Management and outcome of bilateral testicular germ cell tumors: Twenty-five year experience in Munich

Analysis of clinical characteristics, treatment patterns, and outcome of patients with bilateral testicular germ cell tumors

INTRODUCTION

Bilateral testicular germ cell tumor (BGCT) is a rare disease, occasionally considered to be more aggressive than unilateral germ cell tumors (GCT) in some reports. Among BGCT, a synchronous disease might be diagnosed at a higher stage than a metachronous disease, resulting in lower cancer-specific survival. Hence, our study aimed to perform a comparative analysis between unilateral testicular GCT, bilateral synchronous GCT, and bilateral metachronous GCT, aiming to verify the possibility that BGCT is diagnosed with a higher stage and may require more aggressive management.

MATERIAL AND METHODS

In our multicenter retrospective study we reviewed medical records of 40 patients with BGCT (24 metachronous and 16 synchronous). Clinical characteristics, pathological features of the primary and secondary tumors, adjuvant treatments (chemotherapy and radiotherapy)and sperm quality were evaluated as well as cancer-specific survival and overall survival. A cohort of one-to-one matched patients with unilateral GCT were used to determine risk factors for developing BGCT.

RESULTS

Patients with BGCT were slightly younger compared to those with unilateral GCT and had more advanced disease. Despite similar T-stage distribution between the two groups, nodal involvement was nearly twofold more frequent in patients with BGCT disease (42% vs 22%, p = 0.056). Additionally, although similar histological subtypes distribution at presentation among the two groups, the synchronous disease was diagnosed with a higher local T-stage (OR = 3.4), higher proportions of patients with elevated serum BHCG levels, and more frequent nodal involvement (OR = 2.2). This was later translated into an 18% higher disease-specific mortality rate. The median time to develop a contralateral tumor was 92 months. Pathological local T-stage (T2-T3) of the primary tumor predicted a shorter time interval to a diagnosis of a second contralateral tumor (HR 0.92, P < 0.05).

CONCLUSION

BGCT presents at a younger age and potentially with more advanced disease. Synchronous BGCT is diagnosed at a later stage compared to metachronous BGCT and has higher disease-specific mortality. Metachronous tumors might have a long time interval for the development of a contralateral neoplasm. The main predictor of developing an early metachronous disease is a high primary T stage.

Metachronous bilateral testicular germ cell tumors with different histopathology: A case report

Background

Testicular cancer is the most common solid tumor affecting men aged 20-39 years old. About 95% of all testicular tumor is testicular germ cell tumor. Bilateral testicular tumor is a rare incident and has similar histopathology only in less than 5% of all testicular cancer patients. Besides oncological issues, bilateral testicular tumors could lead to further consequences, such as psychosocial and hormonal issues. This article shows a case of different histopathology in the metachronous bilateral testicular tumors.

Case presentation

A 34-years-old male came with right radical orchiectomy due to testicular pure seminoma pT1N0M0S0 three and half years ago. He underwent bleomycin, etoposide phosphate (BEP) chemotherapy for progressive multiple lymphadenopathies in paracaval and interaortacaval region from positron emission tomography (PET)/computerized tomography (CT) scan a year later. Sperm banking was done before initiated chemotherapy. High metabolic activity was detected in contralateral testis from follow up PET-scan. Left testicle enlargement with hard consistency was found on physical examination and there is an elevation of alpha-feto protein (AFP) and β-hCG. Intraoperatively, the frozen section identified a malignant tumor and the patient was decided to undergo radical left orchiectomy. Postoperative pathological results showed a mixed germ cell tumor of 3.5 × 2.5 × 2 cm consisting of immature teratoma, yolk sac tumor and embryonic carcinoma without lympho-vascular invasion and involvement of the spermatic cord. Post-operative imaging and testicular tumor marker did not identify any metastases. BEP chemotherapy, testosterone replacement therapy was planned for further management in this patient with complete blood count, prostate serum antigen (PSA) and digital rectal examination should be measured three to six weeks after initiation.

Conclusion

Metachronous bilateral TGCT with different histopathology is a rare disease. The treatment depends on histology of second tumor and its stage. TRT is mandatory for patient undergoing bilateral orchidectomy to address lack if testosterone.

