Mature Testicular Teratoma with Positive Estrogen Receptor Beta Expression in a Transgendered Individual on Cross-Sex Hormonal Therapy: A Case Report

Urologic oncology considerations in transgender and gender diverse patients

PURPOSE OF REVIEW

This review delves into the pressing issue of urologic oncology considerations within the transgender and gender-diverse (TGD) community. With estimates suggesting that TGD individuals constitute 0.3 to 0.5% of adults worldwide, and this number steadily rising, our review examines the barriers that impede the delivery of excellent quality care, particularly in the context of cancer diagnosis and treatment.

RECENT FINDINGS

Recent findings highlight disparities in cancer screening, diagnosis, and treatment access for TGD individuals. These challenges are compounded by a dearth of research and the failure of healthcare systems to account for gender identity and its nuances in data collection. Main themes in the literature include the impact of gender-affirming hormone therapy and surgery on cancer risk, challenges in prostate cancer screening and management, and considerations pertinent to testicular and other urological cancers in TGD patients.

SUMMARY

The implications for clinical practice and research are profound and emphasize the need for multidisciplinary approaches that cater to the unique healthcare needs of TGD individuals. This includes comprehensive strategies for inclusive and accurate data collection, alongside the development of evidence-based guidelines for cancer screening and management tailored specifically to this population.

Successful Treatment of Primary Mediastinal Large B-cell Lymphoma with DA-EPOCH-Rituximab Therapy in a Transgender Woman

In recent years, lesbian, gay, bisexual, and transgender (LGBT) populations have been gaining acceptance in society. However, very few cases of malignancy in the LGBT population have been reported thus far. We herein report a transgender woman receiving estrogen supplementation who developed primary mediastinal large B-cell lymphoma (PMBCL) and was treated with dose-adjusted EPOCH-rituximab (DA-EPOCH-R) therapy. The patient achieved complete remission after the sixth course of DA-EPOCH-R therapy. To help this LGBT patient continue receiving chemotherapy smoothly on admission, adjusting the hospital environment, such as the allocation of rooms, was essential.

Cancer screening and management in the transgender population: Review of literature and special considerations for gender affirmation surgery

BACKGROUND

Literature focused on cancer screening and management is lacking in the transgender population.

AIM

To action to increase contributions to the scientific literature that drives the creation of cancer screening and management protocols for transgender and gender nonconforming (TGNC) patients.

METHODS

We performed a systematic search of PubMed on January 5th, 2022, with the following terms: "TGNC", OR "transgender", OR "gender non-conforming", OR "gender nonbinary" AND "cancer screening", AND "breast cancer", AND "cervical cancer", AND "uterine cancer", AND "ovarian cancer", AND "prostate cancer", AND "testicular cancer", AND "surveillance", AND "follow-up", AND "management". 70 unique publications were used. The findings are discussed under "Screening" and "Management" categories.

RESULTS

Screening: Current cancer screening recommendations default to cis-gender protocols. However, long-term gender-affirming hormone therapy and loss to follow-up from the gender-specific specialties contribute to a higher risk for cancer development and possible delayed detection. The only known screening guidelines made specifically for this population are from the American College of Radiology for breast cancer. Management: Prior to undergoing Gender Affirmation Surgery (GAS), discussion should address cancer screening and management in the organs remaining in situ. Cancer treatment in this population requires consideration for chemotherapy, radiation, surgery and/or reconstruction. Modification of hormone therapy is decided on a case-by-case basis. The use of prophylactic vs aesthetic techniques in surgery is still debated.

CONCLUSION

When assessing transgender individuals for GAS, a discussion on the future oncologic risk of the sex-specific organs remaining in situ is essential. Cancer management in this population requires a multidisciplinary approach while the care should be highly individualized with considerations to social, medical, surgical and gender affirming surgery related specifications. Special considerations have to be made during planning for GAS as surgery will alter the anatomy and may render the organ difficult to sample for screening purposes. A discussion with the patient regarding the oncologic risk of remaining organs is imperative prior to GAS. Other special considerations to screening such as the conscious or unconscious will to unassociated with their remaining organs is also a key point to address. We currently lack high quality studies pertinent to the cancer topic in the gender affirmation literature. Further research is required to ensure more comprehensive and individualized care for this population.

