Spermatogenesis in the contralateral testis of patients with testicular germ cell cancer: histological evaluation of testicular biopsies and a comparison with healthy males

Partial orchiectomy vs. radical orchiectomy for pediatric testis tumors

While radical orchiectomy remains the gold standard for testicular cancer, partial orchiectomy has become a well-accepted organ-sparing approach for benign testicular tumors in pre-pubertal patients. The aims of testicular-sparing surgery include prevention of over-treatment, preservation of future hormonal and reproductive function, and provision of a durable cure. For pre-pubertal patients, who have a high likelihood of benign lesions, partial orchiectomy provides effective treatment, owing to the high reliability of scrotal ultrasound (US) and intraoperative frozen section. In adolescent and young adult patients, who are more likely to harbor malignant pathology, the role of partial orchiectomy is less clear. Testis-sparing surgery is being reported with greater frequency in the adult literature for small testicular masses and for situations in which radical orchiectomy would result in an anorchia. More recently, a testis-sparing approach has also been described for carefully-selected post-pubertal pediatric patients. This review will highlight the role of partial orchiectomy in pediatric patients (<18 years old).

ESMO Consensus Conference on testicular germ cell cancer: diagnosis, treatment and follow-up

The European Society for Medical Oncology (ESMO) consensus conference on testicular cancer was held on 3-5 November 2016 in Paris, France. The conference included a multidisciplinary panel of 36 leading experts in the diagnosis and treatment of testicular cancer (34 panel members attended the conference; an additional two panel members [CB and K-PD] participated in all preparatory work and subsequent manuscript development). The aim of the conference was to develop detailed recommendations on topics relating to testicular cancer that are not covered in detail in the current ESMO Clinical Practice Guidelines (CPGs) and where the available level of evidence is insufficient. The main topics identified for discussion related to: (1) diagnostic work-up and patient assessment; (2) stage I disease; (3) stage II-III disease; (4) post-chemotherapy surgery, salvage chemotherapy, salvage and desperation surgery and special topics; and (5) survivorship and follow-up schemes. The experts addressed questions relating to one of the five topics within five working groups. Relevant scientific literature was reviewed in advance. Recommendations were developed by the working groups and then presented to the entire panel. A consensus vote was obtained following whole-panel discussions, and the consensus recommendations were then further developed in post-meeting discussions in written form. This manuscript presents the results of the expert panel discussions, including the consensus recommendations and a summary of evidence supporting each recommendation. All participants approved the final manuscript.

Preservation of Fertility in Testis Cancer Management

The presence of cancer in the testis, as well as the therapies used to treat testis cancer, can impair fertility potential for affected men. Fertility preservation is an important aspect of survivorship care and should be offered to all patients before initiating treatment. The only established means of fertility preservation in men is cryopreservation of sperm. Methods for fertility preservation in prepubertal boys are still experimental. Physicians treating men with testicular cancer should be familiar with the available options. This article outlines testicular cancer and its treatment's effects on fertility, fertility preservation options, and barriers to accessing this specialized care.

Recently Described and Clinically Important Entities in Testis Tumors: A Selective Review of Changes Incorporated Into the 2016 Classification of the World Health Organization

Context.—

In 2016 the World Health Organization published a revised classification of testicular neoplasms based upon advances in understanding their pathogenesis and molecular biology. The rationale for this revision and additional clinically relevant observations were the topics of a talk given to the Houston Society of Clinical Pathologists in April 2017. This paper summarizes that talk.

Objective.—

To summarize and explain the most important changes to the classification of testicular neoplasms in the World Health Organization 2016 revision.

Data Sources.—

Peer-reviewed published literature and contributions by individuals with expertise in this area that were also reviewed by genitourinary pathologists.