Bilateral synchronous testicular cancer: A case report

INTRODUCTION AND IMPORTANCE

Testicular cancer is the most common type of malignancy in young adult males, accounting for 1 % of all cancer diagnosis in men and 5 % of all urologic tumors. It is one of the malignancies with the highest cure rate. Bilateral germ cell tumor of the testicles is rare, representing only 1 % of all new cases of testicular cancer, around 30 % of which occur synchronously. Interestingly, there is not yet an occurrence where the bilateral synchronous testicular cancer has different histopathological type.

CASE PRESENTATION

In this paper, we performed bilateral radical orchiectomy in different occasion, followed by adjuvant chemotherapy (BEP regiment).

CLINICAL DISCUSSION

Since the clinical result is excellent, this finding could be a breakthrough in testicular cancer study. A cellular communication between different cancer cell type through chemokine which could affect response to chemotherapy.

CONCLUSION

Treatment with surgery and chemotherapy is well tolerated and received. A further specific clinical study needs to be performed to investigate this finding in the future.

Clinical characteristics and treatment outcomes of germ cell tumor in Jordan: A tertiary center experience

Objective

In the Middle East, there is a paucity of data regarding germ cell tumor characteristics and treatment outcomes. Herein, we aim to present the largest series in Jordan reporting our cancer center experience managing GCT.

Methods

Between 2010 and 2020, a total of 241 patients with a pathological diagnosis of GCT were treated at our cancer center. Demographic, epidemiologic, and pathological data were retrospectively collected. In addition, survival and relapse outcomes based on tumor stage and adjuvant treatment were collected.

Results

A total of 241 patients were diagnosed with GCT, of whom 108 (44.8%) had seminoma and 133 (55.2%) had non-seminoma tumors (NSGCT). Median age (interquartile range) at diagnosis was 31 years (25-36). Patients with seminoma (68.5%) had pT1 disease post orchiectomy, while only 37.5% of patients with NSGCT had pT1 on final pathology. Elevated tumor markers such as beta-human chorionic gonadotropin were present in 10% of seminomas. Following radical orchiectomy and staging, 88 (36.5%) went for active surveillance while 153 patients (63.5%) received adjuvant treatment. With regard to pathology slides read outside, rereading by our genitourinary pathologist yielded a discrepancy on GCT type in 41 (19.3%) out of 212 patients. The median follow-up was 36 (24-48) months. Twenty-two patients relapsed after an average follow-up time of 39 months. The 5-year overall survival for stage I, II, and III was 98%, 94%, and 87%, respectively, and 3-year recurrence-free survival for stage I, II, and III was 94.8%, 78%, and 67%, respectively.

Conclusion

Our data on testicular GCT including demographic, histological, and treatment outcomes were comparable to that of developed countries. In light of the pathology discrepancy rate revealed in our study, authors recommend a second review by expert genitourinary pathologists to ensure proper classification and management of GCT.

Synchronous Bilateral Primary Testicular Tumors With Discordant Histopathology

Concomitant presentation of histologically distinct bilateral testicular tumors is exceedingly rare. Here we report the case of a 20-year-old male who presented with a left testicular mass. He was found to have bilateral testicular masses on ultrasound and underwent bilateral orchiectomy. Left testicular pathology revealed a mixed germ cell tumor consisting of teratoma, seminoma, and germ cell neoplasia in situ; right testicular pathology revealed two foci of pure seminomas. He is currently on active surveillance and remains in remission at 18-month follow-up. Our case demonstrates the rare occurrence of bilateral primary synchronous testicular tumors with different histopathology in each testis. Despite the rarity of this condition, its treatment is based on standard management of unilateral testicular carcinoma, with the added element of prioritization of one tumor over the other. It is important for clinicians to tailor management for bilateral testicular germ cell tumors according to the most aggressive component.

Synchronous bilateral testicular cancer with discordant histopathology occurring in a 20-year-old patient: A case report and review of the literature

INTRODUCTION

Bilateral testicular tumors are very rare, accounting for 1%-5% of all testicular germ-cell tumors (TGCTs). The vast majority of primary bilateral TGCTs are metachronous, with synchronous tumors comprising approximately 0.5%-1% of all cases. Those occurring synchronously share mostly the same histological pattern, predominantly seminoma, with synchronous bilateral TGCTs (SBTGCTs) with discordant subtypes being extremely rare.