Clinicopathologic features and proposed grossing protocol of orchiectomy specimens performed for gender affirmation surgery

Gender affirmation surgery performed for gender dysphoria is increasing to instigate changes more closely approximating gender identity. We investigated the clinicopathologic features of gender-affirming orchiectomies performed at our institution and devised a grossing protocol for these increasingly encountered specimens. We obtained 45 orchiectomies from 23 patients and reviewed clinicopathologic features. The number of sections per case was noted and reviewed to devise an optimal grossing protocol to assess pathologic findings. Twenty-three patients had bilateral orchiectomy with 1 unilateral. The average patient age was 39.4 years (range, 21-71 years); all received hormones for a mean of 66.1 months (range, 12-348 months). The average number of slides per orchiectomy was 8 slides (range, 1-11). Aspermatogenesis occurred in 32 (71%), hypospermatogenesis in 8 (18%), and normal spermatogenesis in 5 (11%) testes. Twenty-five (56%) exhibited scattered cells with nuclear cytomegaly, concerning for germ cell neoplasia in situ (GCNIS), but OCT4 negative. Six (13%) had multinucleated stromal cells. Leydig cells were markedly reduced/absent in 38 testes (85%). Epithelial hyperplasia was identified in 15 rete testes (33%) and 24 epididymes (53%), while 18 (40%) showed periepididymal muscular hyperplasia. All findings were identified in the initial 2 slides including rete testis/epididymis, except for 3 cases, missing only focal tubular sclerosis. Despite all received treatment, only a subset showed changes of exogenous hormone therapy. The presence of nuclear cytomegaly can mimic GCNIS and may be a potential pitfall. Two sections to include rete testis/epididymis and a third of cord margin are sufficient to identify the relevant pathology and germ cell tumors overall are uncommon in orchiectomies performed for gender affirmation.

Incidence of Testicular Cancer in Transfeminine Patients following Vaginoplasty with Orchidectomy

Background

Little is known about the prevalence of testicular cancer in the transfeminine population. Only six cases have been reported in the literature. This case series reports six additional cases of various testicular cancers found in transfeminine patients who underwent vaginoplasty with orchidectomy in our institution.

Methods

In our institution, all specimens are routinely sent to pathology following vaginoplasty with orchidectomy. This permitted the identification of all positive cases of testicular cancer. A chart review was conducted to retrieve patient demographics, duration of hormonotherapy, type of neoplasm, the context of its discovery, and cancer follow-up.

Results

A total of 2555 patients underwent vaginoplasty with orchidectomy between January 2016 and January 2021. All specimens were sent to pathology for analysis. A total of six (0.23% of patients) specimens revealed malignant lesions.

Conclusions

Increased societal awareness toward the transgender population encourages recourse to gender-affirming procedures. Little is known about the incidence of testicular cancer in the transfeminine population. In total, 0.23% of patients in our cohort presented with positive pathology findings indicative of testicular cancer. All cancers were found to be only locally invasive, and all patients were successfully treated. We therefore encourage routine pathology examination for all specimens following vaginoplasty with orchidectomy.

Testicular mixed germ cell tumor in a transgender woman

Transgender women who have not undergone orchiectomy remain at risk for the development of testicular cancer. Unfortunately, many physicians self-report a weak fund of knowledge around transgender health issues and some are uncomfortable performing proper exams or advising patients on self-exams. Here we report the first case of a testicular mixed germ cell tumor that developed in a transgender woman and discuss the salient points of caring for transgender patients.

Incidence of testicular cancer in trans women using gender-affirming hormonal treatment: a nationwide cohort study

Objective

To assess the incidence of testicular cancer in trans women (male sex assigned at birth, female gender identity) using gender‐affirming hormonal treatment.

Patients and Methods

Data of trans women starting hormonal treatment at our gender identity clinic between 1972 and 2017 were linked to the national pathology database to obtain testicular cancer diagnoses. The standardised incidence ratio (SIR) was calculated using the number of observed testicular cancer cases in our cohort and the number of expected cases based on age‐specific Dutch incidence rates. Subgroup analyses were performed in testicular tissues sent for histopathological analysis at the time of bilateral orchidectomy, and when follow‐up exceeded 5 years.

Results

The cohort consisted of 3026 trans women with a median follow‐up time of 2.3 interquartile range (IQR) (1.6–3.7) years. Two testicular cancer cases were identified whilst 2.4 cases were expected (SIR 0.8, 95% confidence interval 0.1–2.8). In addition, one testicular cancer case was encountered in an orchidectomy specimen (0.1%). In the 523 trans women with a follow‐up time of >5 years (median [IQR] 8.9 [6.4–13.9] years), no testicular cancer was observed.

