR-367-3p as Serum Biomarkers in Metastatic Testicular Germ Cell Cancers Before, During and After Chemotherapy

BACKGROUND

LDH (lactate dehydrogenase), AFP (alpha-fetoprotein) and β-HCG (human chorionic gonadotropin) are used in diagnosis and follow-up of testicular germ cell cancer (TGCC) patients. Our aim was to investigate the association between levels of miR-371a-3p, miR-373-3p and miR-367-3p and clinical features in metastatic TGCC.

METHODS

relative levels of miR-371a-3p, miR-373-3p and miR-367-3p were evaluated in serum of metastatic TGCC patients. A prospectively included and a retrospectively selected cohort were studied (total patient number = 109). Blood samples were drawn at start of chemotherapy and during follow-up. Serum microRNA (miR) levels were determined using the ampTSmiR test.

RESULTS

at start of chemotherapy, miR-371a-3p, miR-373-3p and miR-367-3p levels were positively correlated to LDH. The median level of these miRs was higher in patients who developed a relapse after complete biochemical remission (n = 34) than in those who had complete durable remission (n = 60). Higher levels of miR-367-3p were found in patients with refractory disease (n = 15) compared to those who had complete response. miR levels decreased during the first week of chemotherapy in patients with complete response and stayed below threshold after one year of treatment.

CONCLUSION

high miR levels at start of chemotherapy are associated with worse clinical outcome and can assist in early diagnosing of relapses.

The association between copper transporters and the prognosis of cancer patients undergoing chemotherapy: a meta-analysis of literatures and datasets

Copper transporter 1 (CTR1), copper transporter 2 (CTR2), copper-transporting p-type adenosine triphosphatase 1 and 2 (ATP7A and ATP7B) are key mediators of cellular cisplatin, carboplatin and oxaliplatin accumulation. In this meta-analysis, we aimed to evaluate the relation of CTR1, CTR2, ATP7A and ATP7B to overall survival (OS), progression-free survival (PFS), disease-free survival (DFS) and treatment response (TR) of cancer patients who received chemotherapy based on published literatures, the Gene Expression Omnibus (GEO) and the Cancer Genome Atlas (TCGA) datasets. Hazard ratios (HRs) and odds ratios (ORs) were pooled using random-effect models. Subgroup analysis and sensitivity analysis were conducted; heterogeneity and publication bias were assessed. Twelve literatures and eight datasets with 2149 patients were included. Our results suggested that high CTR1 expression was associated with favorable OS, PFS, DFS and TR in cancer patients who underwent chemotherapy with acceptable heterogeneity. The relationship of CTR1 to cancer prognosis remained significant in the subgroup of patients who underwent platinum-based chemotherapy, the patients with ovarian cancer and those with lung cancer. The significance of these relationships was not influenced by geological region of publication, data origin or detection method. However, there was no evidence for relation of CTR2, ATP7A or ATP7B to OS, PFS, DFS or TR. Test of publication bias and sensitivity analysis suggested a robustness of all the summary effect estimates. In conclusion, high CTR1 level predicts prolonged survival and enhanced response to chemotherapy in cancer patients who underwent chemotherapy and CTR1 might be a potential target to circumvent chemotherapy resistance.