CASE PRESENTATION

We present the case of a 20-year-old male complaining of a palpable painless right testicular mass incidentally noticed during sexual intercourse. Ultrasonography (US) and magnetic resonance imaging (MRI) of the scrotum demonstrated bilateral testicular lesions, while staging with contrast-enhanced computed tomography (CT) exhibited normal findings. Right radical orchiectomy and left testis-sparing surgery (TSS) with concomitant onco-testicular sperm extraction (onco-TESE) were initially performed. Histology of the right testis revealed a mixed germ-cell tumor, consisting of seminoma and embryonal carcinoma, while that from the left testis disclosed embryonal carcinoma and intratubular germ-cell neoplasia unclassified (IGCNU) infiltrating the surgical margins. Hence, left orchiectomy was subsequently scheduled with histology unveiling IGCNU in the greatest part of the remaining testicular parenchyma. Following adjuvant chemotherapy, with bleomycin, etoposide, and cisplatin (BEP), the patient received testosterone replacement therapy and remained free of recurrence at an 18-month follow-up.

CONCLUSION

This case highlights both the rarity of a bilateral testicular tumor's synchronous appearance and its extremely infrequent discordant histopathology. A comprehensive review of the major series of SBTGCTs with discordant histology cited in the literature is additionally presented.

Incidence and clinical pattern of contralateral synchronous and metachronous germ cell testicular cancer

BACKGROUND

Incidence of a second testicular tumor is higher in patients diagnosed with testicular cancer than in the general population. As incidence of unilateral germ cell cancer is increasing worldwide and most of these patients are cured, a growing number of patients at risk of developing a contralateral testis cancer is expected.

OBJECTIVE

To analyze clinical and histological characteristics, as well as the absolute and cumulative incidence of a second testicular cancer in a cohort of 3,834 patients diagnosed with germ cell testicular cancer between I/1994 and I/2018 in 18 referral hospitals of the Spanish Germ Cell Cancer Group.

METHODS

Patients were treated according to stage and year of diagnoses. Contralateral testis biopsy was not routinely performed, according to European Association of Urology rules. Follow-up of the contra lateral testis consists of a physical exam only and an annual optional testicular ultrasound for 10 years.

RESULTS

Median age of the patients included was 32 years (18-82). With a median follow-up of 61 months (0-240), 67/3,834 patients (1.74%) were diagnosed with a second testicular tumor. The second testicular tumor was synchronic (diagnosed within 6 months of the first orchiectomy) in 19 patients, and metachronous in 48. Pathology of the second tumor was reported as a seminomatous testis tumor in 47 patients and a nonseminomatous cancer in 20. Cumulative incidence of contralateral testicular cancer was 2% at 5 years, and 4% (IC 95% 3%-5%) at 14 years. Younger age was a risk factor for developing a second testicular tumor (P = 0.006), whereas chemotherapy reduced the risk for a metachronous testicular cancer (P = 0.046). Within our cohort, 6 families with testicular cancer aggregation (more than 2 tumors in the same family) were identified.

CONCLUSIONS

Incidence of second testicular neoplasm in this cohort of 3,834 patients was similar to that which has been reported in other countries. Metachronous tumors and seminomas are more common. Follow-up of the contralateral testis is mandatory, as well as adequate information for patients to prevent a second neoplasm if feasible, and to detect and treat it as soon as possible.

Incorporating age into International Germ Cell Consensus Classification (IGCCC): a time to move forward?

BACKGROUND

Older age is a poor prognostic indicator among patients with germ cell tumors. The current study evaluates an age-integrated international germ cell consensus classification (IGCCC) for advanced germ cell tumors.

METHODS

SEER database (2004-2014) was accessed through SEER*Stat program and both IGCCC and age-integrated IGCCC were calculated based on site of the primary, site of the metastasis and level of tumor markers. Overall survival analyses according to IGCCC and age-integrated IGCCC were conducted through Kaplan-Meier analysis.

RESULTS

Overall survival was compared according to IGCCC and age-integrated IGCCC for patients with seminoma and Non-seminomatous germ cell tumors (NSGCTs). P values were significant (P <0.001) for all scenarios. c-index for seminoma for IGCCC was 0.553; c-index for seminoma for age-integrated IGCCC was 0.664;c-index for NSGCTs for IGCCC was 0.729; and c-index for NSGCTs for age-integrated IGCCC was 0.738. A Cox-regression multivariate model of factors affecting cancer-specific survival (adjusted for race and surgical treatment) was conducted. All P values for pair wise comparisons (among different age-integrated IGCCC categories) were significant for both seminoma and NSGCTs (P<0.01).