Conclusions.—

Most changes occurred in the germ cell tumor classification, including replacement of the terms intratubular germ cell neoplasia unclassified and carcinoma in situ by germ cell neoplasia in situ; subdivision of the tumors into 2 main categories, those derived from germ cell neoplasia in situ and those not derived from germ cell neoplasia in situ; distinction of germ cell neoplasia in situ from germ cells with delayed maturation and pre–germ cell neoplasia in situ; expansion of the trophoblastic tumor category to include epithelioid trophoblastic tumor and cystic trophoblastic tumor; and substitution of spermatocytic tumor for spermatocytic seminoma and its placement in the non–germ cell neoplasia in situ group. Other revisions included eliminating sclerosing Sertoli cell tumor as a distinct entity; the recognition of intratubular hyalinizing Sertoli cell tumor; and acceptance of the role of undifferentiated gonadal tissue in the pathogenesis of gonadoblastoma.

Toxicities Associated with Cisplatin-Based Chemotherapy and Radiotherapy in Long-Term Testicular Cancer Survivors

Testicular cancer has become the paradigm of adult-onset cancer survivorship, due to the young age at diagnosis and 10-year relative survival of 95%. This clinical review presents the current status of various treatment-related complications experienced by long-term testicular cancer survivors (TCS) free of disease for 5 or more years after primary treatment. Cardiovascular disease and second malignant neoplasms represent the most common potentially life-threatening late effects. Other long-term adverse outcomes include neuro- and ototoxicity, pulmonary complications, nephrotoxicity, hypogonadism, infertility, and avascular necrosis. Future research efforts should focus on delineation of the genetic underpinning of these long-term toxicities to understand their biologic basis and etiopathogenetic pathways, with the goal of developing targeted prevention and intervention strategies to optimize risk-based care and minimize chronic morbidities. In the interim, health care providers should advise TCS to adhere to national guidelines for the management of cardiovascular disease risk factors, as well as to adopt behaviors consistent with a healthy lifestyle, including smoking cessation, a balanced diet, and a moderate to vigorous intensity exercise program. TCS should also follow national guidelines for cancer screening as currently applied to the general population.

A Brief Review of the Link between Environment and Male Reproductive Health: Lessons from Studies of Testicular Germ Cell Cancer

During the past few decades there has been a significantly increasing trend in germ cell tumours all over the world, particularly in countries with Caucasian populations. The changes in incidence have occurred so fast that only environmental factors can explain this development. This review focuses on the hypothesis that testicular germ cell cancer, which originates from germ cell neoplasia in situ, is of foetal origin and associated with other male reproductive problems through a testicular dysgenesis syndrome, also including foetal origin of impaired spermatogenesis, hypospadias and cryptorchidism. There is little doubt that environmental factors associated with modern lifestyles have - in a broad sense - had an adverse influence on male reproductive health. The hypothesis that exposure to endocrine-disrupting chemicals plays a fundamental role in this trend is plausible. This is based on evidence from animal studies that demonstrate adverse reproductive effects caused by a number of endocrine-disrupting chemicals to which humans are exposed as part of our modern lifestyle.

Organ-sparing surgery for testicular tumours

PURPOSE OF REVIEW

Testicular cancer represents the majority of testicular masses, and radical orchiectomy is still considered the standard-of-care. Testis-sparing surgery (TSS) can be an alternative to radical surgery in patients with small testicular tumours, bilateral or solitary testis masses. The aim of this manuscript is to review the current indications, oncological and functional outcomes of TSS.

RECENT FINDINGS

Our review confirmed that literature lacks studies with a high level of evidence on comparing TSS with radical surgery. Indications for TSS are controversial, specifically for patients with normal contralateral testis. For nonpalpable testicular masses less than 2 cm, bilateral tumours and solitary testis mass, TSS seems to be a viable treatment option. Frozen-section examination is a critical tool for assessment at the time of TSS that allows for diagnosis of benign from malignant tumours and evaluation of margin. TSS has been shown to be associated with less fertility alterations, hormonal deficit and potential lower impact on sexual and psychosocial aspects. Intermediate to long-term follow-up results have not revealed any significant risk of local and/or distant recurrences after TSS.

SUMMARY

TSS is well tolerated and feasible for selected patients with testicular mass without compromising oncological and functional outcomes. Further studies with a higher level of evidence are needed to confirm these findings.