Testicular Seminoma and Its Mimics: From the Radiologic Pathology Archives

Testicular seminoma is the most common malignant tumor of the testis. It classically manifests as a painless mass. Radiologic evaluation with high-frequency ultrasonography (US) is critical for diagnosis. Seminomas are usually homogeneously hypoechoic masses at US. In challenging cases, magnetic resonance (MR) imaging may help confirm that a mass is intratesticular and provide data for local staging. Computed tomography (CT) provides valuable information for staging, including the presence and size of retroperitoneal lymph nodes. Testicular seminoma is treated with radical inguinal orchiectomy and is highly curable even at advanced stages of disease. Several neoplastic and nonneoplastic conditions may mimic testicular seminoma at imaging. Benign mimics include segmental infarction, hematoma, infection, epidermoid cyst, adrenal rests, sarcoidosis, splenogonadal fusion, and sex cord-stromal tumors. Malignant mimics include nonseminomatous germ cell tumors, lymphoma, and metastases. These conditions are individually reviewed with emphasis on features that allow differentiation from seminoma. Spermatocytic tumor, formerly known as spermatocytic seminoma, accounts for only 1% of testicular tumors. It is distinct from classic seminoma, with unique histologic, molecular, and genetic features. It affects an older patient population than classic seminoma and demonstrates indolent clinical behavior. Radiologists serve a key role in diagnosis, staging, and surveillance of patients with seminoma. A thorough knowledge of related clinical, radiologic, and pathologic findings will help the radiologist contribute to high-quality interdisciplinary care of affected patients.

How has early testicular cancer affected your life? A study of sexual function in men attending active surveillance for stage one testicular cancer

PURPOSE

Testicular cancer is the most common cancer in young men, it is frequently diagnosed at key times in relationship formation. In early stage disease the vast majority of tumours will be cured by surgery alone with patients being offered active surveillance rather than adjuvant therapies. To date, research has not evaluated how surveillance alone impacts on sexual function.

METHODS

The aim of this quantitative longitudinal study was to ascertain the sexual function of men with stage one disease at 3 and 12 months post diagnosis and to compare with normative data. Additional data was collected on the information men sought regarding sexual function and media they used to access this.

RESULTS

This study shows that men's sexual function is altered at diagnosis and improves by 3 months. At 12 months, whilst not statistically significant, sexual function improves but not to the same level as normative data comparison. Men appear to find verbal information useful at 3 months, however men appear to be seeking written and online information at 12 months.

CONCLUSION

The intricacies of sexual function together with the low number of participants may have been best met with a qualitative approach. However, the information data indicates the importance of further research into the effects of early stage testicular cancer on sexual function. Therefore, further qualitative research is recommended to explore the effects of early stage testicular cancer in relation to sexual function.

DNA methyltransferase 3B expression is associated with poor outcome of stage I testicular seminoma

AIMS

  To examine in testicular seminomas the expression of DNA methyltransferase 3B (DNMT3B), which is known to be associated with early embryonic development and carcinogenesis, and to obtain a predictive marker for relapse of stage I seminomas.

METHODS AND RESULTS

  Immunohistochemical examination of DNMT3B was performed in 88 cases of seminoma, 35 (39.8%) of which showed widely scattered nuclear immunoreactivity for DNMT3B, and 53 (60.2%) of which were completely negative. The incidence of focal DNMT3B expression was higher in stage III seminomas (5/5, 100%) than in stage I (25/70, 35.7%) or stage II (5/13, 38.5%) seminomas (P = 0.011). In stage I seminomas there were no significant correlations between DNMT3B expression and tumour size, invasion of the rete testis, or lymphatic or vascular involvement. Six of 25 cases (24%) showing DNMT3B expression relapsed, whereas only 3/45 cases (6.7%) lacking such expression did so (P = 0.037). Patients with seminomas showing DNMT3B expression had a significantly lower relapse-free survival rate than patients whose tumours lacked this feature (P = 0.0464).

CONCLUSIONS

  Patients with seminomas showing focal DNMT3B expression are at increased risk of relapse, and should be followed up carefully.

Stage I seminoma: treatment outcome at King Hussein Cancer Center in Jordan

BACKGROUND

The aim of this report is to address treatment outcomes of patients with early-stage seminoma in a single institution with special reference to patients with history of surgical violation of the scrotum.

METHODS

Seventy four patients with pure seminoma were treated at King Hussein Cancer Center (Amman, Jordan) between 2003 and 2010. All patients underwent orchiectomy. All but 3 patients received adjuvant radiotherapy. Patients who underwent surgical violation of the scrotum prior to referral were managed by further excision or irradiation of the scrotal scar. The follow-up ranged from 1 to 200 months (mean, 33 months).