CONCLUSION

Compared to traditional IGCCC, age-integrated IGCCC is more discriminatory and the new risk groups introduced within it are prognostically relevant.

Synchronous bilateral testis cancer: clinical and oncological management

Synchronous bilateral testis cancer (SBTC) is a rare event. It represents only 0.5–1% of all new cases of testicular cancer. Patients with this disease require careful management for psychological, oncological, and medical problems.

We performed a PubMed search for all series that reported SBTC. We considered only articles in English, reporting on more than three cases. We also performed an analysis of the reported evidence regarding testosterone replacement and surgical treatment.

We found 10 studies satisfying inclusion criteria for a total of 73 patients. The majority are bilateral seminoma, which present with a low stage at diagnosis, and mixed histology tumours, both with a good overall survival. On the other hand, cases with bilateral non-seminoma histology are associated with poor prognosis and high stage at presentation.

Testis-sparing surgery should be an eligible choice in selected cases, to preserve fertility and avoid testosterone deficiency. Multiple biopsies are recommended in these patients, and in the case of intratubular germ cell neoplasia (ITGCN) presence, scrotal radiotherapy is mandatory. Subcutaneous testosterone pellets guarantee higher patient acceptance and physiological testosterone levels. Lifelong follow-up and psychological support, with special care for infertility and erectile dysfunction, must be considered in this cohort of patients.

Bilateral testicular germ cell tumors

Testicular cancer represents 1% to 1.5% of neoplasias in males and 5% of urologic tumors in general. The incidence of bilateral testicular tumors is 1-5%. Approximately one third of the cases are diagnosed as synchronous, while the other two thirds are diagnosed as metachronous tumors. Additionally, 5% of all patients diagnosed with testicular cancer may have contralateral intratubular germ cell neoplasia and may develop a contralateral germ cell tumor. However, few data are available regarding bilateral testicular germ cell tumors (BTGCTs). In this review, we aim to provide an overview of the incidence, pathological features and clinical outcomes.of BTGCTs.

Distribution of testicular tumors in Lebanon: a single institution overview

BACKGROUND

Testicular tumors constitute a rare type of cancer affecting adolescents and young adults with recent reports confirming an increase in incidence worldwide. The purpose of this study was to estimate the epidemiological characteristics and histological subtypes of testicular tumors in the Lebanese population according to the WHO classification of testicular and paratesticular tumors.

MATERIALS AND METHODS

In this single institutional retrospective study, all patients diagnosed with a testicular tumor in Hotel-Dieu de France Hospital University in Beirut between 1992 and 2014 were enrolled. The age, subtype based on the 2004 WHO classification and body side of tumor were analyzed.

RESULTS

A total of two hundred and forty-four (244) patients diagnosed with a testicular tumor in our institution were included in the study. Two hundred and one patients (82.4% of all testicular tumors) had germ cell tumors (TGCT). Among TGCT, 50% were seminomatous tumors, 48% non-seminomatous tumors (NST) and 2% were spermatocytic seminomas. The NST were further divided into mixed germ cell tumors (63.9%), embryonic carcinomas (18.6%), teratomas (15.4%) and yolk sac tumors (2.1%). The mean age for testicular tumors was 32 years. The mean age for germ cell tumors was 31 years and further subtypes such as seminomatous tumors had a mean age of 34 years, 28 years in non-seminomatous tumors and 56 years in spermatocytic seminoma. Patients with right testicular tumor were the predominant group with 55% of patients. Three patients (1.2%) presented with bilateral tumors.

CONCLUSIONS

The distribution of different subgroups and the mean age for testicular tumors proved comparable to most countries of the world except for some Asian countries. Germ cell tumors are the most common subtype of testicular tumors with seminomatous tumors being slightly more prevalent than non-seminomatous tumors in Lebanese patients.

Male infertility and androgen replacement therapy for subjects with bilateral testicular tumors

Purpose

The purpose of this study was to investigate andrological aspects, including male infertility and androgen deficiency, after treatments of bilateral testicular tumors.

Methods

Five subjects with bilateral testicular cancer were clinically analyzed between April 1996 and March 2013.