Conclusion

Testicular cancer risk in trans women is similar to the risk in cis men. The testicular cancer cases occurred within the first 5 years after commencing hormonal treatment, and the percentage of cases encountered at the time of bilateral orchidectomy was low. As no testicular cancer was observed in trans women with a long follow‐up period, long‐term hormonal treatment does not seem to increase testicular cancer risk.

Histologic Findings in Surgical Pathology Specimens From Individuals Taking Feminizing Hormone Therapy for the Purpose of Gender Transition: A Systematic Scoping Review

CONTEXT.—

Transgender women experience health disparities in all areas of medicine. Within surgical pathology, knowledge gaps relating to the concepts of transgender care exist. Medical transition for transgender women and transfeminine persons may involve hormone therapy and/or surgery to feminize the body. Understanding the common histologic changes in specimens from feminizing surgeries, as well as other specimens from patients on feminizing hormone therapy, will aid surgical pathologists in providing better care to this unique patient population.

OBJECTIVE.—

To summarize histologic findings in surgical pathology specimens from transgender women taking feminizing hormones.

DATA SOURCES.—

A systematic review of the OVID Medline and PubMed databases was performed to identify all studies describing histologic findings in surgical pathology specimens from transgender women from 1946 to 2019.

CONCLUSIONS.—

Much of the literature to date describing histologic findings in transgender women comes from the examination of genitourinary specimens removed during feminizing surgeries. Common benign changes associated with feminizing hormone therapy include the development of acini and lobules in the breast, testicular tubular changes, and squamous metaplasia of the prostate and urethra. Neoplastic cases include breast adenocarcinoma and fibroepithelial lesions, testicular germ cell tumors, prostatic adenocarcinoma, anal squamous cell carcinoma, pituitary adenomas, and meningiomas. Additional studies assessing the findings in other organ systems as well as population-based studies assessing rates of neoplasia are needed. However, future research relies on engagement within the surgical pathology community as well as collaboration with clinicians and patients to achieve optimal results.

Incidence of Cancer and Premalignant Lesions in Surgical Specimens of Transgender Patients

BACKGROUND

Gender-affirming surgery is becoming increasingly more common. Procedures including chest masculinization, breast augmentation, vaginoplasty, metoidioplasty, and phalloplasty routinely generate discarded tissue. The incidence of finding an occult malignancy or premalignant lesion in specimens from gender-affirming surgery is unknown. The authors therefore conducted a retrospective review of all transgender patients at their institution who underwent gender-affirming surgery to determine the incidence of precancerous and malignant lesions found incidentally.

METHODS

A retrospective review of transgender patients who underwent gender-affirming surgery at the authors' institution between 2017 and 2018 performed by a single plastic surgeon and a single reconstructive urologic surgeon was conducted. Only transgender patients who underwent gender-affirming surgery that led to routine pathologic review of discarded tissue (mastectomy, vaginoplasty, vaginectomy as part of phalloplasty) were included. Charts were reviewed and patient demographics, duration of hormonal therapy, medical comorbidities, genetic risk factors for cancer, medications (including steroids or other immunosuppressants), pathology reports, and cancer management were recorded.

RESULTS

Between 2017 and 2018, 295 transgender patients underwent gender-affirming surgery that generated discarded tissue sent for pathologic evaluation. During this period, 193 bilateral mastectomies, 94 vaginoplasties with orchiectomies, and eight vaginectomies were performed; 6.4 percent of all patients had an atypical lesion found on routine pathologic evaluation.

CONCLUSIONS

Gender-affirming surgery is increasingly more common given the increase in access to care. The authors' review of routine pathologic specimens generated from gender-affirming surgery yielded a 6.4 percent rate of finding atypical lesions requiring further evaluation. The authors advocate that all specimens be sent for pathologic evaluation.