RESULTS

At the time of follow-up; all but one patient remain alive. The 3-year relapse-free survival for the entire cohort was 95.9%. Three patients developed relapse, all of whom received adjuvant irradiation following inguinal orchiectomy and initially harbored tumors larger than 4 cm upon pathological examination. Median time to relapse was 14 months (range, 8-25 months). None were associated with elevated tumor markers prior to detection of relapse. All but one patient were successfully salvaged by chemotherapy.

CONCLUSIONS

Our results confirm the excellent prognosis of patients with early-stage seminoma treated by orchiectomy and adjuvant radiotherapy in a developing country. Although all patients who developed relapse demonstrated adverse pathological findings upon initial assessment, no consistent predictor of relapse was found. Scrotal scar re-excision or irradiation in patients with prior history of surgical violation of the scrotum are effective measures in preventing local failure.

Management options for stage I seminoma

Stage I seminoma is the most common clinical scenario among patients with testicular cancer. Following orchiectomy, various treatment alternatives (adjuvant radiotherapy, surveillance, chemotherapy) can be offered that yield similar efficacy results and definitive cure is the rule. However, there is no consensus on the optimal management choice and considerable debate has been raised in recent years. The pros and the cons associated with each therapy, as well as their long-term outcomes are discussed in this review. Overall burden of treatment needed, therapy-related morbidity, economic costs, quality of life issues and patient preferences should all be considered. Refinement in the knowledge of predictive factors for relapse and mounting experience with both surveillance and adjuvant chemotherapy have led to consideration of risk-adapted treatment strategies as an alternative to standard radiotherapy. Although this model needs to be improved and validated, active close surveillance for low-risk patients and adjuvant therapy for those uncompliant or at higher risk of relapse seem to be acceptable options for patients with stage I seminoma.

Quality of care for testis cancer

This article explores the delivery of high quality care in patients with testicular cancer. Critical issues relate to an individualized, risk-stratified, and multidisciplinary approach to patient care at centers of excellence and subsequent close patient follow-up. The necessary integration of multiple therapeutic modalities makes testis cancer outcomes highly susceptible to variations in quality of care, which deserves further investigation in well designed population-based studies.

Serum human chorionic gonadotropin is associated with angiogenesis in germ cell testicular tumors

BACKGROUND

Germ cell testicular tumors have survival rate that diminishes with high tumor marker levels, such as human chorionic gonadotropin (hCG). hCG may regulate vascular neoformation through vascular endothelial growth factor (VEGF). Our purpose was to determine the relationship between hCG serum levels, angiogenesis, and VEGF expression in germ cell testicular tumors.

METHODS

We conducted a retrospective study of 101 patients. Serum levels of hCG, alpha-fetoprotein (AFP), and lactate dehydrogenase were measured prior to surgery. Vascular density (VD) and VEGF tissue expression were determined by immunohistochemistry and underwent double-blind analysis.

RESULTS

Histologically, 46% were seminomas and 54%, non-seminomas. Median follow-up was 43 +/- 27 months. Relapse was present in 7.5% and mortality in 11.5%. Factors associated with high VD included non-seminoma type (p = 0.016), AFP > or = 14.7 ng/mL (p = 0.0001), and hCG > or = 25 mIU/mL (p = 0.0001). In multivariate analysis, the only significant VD-associated factor was hCG level (p = 0.04). When hCG levels were stratified, concentrations > or = 25 mIU/mL were related with increased neovascularization (p < 0.0001). VEGF expression was not associated with VD or hCG serum levels.

CONCLUSION

This is the first study that relates increased serum hCG levels with vascularization in testicular germ cell tumors. Hence, its expression might play a role in tumor angiogenesis, independent of VEGF expression, and may explain its association with poor prognosis. hCG might represent a molecular target for therapy.

Adjuvant radiotherapy in stage I seminoma: is there a role for further reduction of treatment volume?