Results

The mean age at initial treatment was 29.4 ± 3.3 years old. In the 4 metachronous cases, a contralateral tumor occurred after 79.0 ± 50.0 months. Histologically, bilateral seminoma occurred in 3 cases and seminoma and nonseminoma was combined in 2 cases. All subjects underwent bilateral orchiectomy, with additional chemotherapy, radiation therapy, and surgery for metastasis. No tumor recurrence was observed in the 5-34 years following initial treatment. Two subjects married following bilateral orchiectomy after receiving informed consent from their wives. One had two children before contralateral testicular treatment. The other was single and had undergone micro-testicular sperm extraction at contralateral orchiectomy, although no sperm was found. The other one was unknown because long-term followup failed. Androgen replacement therapy (ART) was applied for 4 subjects, and relieved physical and psychological symptoms due to testosterone deficiency without adverse reactions.

Conclusions

ART safely and effectively relieves symptoms in subjects with bilateral testicular tumors. However, male infertility treatment is insufficient, and more aggressive management may be required.

Adjuvant radiotherapy for synchronous bilateral testicular seminoma: a case report and a review of the pertinent literature

Few cases of synchronous bilateral stage I seminomas have been reported in the world literature. We present a case of bilateral synchronous testicular seminoma, the current literature on the management of stage I seminoma, and the implications for radiotherapy. A forty-year-old man presented with synchronous bilateral classical seminomas, both stage IA. After undergoing bilateral inguinal orchiectomy, he received adjuvant external beam radiotherapy, with a standard paraaortic field. After 18 months of followup, he remains well, without evidence of recurrence. Bilateral germ cell tumors (BGCTs) are reported consistently at a low rate. Bilateral radical inguinal orchiectomy is standard of care, yet some groups have proposed an organ preservation approach. Of the reported cases of bilateral stage I synchronous GCT, with concordant seminoma histology, most of them were treated with bilateral orchiectomy and adjuvant radiotherapy. Although morbidity associated with radiotherapy directed at the abdomen is not negligible, adjuvant paraaortic radiotherapy remains safe and well-tolerated treatment regime. Bilateral synchronous stage I seminoma of the testes is rare. Organ preservation remains investigational. Chemotherapy is probably a reasonable option. We propose that patients with bilateral stage I synchronous GCT, with concordant seminoma histology, should be managed with bilateral orchiectomy, followed by paraaortic radiotherapy.

Probability of metachronous testicular cancer in patients with biopsy-proven intratubular germ cell neoplasia depends on first-time treatment of germ cell cancer

PURPOSE

To evaluate the probability of subsequent testicular cancer (STC) in patients with intratubular germ cell neoplasia unclassified (IGCNU) treated for first-time invasive germ cell cancer.

PATIENTS AND METHODS

Sixty-one patients with germ cell testicular cancer or extragonadal germ cell cancer received follow-up from diagnosis of IGCNU to development of STC, initiation of IGCNU-definitive treatment (orchiectomy/radiotherapy), emigration, death, or end of follow-up. The probability of STC was assessed in subgroups according to chemotherapy burden.

RESULTS

The probability of STC in the nonexposed patients was significantly increased compared with those exposed to chemotherapy (P = .05; 5-year probability of 54% [95% CI, 33% to 78%] and 23% [95% CI, 11% to 45%], respectively). In the group of patients treated with one to three cycles or no chemotherapy, the probability of STC was significantly increased compared with those exposed to four or more cycles (P = .03; 5-year probability of 42% [95% CI, 27% to 62%] and 22% [95% CI, 8% to 54%], respectively). Twenty-two of 22 patients were tumor-free and alive at a median of 56 months (range, 2 to 184 months) after diagnosis of STC.

CONCLUSION

Platinum-based chemotherapy may reduce the probability of STC in patients with IGCNU, particularly in those treated with four or more cycles of chemotherapy. A watch-and-wait strategy for patients with IGCNU may be justified in selected patients with future plans for paternity.

Risk and prognostic significance of metachronous contralateral testicular germ cell tumours

BACKGROUND

Testicular germ cell tumour (TGCT) patients are at increased risk of developing a contralateral testicular germ cell tumour (CTGCT). It is unclear whether TGCT treatment affects CTGCT risk.

METHODS

The risk of developing a metachronous CTGCT (a CTGCT diagnosed ≥6 months after a primary TGCT) and its impact on patient's prognosis was assessed in a nationwide cohort comprising 3749 TGCT patients treated in the Netherlands during 1965-1995. Standardised incidence ratios (SIRs), comparing CTGCT incidence with TGCT incidence in the general population, and cumulative CTGCT incidence were estimated and CTGCT risk factors assessed, accounting for competing risks.