The efficiency of Poly(ADP-Ribose) Polymerase (PARP) cleavage on detection of apoptosis in an experimental model of testicular torsion

The aim of this study was to evaluate the histopathological and apoptotic changes occurring in the rat ipsilateral and contralateral testes, after experimental spermatic cord torsion, and to explore and the role of poly(ADP-ribose) polymerase (PARP) cleavage in testicular torsion-detorsion injury. A total of 37 Wistar albino rats were subjected to 720° unilateral spermatic cord torsion for 1, 2 and 4 h, followed by 4-h reperfusion, or else to a sham operation (control group). Histology of the testicle was evaluated using haematoxylin-eosin (H&E) staining and Johnsen's scoring system. Germ cell apoptosis was evaluated via active caspase-3 immunostaining, and PARP expression levels were evaluated via Western blotting. The mean Johnsen's tubular biopsy scores (JTBS) of the ipsilateral testicles were lower for all torsion groups than for the controls (P < 0.05), but the JTBS of the contralateral testicles were only lower in the 4-h torsion group (P < 0.05). The mean apoptosis score (AS) of the ipsilateral and contralateral testicles was significantly higher in the torsion groups than in the sham group. AS increased correlatively with torsion time, in both testicles. The effect of testicular torsion on PARP cleavage was time dependent, with the highest effect observed after 4 h of testicular torsion (P < 0.05). Testicular torsion caused time-dependent histological changes, apoptosis and increases in PARP cleavage. Our results suggest that testicular torsion-detorsion injury caused cell damage and germ cell apoptosis that apparently involved cleavage of PARP. Increased PARP cleavage could, in turn, lead to enhanced apoptosis.

The effects of carvedilol on ischemia-reperfusion injury in the rat testis

OBJECTIVE

To analyze the oxidative damage and histopathological alterations caused by ischemia-reperfusion (I/R) injury and ameliorative effects of carvedilol (CVD) in the rat testis.

MATERIALS AND METHODS

Twenty-one male rats were randomized into 3 groups as follows: Group I (n = 7); control (sham) group, Group II (n = 7); I/R group, in which I/R injury was performed by torsing the left testis 720 ° clockwise for 2 hours and detorsing for 2 hours. Group III (n = 7); CVD treatment group; in addition to I/R process, one-dose of CVD was administered (2mg/kg, i.p) 30 min. before detorsion. Levels of antioxidant enzymes, superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) and levels of malondialdehyde (MDA) and protein carbonyl (PC) were determined in testicular tissues and serum of rats. Testicular tissues were also examined histopathologically and Johnsen scores were determined.

RESULTS

Activities of SOD and GSH-Px in serum and testicular tissues were increased by I/R, but administration of CVD decreased these levels (p < 0.001 and p = 0.001). Significantly increased MDA levels in serum and testicular tissues were decreased by CVD treatment (p < 0.001 and p = 0.001). Concerning PC levels in serum and testicular tissues, there was no statistically significant difference between the groups (p = 0.989 and p = 0.428). There was not a statistically significant difference in terms of mean Johnsen scores between the groups (p = 0.161).

CONCLUSIONS

Administration of CVD decreased oxidative damage biochemically in the rat testis caused by I/R injury, but histopathologically no change was observed betwe¬en all of the groups.

Sperm cryopreservation before cancer treatment: a 15-year monocentric experience

Sperm banking is an important procedure to preserve fertility before cancer therapy. The aim of this study was to comprehensively analyse cryopreservation activity retrospectively for 1080 patients referred to the sperm bank for sperm cryopreservation before cancer treatment. This study included 1007 patients diagnosed with testicular cancer (TC) (41.7%), lymphoma (26%), other haematological cancers (9.4%) or other types of cancer (22.8%); of these, 29 patients did not produce any semen sample and cryopreservation was impossible for 67 patients. Semen characteristics before treatment were within normal ranges, except moderate asthenospermia. Sperm concentration was significantly lower in TC than in non-TC. Straws from 57 patients (6.3%) were used in assisted reproductive technologies, which led to a 46.8% cumulative birth rate. Straws were destroyed for 170 patients (18.7%) and 140 patients performed semen analyses after cancer therapy. After an average delay of 22.5 months after the end of therapy, 43 patients (30.7%) exhibited azoospermia. This study of a large population of cancer patients revealed a high level of successful sperm storage. Utilization of cryopreserved spermatozoa led to good chances of fatherhood. Nevertheless, sperm banks should be aware of the low rates of straw use and straw destruction by cancer patients.