An analysis was performed to determine whether a cranial reduction of the portals to the T11/T12 junction instead of the common T10/T11 junction would alter the outcome of patients with stage I seminoma. Of 163 consecutive patients with newly diagnosed testicular seminoma referred to the authors' institution between April 1992 and April 1999, 80 patients with stage I seminoma were treated with cranially reduced para-aortic treatment fields reaching from the top of T12 to the bottom of L4. Median total dose was 20.0 Gy (range, 19.8-27.2 Gy). Patients were followed-up by the use of CT in regular intervals. After a median follow-up of 7.1 years (range, 4.1-11.1 years), four patients (5%) had relapsed resulting in an actuarial 5-year relapse-free survival of 95%. No patients relapsed within the cranially reduced treatment volume above the top of T12. The cranial reduction of the para-aortic treatment fields resulted in a median reduction of treatment volume of 16% (range, 13-21%). The achieved median reduction in treatment volume of 16% appears to be relevant and is not associated with an increased relapse rate. This approach is recommended in analogy to the surgical approach in NSGCT to further minimize the risk of radiation-related late effects.

[Testis cancer: the UK as a model]

Over the course of the past 30 years progress in identification of risk factors, improvements in therapy regimens and advances in treatment delivery have all served to render testis cancer a treatable and survivable malignancy. Institution of specialised oncology centres in the UK to address treatment options for urological cancers has proven to be an effective approach to managing testis cancer by drawing on interdisciplinary expertise and applying insights gained from ongoing R&D. This strategy could become a model for treating other cancers as well.

Biology of testicular germ cell tumors

Germ cell tumors are derived from cells of the germ cell lineage and are the most common solid malignancies to affect young Caucasian men between the ages of 15 and 40 years. All testicular germ cell tumors develop from the same precursor lesion, intratubular germ cell neoplasia unclassified, which in turn is thought to arise from malignant transformation of a primordial germ cell or gonocyte. These tumors are characterized by extreme chemosensitivity and are considered a model for curative disease. In spite of this, a small subset of patients with metastatic disease fail to achieve a complete response with cisplatin-based chemotherapy or relapse from complete remission. Understanding the molecular biology may help the design of new therapies for those patients with a poor prognosis and could also improve the treatment of cancer in general. Current understanding of the role of genetic and epigenetic factors in the etiology of germ cell tumors and the biochemical mechanisms underlying chemotherapy sensitivity and resistance is discussed in detail in this review.

Testicular cancer patients: considerations in long-term follow-up

Over the past 30 years, testicular tumors have become the paradigm for a curable adult cancer. Numerous factors have contributed to this success, including the introduction of newer treatment approaches, such as cisplatin-based combination chemotherapy and curative retroperitoneal lymph node dissection. Moreover, the last three decades have witnessed the evolution of newer diagnostic methods, improvements in staging, the evaluation of patient response, and the monitoring of relapse. These treatment successes have been accompanied by the emergence of the late effects of testicular cancer and its treatment, including second primary cancers, cardiovascular sequelae, the metabolic syndrome, gonadal toxicity, neurotoxicity, and pulmonary sequelae. An overview of these late effects and recommendations for patient follow-up are presented in this article.

A rare case of classic testicular seminoma in an 86-year-old shows similar proliferation rate as in younger men

We present a rare case of classic seminoma in an 86-year-old man. Combined mitotic count, the presence or absence of intravascular invasion, and the expression of PCNA, Ki67, and p53 were compared between this octogenarian and the tumors of four randomly selected standard younger men. These histologic features were chosen to compare the potential biologic activity of these tumors. The phenotype of classic seminomas in octogenarians seems to be the same as in younger men, and treatment paradigms should remain unchanged.