RESULTS

Median follow-up was 18.5 years. Seventy-seven metachronous CTGCTs were diagnosed. The SIR for metachronous CTGCTs was 17.6 (95% confidence interval (95% CI) 13.9-22.0). Standardised incidence ratios remained elevated for up to 20 years, while the 20-year cumulative incidence was 2.2% (95% CI 1.8-2.8%). Platinum-based chemotherapy was associated with a lower CTGCT risk among non-seminoma patients (hazard ratio 0.37, 95% CI 0.18-0.72). The CTGCT patients had a 2.3-fold (95% CI 1.3-4.1) increased risk to develop a subsequent non-TGCT cancer and, consequently, a 1.8-fold (95% CI 1.1-2.9) higher risk of death than patients without a CTGCT.

CONCLUSION

The TGCT patients remain at increased risk of a CTGCT for up to 20 years. Treatment with platinum-based chemotherapy reduces this risk.

Testicular cancer survivorship

Because of a rising incidence of, and declining mortality from, testicular cancer, there are an increasing number of survivors of testicular cancer. Given their young age at diagnosis, the survivors have many years of life ahead of them during which they may experience adverse consequences from cancer and its treatment. Over the past few decades and particularly in this century, research into the short- and long-term effects of treatments of testicular cancer has grown rapidly, and now there exist a much greater body of data to help us counsel patients about the risks and side effects of these treatments.

Bilateral synchronous seminoma with bilateral cryptorchidism of the testis

Synchronous bilateral germ cell tumo (BGCT) of the testis is rare and its association with bilateral cryptorchidism is even rarer. We report one case of BGCT of testis with bilateral cryptorchidism who presented as blunt injury abdomen in emergencyand was not diagnosed preoperatively. Postoperatively after an appropriate diagnosis, he was managed with chemotherapy. In this report, we have reviewed the larger series of BGCT for the presentation and management of synchronous BGCT to derive some conclusions.

Intratubular germ cell neoplasms of the testis and bilateral testicular tumors: clinical significance and management options

Objectives:

Intratubular germ cell neoplasia (ITGCN) is the precursor lesion for invasive testicular germ cell tumors (TGCTs) of adolescents and young adults. The rising incidence of these tumors has prompted a rigorous investigation of the etiology, diagnosis and management of ITGCN. Bilateral testicular cancer is closely linked with ITGCN, as patients with unilateral testicular cancer are at the highest risk for a future malignancy in the contralateral testicle.

Methods:

A literature review directed at ITGCN and bilateral testis cancer was performed using the Medline/PubMed database. Our review focused on the pathogenesis, risk factors, diagnosis and treatment regimens utilized.

Results:

Major advances have been made in the understanding of ITGCN over the past 30 years. There is evidence that TGCTs arise from ITGCN, ITGCN is closely related to fetal gonocytes, and that events in pre- and perinatal period may result in abnormal persistence of fetal gonocytes leading to ITGCN and subsequent TGCT. Controversy exists regarding the need to biopsy men at increased risk of TGCT, as well as the best approach to managing patients with known ITGCN. Bilateral testicular cancer has excellent outcomes in the current era of platinum-based chemotherapy.

Conclusion:

The optimal management of patients at risk for ITGCN and future TGCT is still a matter of debate. Individualization of management, including biopsy and treatment, should be based on risk factors for TGCT, compliance with potential surveillance, and patient preferences particularly with regard to fertility.

Risk of bilateral renal cell cancer

PURPOSE

The risk of developing bilateral kidney cancer has not been adequately defined in any large, population-based study with long-term follow-up to our knowledge.

PATIENTS AND METHODS

We estimated the risk of metachronous bilateral renal cell cancer in patients diagnosed with unilateral kidney cancer, as recorded in the nationwide cancer registries of Norway and Sweden. Altogether 28,642 patients were followed for an average of 4.4 years. The standardized incidence ratio--the ratio of the observed number of bilateral cancers to the number expected on the basis of the incidence in the Norwegian and Swedish population at large--was used as a measure of relative risk. We used multivariate Poisson regression to separate the effects of the explanatory variables.