Unmasked Testicular Seminoma During Use of Hormonal Transgender Woman Therapy: A Hidden hCG-Secreting Tumor

Management of gender-affirming hormone therapy (HT) in transgender women includes surveillance of testosterone (T) levels. Failure of T to suppress, despite adherence to therapy, warrants additional investigations for unexpected sources of T or factors stimulating T secretion. Possible causes include T or gonadotropin production by an occult neoplasm. Testicular cancer is the most common malignancy affecting biological men aged between 15 and 35 years. Patients may be asymptomatic until tumor burden is high and/or metastatic. Hormone-producing tumors have rarely been reported in treated transgender women. Routine screening tests are recommended in a gender-incongruent person as per the 2017 Endocrine Society guidelines with measurement of T levels every 3 months initially to reach a goal of less than 50 ng/dL. Expectations should be discussed in detail with the transgender person since anticipated physical changes may not be notable for 6 to 18 months. We herein describe a case of a transgender woman who underwent standard HT including gonadotropin suppression with a gonadotropin-releasing hormone agonist, whose total T level failed to suppress. Testing revealed an elevated serum level of the beta subunit of human chorionic gonadotropin (β-hCG), diagnostic of an hCG-secreting testicular seminoma, as the underlying cause of unexpected T production. This case illustrates how easily a testicular cancer can remain unnoticed because it can be asymptomatic and the necessity to be alert to, and act on, anomalous laboratory results during treatment of a transgender person.

Orchiectomy as Bridge or Alternative to Vaginoplasty

Simple orchiectomy for gender affirmation is a low-risk, minimally invasive, generalizable procedure that eliminates circulating endogenous testosterone, allowing reduced hormonal supplementation. This article describes a technique that serves as a step in definitive phenotypic transition while maximally preserving healthy tissue for future sex reassignment surgery. Orchiectomy should be offered routinely as a bridge or alternative to vaginoplasty, particularly in the setting of limited access to specialized centers for transgender surgery.

Health considerations for transgender women and remaining unknowns: a narrative review

Transgender (trans) women (TW) were assigned male at birth but have a female gender identity or gender expression. The literature on management and health outcomes of TW has grown recently with more publication of research. This has coincided with increasing awareness of gender diversity as communities around the world identify and address health disparities among trans people. In this narrative review, we aim to comprehensively summarize health considerations for TW and identify TW-related research areas that will provide answers to remaining unknowns surrounding TW's health. We cover up-to-date information on: (1) feminizing gender-affirming hormone therapy (GAHT); (2) benefits associated with GAHT, particularly quality of life, mental health, breast development and bone health; (3) potential risks associated with GAHT, including cardiovascular disease and infertility; and (4) other health considerations like HIV/AIDS, breast cancer, other tumours, voice therapy, dermatology, the brain and cognition, and aging. Although equally deserving of mention, feminizing gender-affirming surgery, paediatric and adolescent populations, and gender nonbinary individuals are beyond the scope of this review. While much of the data we discuss come from Europe, the creation of a United States transgender cohort has already contributed important retrospective data that are also summarized here. Much remains to be determined regarding health considerations for TW. Patients and providers will benefit from larger and longer prospective studies involving TW, particularly regarding the effects of aging, race and ethnicity, type of hormonal treatment (e.g. different oestrogens, anti-androgens) and routes of administration (e.g. oral, parenteral, transdermal) on all the topics we address.

Cancer's Margins: Trans* and Gender Nonconforming People's Access to Knowledge, Experiences of Cancer Health, and Decision-Making

PURPOSE

Research in Canada and the United States indicates that minority gender and sexuality status are consistently associated with health disparities and poor health outcomes, including cancer health. This article investigates experiences of cancer health and care, and access to knowledge for trans* and gender nonconforming people diagnosed with and treated for breast and/or gynecologic cancer. Our study contributes new understandings about gender minority populations that will advance knowledge concerning the provision of culturally appropriate care. This is the first study we are aware of that focuses on trans* and gender nonconforming peoples' experiences of cancer care and treatment, support networks, and access to and mobilization of knowledge.

METHODS

This article analyzes trans* and gender nonconforming patient interviews from the Cancer's Margins project ( www.lgbtcancer.ca ): Canada's first nationally-funded project that investigates the complex intersections of sexual and/or gender marginality, cancer knowledge, treatment experiences, and modes of the organization of support networks.

RESULTS

Our analysis documents how different bodies of knowledge relative to cancer treatment and gendered embodiment are understood, accessed, and mobilized by trans* and gender nonconforming patients. Findings reported here suggest that one's knowledge of a felt sense of gender is closely interwoven with knowledge concerning cancer treatment practices; a dynamic which organizes knowledge mobilities in cancer treatment.

CONCLUSIONS

The findings support the assertion that cisgender models concerning changes to the body that occur as a result of biomedical treatment for breast and/or gynecologic cancer are wholly inadequate in order to account for trans* and gender nonconforming peoples' experiences of cancer treatments, and access to and mobilization of related knowledge.