College Men's Knowledge, Attitudes, and Beliefs About Testicular Cancer

There is a paucity of information about what college-age men know about testicular cancer, making targeted educational programs difficult. The most common age group affected by testicular cancer is 15- to 40-yearolds. Therefore, educating young men, including the college population, becomes paramount. Six focus groups were conducted with men between the ages of 18 and 23 years ( N = 31) at a large public university in the Northeast. Major topics included risk factors for testicular cancer, screening and diagnosis, treatments, psychological effects, and beliefs about prevention and cure. Focus groups revealed college students have poor knowledge and even less understanding of testicular cancer. Students were interested in learning about testicular cancer and other health topics affecting college men, such as healthy diet and exercise and common infectious diseases on college campuses. Simple means to educate college men included courses or assignments that focused on health issues, brief factual information, health fairs, peer educators, and celebrity guest speakers.

Long-term outcome of stage I seminoma

PURPOSE

To report on long-term outcomes among patients with stage I seminoma treated by orchiectomy with or without adjuvant radiation.

MATERIALS AND METHODS

A retrospective review of medical records of patients treated between 1974 and 2002 was undertaken to identify factors associated with patient outcomes.

RESULTS

With a median follow-up of 7.7 years, 80% (4 of 5) of the surveillance group experienced a disease relapse, while only 3% (2 of 70) in the radiation therapy group had disease relapse. This difference in relapse rates was statistically significant, but there was no significant difference in overall survival between the 2 groups. There was a significant relationship between patient age and disease relapse, whereby all of the relapses were seen in patients younger than 36 years at diagnosis (P = 0.03). Of the total 75 patients, 7 (9%) developed second primary tumors. Six of them (6 of 7) were treated with adjuvant radiation, and 1 patient (1 of 7) was on surveillance.

CONCLUSION

In this study, risk of relapse was significantly associated with surveillance and in patients younger than 36 years at diagnosis. These results suggest that surveillance can only be safely adopted for patients who can be followed up closely. We consider adjuvant radiation a very effective choice despite the low risk of associated secondary malignancies.

Ten-year survival and risk of relapse for testicular cancer: A EUROCARE high resolution study

Effective treatments for testicular cancer have been available since the 1970s, yet EUROCARE uncovered marked inter-country survival differences for this disease. To investigate these differences, we reviewed clinical records of 1350 testicular cancer cases diagnosed during 1987-1992 from 13 population-based cancer registries in nine European countries. Patients were followed up for life status and relapse. Ten-year observed survival was estimated by the Kaplan-Meier method. Cox multivariable analyses were performed separately for seminomas and non-seminomas. Overall, 66% of seminomas and 36% of non-seminomas were limited to the testis. Ten-year survival was 63% (Estonia) to 94% (Switzerland, Slovenia) for seminoma; 47% (Estonia) to 90% (Yorkshire, UK, The Netherlands) for non-seminoma. Multivariable analysis adjusted for country, age and stage showed that hazard ratios (HRs) of death differed little between western European registries, and were mainly attributable to differing stage at diagnosis. Significantly higher than reference HRs in Estonia and Poland suggest inadequacy or unavailability of treatments.

Testicular cancer mortality in the Americas, 1980–2003

BACKGROUND

Testicular cancer is generally curable if appropriate treatment is given. Data and statistics on testicular cancer mortality over the last decades are available from the US and Canada, but are more difficult to find, in a standard and comparable format, for Central and South American countries. The objective of the study was to compare death rates and trends over the 1980-2003 period in all the American countries that provide data.

METHODS

Overall and 20 to 44 years age-standardized (world population) mortality rates from testicular cancer, derived from the World Health Organization (WHO) database, are presented for the most recent available calendar years in 10 American countries. Trends in mortality for selected countries of the Americas are also given over the period 1980-2003.