RESULTS

A synchronous bilateral renal cell cancer was reported in 86 patients. A total of 112 metachronous bilateral cancers were recorded during 126,493 person-years of follow-up compared with 35.8 expected, yielding an overall relative risk (RR) of 3.1 (95% CI, 2.6 to 3.8) and a cumulative incidence of 0.8% after 20 or more years of follow-up. In the multivariate analyses, risk increased monotonically with younger age at first diagnosis (P for trend < .001); compared with patients who were 60 years or older, those younger than 40 years were at a 17-fold higher risk (RR = 17.4; 95% CI, 10.1 to 29.8). We also found a modest but statistically significant decreasing trend with increasing duration of follow-up.

CONCLUSION

The risk of metachronous bilateral renal cell cancer is drastically higher among patients first affected at a young age, suggesting a subset of early onset renal cell cancer with a strong genetic component.

The International Testicular Cancer Linkage Consortium: a clinicopathologic descriptive analysis of 461 familial malignant testicular germ cell tumor kindred

OBJECTIVES

Familial aggregation of testicular germ cell tumor (TGCT) has been reported, but it is unclear if familial TGCT represents a unique entity with distinct clinicopathologic characteristics. Here we describe a collection of familial TGCT cases from an international consortium, in an effort to elucidate any clinical characteristics that are specific to this population.

MATERIALS AND METHODS

Families with >or=2 cases of TGCT enrolled at 18 of the sites participating in the International Testicular Cancer Linkage Consortium were included. We analyzed clinicopathologic characteristics of 985 cases from 461 families.

RESULTS

A majority (88.5%) of families had only 2 cases of TGCT. Men with seminoma (50% of cases) had an older mean age at diagnosis than nonseminoma cases (P = 0.001). Among individuals with a history of cryptorchidism, TGCT was more likely to occur in the ipsilateral testis (kappa = 0.65). Cousin pairs appeared to represent a unique group, with younger age at diagnosis and a higher prevalence of cryptorchidism than other families.

CONCLUSIONS

Clinicopathologic characteristics in these familial TGCT cases were similar to those generally described for nonfamilial cases. However, we observed a unique presentation of familial TGCT among cousin pairs. Additional studies are needed to further explore this observation.

Management and outcome of bilateral testicular germ cell tumors: a 25-year single center experience

OBJECTIVES

To analyze risk factors, management, histology, and outcome of bilateral testicular germ cell tumors (TGCT) based on a 25-year single center experience.

METHODS

Out of 612 patients treated for TGCT between 1982 and 2007, 17 (3%) were found to have bilateral disease. Data of these patients were reviewed and analyzed.

RESULTS

Eleven patients (65%) were identified with metachronous and 6 (35%) with synchronous bilateral TGCT. One patient had a cryptorchism in childhood. Patients with metachronous bilateral disease presented at lower stages than those with synchronous bilateral disease (stage I: 82% vs 33%, P = 0.02). In metachronous bilateral TGCT, the interval between the tumors ranged from 4 months to 25 years with a median of 47 months. The risk of developing a TGCT in the contralateral testicle was 26-fold higher than the a-priori risk for a healthy individual to develop TGCT. Overall, 74% of the bilateral tumors were seminomas and >50% of the patients had similar histology on both sides. After a median follow up of 121 months for patients with synchronous and 95 months for patients with metachronous bilateral TGCT, all patients were alive with no evidence of disease.

CONCLUSIONS

Most bilateral TGCT develop metachronously and are seminomas. Although patients with synchronous bilateral disease present at higher stages, both synchronous and metachronous bilateral TGCT carry a similar, excellent prognosis. Patients with unilateral TGCT require careful long-term monitoring of the remaining testicle due to a 26-fold increased risk of contralateral disease and a potentially long risk interval of up to 25 years.

[Testicular adrenal rests: the role of imaging]

Testicular adrenal rests are encountered in ACTH hypersecretion syndromes, most often in congenital adrenal hyperplasia attributable to a deficit in 21-hydroxylase. They are discovered clinically or on systematic sonography, generally in the young adult. On sonography, they appear as confluent hypoechogenic masses, often bilateral, that have developed in the region of the testicular hilum. At a late stage, they take on a highly suggestive attenuating aspect. In color Doppler, they have a regular vascular architecture. They generally regress or stabilize with replacement glucocorticosteroid treatment. They can sometimes progress, which then poses the problem of the type of lesion. Biopsy or spermatic vein samples are not reliable. MRI contributes very little more than sonography. Diagnosis comes with follow-up or, as a last resort, orchidectomy.