Effects of endogenous FSH on normal human spermatogenesis in adults

Unilateral orchiectomy (UO) in adult bonnet monkeys and boars elicits a compensatory increase in size and sperm production of the remaining testis. The objective of this study was to investigate whether a similar effect is evident also in humans. We prospectively studied 50 patients from October 2003 to December 2005 who underwent UO for seminomatous tumour, with sperm concentration >20 × 10(6) /mL or total sperm count >40 × 10(6) at diagnosis and without elevation of serum tumour markers. Patients were followed-up with surveillance and they were studied at the time of diagnosis of testicular cancer (T(-1) ), 1 month after unilateral orchiectomy (T(0) ) and yearly for 3 years (T(1) , T(2) , T(3) ) with semen analysis, measurement of plasma levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), inhibin B, total testosterone, and oestradiol and ultrasonographic scanning of the remaining testis. A decline in circulating inhibin B and an increase in FSH levels were evident 1 month after UO. The elevation of FSH was maintained up to 3 years and was associated with a significant increase in testicular volume of 19 and 30%, 2 and 3 years after UO respectively. Although patients had normozoospermia at the time of diagnosis of testicular cancer, they showed a statistically significant increase in total sperm count at T(2) and T(3) with respect to T(-1) and T(0.) In conclusion, we showed that in humans, the testes are not normally operating at their maximal potential in terms of spermatogenesis. Therefore, in physiological situations, FSH secretion is insufficient to stimulate spermatogenesis to its ceiling. A sustained endogenous increase in FSH secretion might drive human testes towards their maximal function.

Zebrafish models of germ cell tumor

Germ cell tumors are neoplasms arising from pluripotent germ cells. In humans, these tumors occur in infants, children and young adults. The tumors display a wide range of histologic differentiation states which exhibit different clinical behaviors. Information about the molecular basis of germ cell tumors, and representative animal models of these neoplasms, are lacking. Germline development in zebrafish and humans is broadly conserved, making the fish a useful model to probe the connections between germ cell development and tumorigenesis. Here, we provide an overview of germline development and a brief review of germ cell tumor biology in humans and zebrafish. We also outline some methods for studying the zebrafish germline.

Long-term clinical outcome in patients with stage-I nonseminomatous germ cell cancer. A critical review of own treatment modalities in a retrospective study

PURPOSE

The optimal management of patients with clinical stage I non-seminomatous germ cell testicular cancer (NSGCT I) was considered controversial until the European Germ Cell Cancer Consensus Group determined unambiguous treatment strategies. In order to assess the long-term outcome we evaluated the data of patients with NSGCT I.

MATERIALS AND METHODS

In a retrospective evaluation, we included 52 patients with a mean age of 26 years (range 15-58) who were treated with different modalities at our department between 1989 and 2003. Mean follow-up was 5.9 years (range 2-14 years). After orchiectomy, 39 patients were treated with chemotherapy, 7 patients underwent retroperitoneal lymph node dissection and 6 men were managed using a surveillance strategy. Survival, recurrence rate and time of recurrence were evaluated. The histological staging and treatment modality was related to the relapse.

RESULTS

Tumor specific overall mortality was 3.8%. The mortality and relapse rate of the surveillance strategy, retroperitoneal lymph node dissection and chemotherapy was 16.7% / 50%, 14.3% / 14.3% and 0% / 2.5% respectively. All relapsed patients in the surveillance group as well as in the RPLND group had at least one risk factor for developing metastatic disease.

CONCLUSIONS

Following the European consensus on diagnosis and treatment of germ cell cancer in patients with NSGCT Stage I any treatment decision must be individually related to the patient according to prognostic factors and care capacity of the treating centre. In case of doubt, adjuvant chemotherapy should be the treatment of choice, as it provides the lowest risk of relapse or tumor related death.

Semen quality in men with disseminated testicular cancer: relation with human chorionic gonadotropin beta-subunit and pituitary gonadal hormones

OBJECTIVE

To compare the semen quality and hormonal status between patients with testicular cancer and normal versus increased serum levels of beta-hCG.