RESULTS

In the early 1980s the highest testicular cancer mortality rates were observed in Chile (1.7/100,000 at all ages, 3.6/100,000 at 20-44 years) and Argentina (0.9/100,000 at all ages, 1.7/100,000 at 20-44 years), as compared with 0.4/100,000 for all ages and 0.6/100,000 at 20 to 44 years in Canada, and 0.3/100,000 for all ages and 0.7/100,000 at 20 to 44 years in the US. In 2001-2003, testicular cancer mortality had fallen to 0.2/100,000 in men aged 20 to 44 years in Canada, and to 0.4/100,000 in the US. Conversely, rates were still 1.6/100,000 in Argentina, 2.2/100,000 in Chile and 1.2/100,000 in Mexico, and were around 0.5-0.6/100,000 in most other Latin American countries that provide data.

CONCLUSIONS

Mortality from testicular cancer in (young) men remains exceedingly high in most Latin American countries. Urgent intervention is required to provide treatment (essentially modern integrated platinum-based chemotherapy) for this largely curable neoplasm in young men.

Diagnosis of Contralateral Testicular Intraepithelial Neoplasia (TIN) in Patients with Testicular Germ Cell Cancer: Systematic Two-Site Biopsies Are More Sensitive Than a Single Random Biopsy

OBJECTIVES

Searching for testicular intraepithelial neoplasia (TIN; carcinoma in situ) in the contralateral testis of patients with germ cell tumour (GCT) may early disclose contralateral GCT. A single biopsy of the testis is thought to accurately detect TIN. Reports on false-negative biopsies have challenged this view. We investigated whether systematic two-site biopsies are more sensitive than single biopsies. We also studied the prevalence of contralateral TIN in a large patient sample.

METHODS

A total of 2318 patients with testicular GCT underwent contralateral double biopsy. All of the biopsy pairs were examined histologically for spermatogenesis and for presence of TIN. Statistical analysis involved first, overall prevalence of contralateral TIN; second, associations of clinical factors with TIN; third, frequency of discordant findings regarding TIN among biopsy pairs; and finally, associations of discordance with clinical factors.

RESULTS

A total of 119 patients (5.13%; 95% confidence interval [CI], 4.27-6.11) had contralateral TIN. TIN is associated with poor spermatogenesis (relative risk [RR] 15.74; 95%CI, 10.38-23.86) and with testicular atrophy (RR 3.78). According to TIN, 31.1% of biopsy pairs were discordant. Discordance was significantly less frequent in atrophic testes and in patients with poor spermatogenesis.

CONCLUSIONS

We confirmed the prevalence of contralateral TIN to be about 5%. TIN is significantly associated with poor spermatogenesis and with testicular atrophy. The diagnostic extra yield imparted by double biopsies is 18%. Discordant results regarding TIN are predominantly encountered in normal-sized testicles. The new standard in diagnosing TIN is two-site biopsy.

Mixed Nonseminomatous Germ Cell Tumor Presenting as a Subcutaneous Tissue Mass

Extragonadal germ cell tumors most commonly arise in the midline of the retroperitoneum or the mediastinum. Primary tumors involving the skin are very rare. Only one case of malignant primary germ cell tumor located in the skin has been reported. We present the case of a 44-year-old white man with a primary subcutaneous mixed nonseminomatous germ cell tumor. This man had a long-lasting subcutaneous lump of the breast, which became painful. Surgery revealed 3 juxtaposed nodules. Microscopic examination showed a mixed germ cell tumor with a 90% immature teratoma component and a 10% embryonal carcinoma component. Testicular ultrasound and computed tomography of the chest, abdomen, pelvis, and brain were normal. Serum human chorionic gonadotrophin, beta-human chorionic gonadotrophin, alpha-fetoprotein, and lactate dehydrogenase were within normal ranges. A further surgical excision was performed. The patient is presently alive with no evidence of disease after a follow-up of 7 years. Review of the literature indicates that primary cutaneous extragonadal germ cell tumors usually occur as cutaneous or subcutaneous solitary nodules or as ulcerated lesions. They mainly consist of mature teratomas in children. Only 2 cases have been reported in adults.

The changing distribution of pT stage in testicular germ cell tumours from 1976 to 2005: a single-centre analysis of histopathological reports

OBJECTIVE

To assess the changing distribution of stage in seminoma and nonseminomatous germ cell tumours (NSGCTs), as recent reports contained no detailed information on pT stage and vascular invasion, important factors in the decision for further treatment.