Bilateral testicular germ cell tumors in Turkey: increase in incidence in last decade and evaluation of risk factors in 30 patients

PURPOSE

The relative risk of germ cell testicular tumor is significantly higher in patients with a testicular tumor history. We reviewed histological and clinical features in 30 patients with bilateral tumors treated at 2 academic centers in Turkey.

MATERIALS AND METHODS

Of 987 patients with testicular germ cell tumors 30 (3.0%) were diagnosed with bilateral disease. Data on clinical information, histopathology and followup records were reevaluated. Contralateral testis biopsy was not performed in any patient at initial orchiectomy.

RESULTS

Of 30 patients 24 had sequential tumors at a median interval of 75 months (range 3 to 260) and 6 (20.0%) had synchronous tumors. Mean age at presentation was 32.3 and 26.7 years, respectively. The second tumor occurred within 2 and 5 years in 20.8% and 41.7% of patients, respectively. Patients with seminoma were at significantly higher risk for bilateral disease (4.5% vs 2.3%), whereas patients with nonseminoma had more advanced disease at presentation. Synchronous tumors had similar tumor histology on each side and more advanced stage at presentation than metachronous tumors. Most patients with metachronous tumors had stage 1 disease, including 81% originally and 95.2% subsequently. Primary tumors were significantly larger than secondary tumors (4.78 vs 2.59 cm). Median time after the first and second germ cell tumors was 128 and 47 months, respectively. At last followup all patients had no evidence of disease.

CONCLUSIONS

The risk of contralateral testicular germ cell tumor in patients with seminoma was 2 times higher than in those without a history of tumor. Synchronous tumors present at advanced stage and have similar histology on each side. Clinical outcome is excellent with appropriate treatment. Contralateral testis biopsy at initial diagnosis is not mandatory.

ITGCN of the Testis, Contralateral Testicular Biopsy and Bilateral Testicular Cancer

Over 30 years ago Skakkebaek was the first to characterize a noninvasive precursor lesion (intratubular germ cell neoplasia or carcinoma in situ) that would progress to invasive testicular tumors. In this article we discuss the molecular changes thought to cause this malignant transformation, various conditions that predispose to the development of testicular germ cell tumors, diagnostic strategies, and treatment options. Additionally we discuss the current patterns of contralateral testicular biopsy to identify intratubular germ cell neoplasia, as well as the incidence and management of bilateral testicular tumors.

c-KIT is frequently mutated in bilateral germ cell tumours and down-regulated during progression from intratubular germ cell neoplasia to seminoma

Testicular germ cell tumours (TGCTs) are the most frequent cancer type in young men; 5% of these patients develop a second TGCT in the contralateral testis. The pathogenesis of TGCT is closely linked to primordial germ cells (PGCs) or gonocytes. The receptor tyrosine kinase (c-KIT) is necessary for migration and survival of PGCs and is expressed in intratubular neoplastic germ cells (IGCNUs) and seminomas. We studied the frequency of c-KIT exon 11 and 17 mutations in 155 unilateral (108 seminomas and 47 non-seminomas) and 22 bilateral (18 seminomas, two embryonal carcinomas, two IGCNU) cases. While no mutations were detected in exon 11, the mutation frequency in exon 17 was significantly higher in bilateral (14/22, 63.6%) compared to unilateral TGCT (10/155, 6.4%) (p < 0.001). Different activating mutations (Y823D, D816V, D816H and N822K) were detected in bilateral TGCT. Y823D mutation was identical in both testes in three cases and quantitative pyrosequencing showed that up to 76% of the cells analysed in tumour samples carried this mutation. One bilateral synchronous seminoma revealed a S821F mutation in one testis and a Y823D mutation contralaterally. To study the role of c-KIT in TGCT progression, we compared its expression in 41 seminomas and adjacent IGCNUs. Immunohistochemical analysis revealed that c-KIT expression was significantly reduced in seminomas compared to IGCNUs (p < 0.006) and that there were no significant changes in c-KIT mRNA copy numbers in progressed compared to low-stage seminomas. In summary, our study shows that patients with c-KIT mutations are more prone to develop a bilateral TGCT and suggests that in a portion of bilateral TGCTs, c-KIT mutations occur early during embryonal development, prior to the arrival of PGCs at the genital ridge. Furthermore, our findings show that c-KIT down-regulation occurs during the progression of IGCNU to seminoma.

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.