DESIGN

Retrospective study.

SETTING

Academic research environment.

PATIENT(S)

All 203 patients with testicular cancer who required chemotherapy in the period 1995-2003 were included.

INTERVENTION(S)

In 107 patients semen samples were stored by cryopreservation; 62 patients could be analyzed because both semen was stored and hormones were determined before starting chemotherapy (median age 25 years, range 17-49 years).

MAIN OUTCOME MEASURE(S)

Total motile sperm count, T, E(2), LH, FSH, and PRL.

RESULT(S)

Total motile sperm count was decreased in patients with increased beta-hCG (median 11.9 x 10(6)) compared with patients with normal beta-hCG (median 21.5 x 10(6)). Testosterone, E(2), and PRL were significantly higher in patients with increased beta-hCG levels, whereas LH and FSH were lower. Semen quality was significantly and negatively correlated with beta-hCG, E(2), and PRL.

CONCLUSION(S)

Patients with increased beta-hCG had an inferior spermatogenesis compared with patients with normal beta-hCG. Increased beta-hCG appears to be associated with impaired spermatogenesis and increased levels of E(2) and PRL.

Application of stem cell markers in search for neoplastic germ cells in dysgenetic gonads, extragonadal tumours, and in semen of infertile men

Germ cell tumours (GCTs) are a complex entity. Current areas of attention include early detection and avoidance of unnecessary over-treatment. Novel findings regarding diagnosis of GCTs located in various anatomical sites are described, particularly testicular GCTs and their common progenitor, carcinoma in situ (CIS). Recognition of CIS enables intervention before tumour development, but nevertheless, testicular GCTs are sporadically diagnosed at the pre-invasive stage where minimal treatment is necessary. As presence of CIS is asymptomatic, a simple screening method is needed when CIS is suspected (i.e. in males investigated for infertility). To develop approaches for early detection CIS gene expression studies have been performed showing many similarities with embryonic stem cells with confirmation of established markers (i.e. PLAP, OCT-3/4, KIT) and identification of novel markers (i.e. AP-2 gamma, NANOG). We have reported a very promising new approach of AP-2 gamma (or OCT3/4) based immunocytological semen analysis (specificity 93.6%, sensitivity 54.5%). Comparative studies of gonadal/extragonadal GCTs have revealed resemblance pointing towards similar, but not identical, origins. Moreover, infertility and testicular cancer are connected in the 'Testicular Dysgenesis Syndrome' and 25% of contralateral testes from testicular GCT patients harbour dysgenetic features, including impaired spermatogenesis. Thus, recent data have provided potential diagnostic tools including CIS detection in semen, microarray-based tumour classification, additional serological GCT markers, and novel stem cell markers for immunohistochemical diagnosis of gonadal and extragonadal GCTs. Many CIS candidate genes are yet uninvestigated, and information from these could increase knowledge about CIS tumour initiation/progression and be used for optimisation of a non-invasive detection method.

Prä- und paraklinische Verbundstudien beim Hodentumor

Testicular malignancy is a rare disease. On average, no more than three patients per year are seen in the majority of urological departments in Germany. Thus, progress regarding management and biological understanding of testicular cancer can only result from cooperative trials. The "German Testicular Cancer Study Group" initiates and supports multicentric studies on testicular cancer focusing on both treatment modalities and basic ("paraclinical") issues. The body size study evaluates the hypothesis that testicular cancer is associated with adult stature. An exploratory study looks at the putative association of testicular cancer and Down syndrome (trisomy 21). Another study documents events of myocardial infarction during chemotherapy for testicular cancer. Finally, late relapses after a disease-free interval of more than two years are evaluated regarding risk factors and prognosis. All of the projects listed here are simple recording studies, i.e. no extended documentation work is required and no clinical intervention is intended. In Germany, chemotherapy for testicular cancer is usually applied by urologists, which is in marked contrast to international custom. Accordingly, urologists are not only facing the responsibility to care for their testis cancer patients but they must also adopt the task of advancing knowledge and clinical expertise with respect to this disease. Opportunities for simple but fruitful contributions to clinical research are offered to even nonacademic institutions by the projects highlighted here.