PATIENTS AND METHODS

Histopathological reports from 1976 to 2005, from patients who had surgery for testicular tumours at the authors' institution, were investigated with special focus on pT stage and its distribution. The whole study period was divided into six 5-year periods. The incidence of seminoma was compared with NSGCT, defined according to the Tumour-Nodes-Metastasis (TNM) classification.

RESULTS

In each 5-year period the median number of tumours treated surgically was 86; the distribution of seminomas and NSGCTs remained stable during the study period (P = 0.201). pT4 and pT3 tumours declined or disappeared in both histopathological groups, while pT2 and pT1 tumours increased during the study period. Since 1996-2000, pT1 tumours decreased, whereas pT2 tumours increased in seminomas (P = 0.085) and NSGCTs (P = 0.003).

CONCLUSION

The incidence of seminoma and NSGCT has not changed over the last 30 years in Vienna. With the establishment of vascular invasion in the TNM classification in 1997, the incidence of pT1 decreased while that of pT2 increased. Since then, the incidence of pT1 tumours in seminomas was 45.8% and 29.1% in NSGCT. According to generally accepted treatment guidelines, these patients might need no adjuvant treatment after surgery.

Epidemiological pattern and time trends in testicular germ-cell tumors: a single institution 20-year experience

INTRODUCTION

Recent studies have suggested a rise in the incidence of testicular germ-cell tumors (TGTs) in the last years, mainly due to an increase of early stage cases. We analysed the time trends in biological features of these patients in order to confirm this tendency in our environment.

MATERIALS AND METHODS

The clinical records of 136 consecutive patients with TGTs treated at a single institution over a 20-year period (1984-2003) were retrospectively reviewed. Pathological, clinical, therapeutic and outcome data were collected. Patients were allocated into four consecutive 5- year intervals and their characteristics were compared by means of the chi-squared test. The survival analysis was performed with the method of Kaplan and Meier.

RESULTS

A progressive increase in the incidence of new cases, and a more frequent diagnosis of stage I versus stage II-IV disease was confirmed within this time period. It was also observed a greater use of postorchiectomy chemotherapy, mainly due to an increase in the adjuvant indications. A significant decrease in the recurrence rate was noted. Ten-year overall survival was 86.5%. There was a trend for improved outcome, but the differences among the two decades were not statistically significant.

CONCLUSIONS

A real increase in the incidence of TGTs and in the proportion of early stages was confirmed. This may be due to an epidemiological change or to an earlier diagnosis. This new pattern is associated with a more frequent use of adjuvant chemotherapy and with a reduction in the relapse rate.

Imaging of testicular germ cell tumours

In testicular germ cell tumour (GCT), imaging plays a central role in assessment of tumour bulk, sites of metastases, monitoring response to therapy, surgical planning and accurate assessment of disease at relapse. The primary modality used for imaging patients with GCT is computed tomography (CT) but plain film radiography, ultrasound, magnetic resonance imaging (MRI) and positron emission tomography (PET) may all have roles to play. This article reviews the role of imaging of testicular germ cell tumours.

Germ cell tumors: An update of recent data and review of active protocols in stage I and metastatic disease

Germ cell tumors are highly curable malignancies even when metastatic. Investigations currently focus on curtailing toxicity in low-risk patients and improving cure rates in poor-risk individuals. Reduced dose radiation schedules and short-course chemotherapy regimens have been evaluated in stage I disease. In metastatic disease, several new nonplatinum agents offer promise for patients with poor risk or relapsed disease. In addition, high-dose chemotherapy regimens with autologous stem cell transplant provide potential for further improvements in survival. This review will highlight recent developments and currently active clinical trials pertinent to the treatment of patients with germ cell tumors.

An unusual presentation of metastatic testicular tumour

We report a unique case of metastatic malignant teratoma from an undescended testis which presented with acute pulmonary embolism. After chemotherapy, the undescended right testicle was resected along with a cord of non- obstructing inferior venal caval tumour which extended into the right atrium with tumour floating free within the atrium at the end of the cord of tumour. The presentation, diagnosis and treatment of testicular tumours is described and the literature pertaining to testicular tumours in military personnel reviewed.

Oncogenic role of NALP7 in testicular seminomas

To isolate novel molecular targets for treatment of testicular germ cell tumor (TGCT), we performed genome-wide expression profile analysis of testicular seminomas using a cDNA microarray. We here report identification of NACHT, leucine-rich repeat and PYD containing 7 (NALP7 ), that was significantly transactivated in testicular seminomas. Subsequent semi-quantitative RT-PCR and northern blot analyses confirmed an approximately 3.3-kb transcript that was expressed exclusively in testis, although the expression level of this gene in normal testis was much lower than in tumor cells, suggesting an important role of this gene in germ-cell proliferation. Immunohistochemical analysis using anti-NALP7 polyclonal antibody detected the endogenous NALP7 protein in the cytoplasm of embryonal carcinoma cells and testicular seminoma tissues. Transfection of small interfering RNA (siRNA) for NALP7 significantly reduced the NALP7 expression and resulted in growth suppression of testicular germ-cell tumors. These findings imply that NALP7 may play a crucial role in cell proliferation, as well as testicular tumorigenesis, and it appears to be a promising candidate for development of targeted therapy for TGCTs.

Laparoscopic RPLND for clinical stage I nonseminomatous germ cell testicular cancer: current status

The purpose of the study was to update the current status of laparoscopic retroperitoneal lymph node dissection in the treatment of clinical Stage I nonseminomatous germ cell testicular cancer. A literature search was conducted to evaluate laparoscopic retroperitoneal lymph node dissection (RPLND) in comparison to other modalities of treatment. All treatment modalities are effective in treating clinical Stage I nonseminomatous germ cell tumors. Morbidity is the major issue that may guide treatment decisions. Laparoscopic RPLND, in its therapeutic form, may replicate open RPLND with a minimally invasive approach. Laparoscopic RPLND is an effective alternative to traditional treatment options.

Testicular tumours (nonseminomatous)

In view of the excellent results of multimodal therapy for nonseminoma testicular tumours, with chemotherapy and surgery, attempts have been made to reduce the side-effects of treatment in patients with a good prognosis, while maintaining efficacy. It is now generally accepted that surveillance after orchidectomy is suitable in patients with low-risk stage I disease. Nerve-sparing retroperitoneal lymph-node dissection as a primary treatment is a good alternative to primary chemotherapy in low-stage disease, i.e. high-risk stage I and stage IIa-b, enabling chemotherapy to be reduced by at least half, and decreasing the long-term side-effects of chemotherapy, especially cardiovascular, neuro-, nephro- and pulmonary toxicity. However, in patients with advanced disease and a poor prognosis, conventional chemotherapy is more likely to fail, and improving the treatment results by new schedules of chemotherapy (although more toxic) remains the main goal.

Genetic predisposition to testicular germ-cell tumours

Testicular germ-cell tumours (TGCT) are the most common neoplasm in young men. Various studies have suggested the existence of an inherited predisposition to development of these tumours. Genome-wide screens subsequently provided evidence of a TGCT susceptibility gene on chromosome Xq27 (TGCT1) that might also predispose to cryptorchism. However, this putative gene has yet to be identified, and other TGCT susceptibility genes probably exist. Completion of the human gene map and advances in genetic research will facilitate further investigation of genetic predisposition to TGCT. Insight into inheritance of TGCT might lead to the identification of individuals at increased risk of developing the disorder, increase our understanding of the mutation pathways that lead to sporadic cases, and contribute to improvement in diagnosis and treatment. Clinicians should record the family history of cancer and urogenital differentiation defects in patients with TGCT.