Complex treatment of residual metastatic germ cell cancer: A single center experience

BACKGROUND

Testicular cancer is the most common solid malignancy among men aged 15-35. Radical orchiectomy and platinum-based chemotherapy (BEP) are curative in the majority of patients, including advanced, metastatic cases. According to current urooncology guidelines all non-seminoma patients harbouring post-chemotherapy residual masses of ≥ 1 cm should undergo salvage retroperitoneal lymph node dissection (RPLND). However, only 10% of residual tumors contain viable disease.

OBJECTIVE

To assess patient outcomes and complications considering different treatment regimens and clinical characteristics.

MATERIALS AND METHODS

In a retrospective cross-sectional study patients (n=127) who underwent postchemotherapy RPLND between 2007 and 2023 at our referral center were evaluated. The patients received systemic treatment at various oncology centers. The number of BEP cycles received were occasionally different from standard. Only patients with normal postchemotherapy serum tumor markers and primary testicular or extragonadal germ cell neoplasms were included. Treatment groups were established according to the number of BEP cycles received, and the extent of RPLND (bilateral or modified template). Treatment outcomes and complications were assessed.

RESULTS

Standard 3-4 courses of BEP were received by 100 (78,7%) patients, while 11 (8,7%) patients underwent less, and 16 (12,6%) more courses than standard. On histopathologic evaluation viable germ cell tumor, teratoma, and necrosis/fibrosis was present in 26 (20,5%), 67 (52,7%) and 34 (26,8%) of specimen, respectively. In the 5-6 BEP series subgroup high rate of viable disease (37,5%) was found and significantly more nephrectomies were performed, than other chemotherapy subgroups. Extratesticular GCT, viable disease in residual mass or progression after RPLND indicated lower survival. Mild (Clavien-Dindo I-II) or no postoperative complications were reported in 93,7% of cases.

CONCLUSIONS

The study suggests no significant benefit from exceeding 3-4 courses of BEP. Timely salvage RPLND should be performed in high volume centers for optimal treatment outcomes with acceptable complication rates. Adherence to the Heidenreich criteria is advisable where practical.

The effect of diagnosis delay in testis cancer on tumor size, tumor stage and tumor markers

INTRODUCTION

In testicular cancer, the positive effect of early diagnosis on survival has been known for many years. In this study, we aimed to determine the diagnostic features of testicular cancer patients, to examine the effect of duration of diagnosis delay (DD) on tumor size, tumor stage, and serum tumor markers, and to reveal the possible benefits of early diagnosis.

METHODS

A total of 71 patients who underwent inguinal orchiectomy due to suspicion of testicular cancer and whose pathology was found to be the germ cell tumor were included in the study. The relationship between the duration of diagnosis delay and tumor size, level of tumor markers, TNM stage, presence of LAP, and presence of metastasis were examined.

RESULTS

Seminoma was detected in 39 (54.9%) patients and non-seminoma tumor was detected in 32 (45.1%) patients. In the correlation analysis between the markers, a significant and positive correlation was found between DD and radiological tumor size, pathological tumor size, retroperitoneal LAP detection rate, LDH and AFP levels, and N stage (respectively; r=0.345 p=0.003, r=0.324 p=0.006, r=0.244 p=0.041, r=0.286 p=0.015, r=0.244 p=0.040, r=0.238 p=0.046). It was determined that a 1-day increase in DD caused an increase of 0.431mm in the pathological size of the tumor.

CONCLUSION

Duration of diagnosis delay is an issue that still keeps its importance for testicular tumors. Delay in diagnosis not only leads to an increase in tumor size but also negatively affects tumor stage and prognostic factors.

Tumor biomarkers for diagnosis, prognosis and targeted therapy

Tumor biomarkers, the substances which are produced by tumors or the body's responses to tumors during tumorigenesis and progression, have been demonstrated to possess critical and encouraging value in screening and early diagnosis, prognosis prediction, recurrence detection, and therapeutic efficacy monitoring of cancers. Over the past decades, continuous progress has been made in exploring and discovering novel, sensitive, specific, and accurate tumor biomarkers, which has significantly promoted personalized medicine and improved the outcomes of cancer patients, especially advances in molecular biology technologies developed for the detection of tumor biomarkers. Herein, we summarize the discovery and development of tumor biomarkers, including the history of tumor biomarkers, the conventional and innovative technologies used for biomarker discovery and detection, the classification of tumor biomarkers based on tissue origins, and the application of tumor biomarkers in clinical cancer management. In particular, we highlight the recent advancements in biomarker-based anticancer-targeted therapies which are emerging as breakthroughs and promising cancer therapeutic strategies. We also discuss limitations and challenges that need to be addressed and provide insights and perspectives to turn challenges into opportunities in this field. Collectively, the discovery and application of multiple tumor biomarkers emphasized in this review may provide guidance on improved precision medicine, broaden horizons in future research directions, and expedite the clinical classification of cancer patients according to their molecular biomarkers rather than organs of origin.

Primary mediastinal seminoma with azoospermia: case report and review of the literature

Introduction

Since the first report, primary mediastinal seminoma has a low incidence in the population, and it mainly affects young and middle-aged men, is clinically rare, and accounts for a very small proportion of mediastinal tumors. In this study, we describe the first case of primary mediastinal seminoma with azoospermia and hypothesize that the coexistence of the two disorders may not be a coincidence.

Case report

A 16-year-old man presented with chest tightness and chest pain, a mediastinal mass on chest CT, and abnormal 18F-fluoro-deoxyglucose uptake on a PET-CT scan. By biopsy of the mass, the pathological diagnosis was a primary mediastinal seminoma. Because chemotherapy is included in the treatment of the tumor, the patient underwent sperm freezing before treatment, considering that chemotherapy can affect fertility, but the patient was diagnosed with azoospermia. Finally, the patient underwent tumor resection and postoperative chemotherapy. No tumor recurrence was observed at the current follow-up.

Conclusion

Primary mediastinal seminoma is mainly confirmed by histopathological examination, and surgery and chemoradiotherapy are the current treatments. In patients with mediastinal seminoma or azoospermia, doctors should be aware that the two disorders may coexist, especially in men who have fertility requirements or long-term infertility, and that examination of the mediastinum and semen may lead to unexpected findings in the diagnosis and treatment. For mediastinal germ cell tumors, genetic testing is of great value in the treatment of tumors and the prediction of associated diseases. Future studies exploring the potential correlation between mediastinal seminoma and azoospermia will be prospective.

Advancing GCT Management: A Review of miR-371a-3p and Other miRNAs in Comparison to Traditional Serum Tumor Markers

MicroRNAs, short non-protein coding RNAs, are overexpressed in GCTs. Circulating levels of germ cell tumor (GCT)-associated miRNAs, such as miR-371a-3p, can be utilized as efficient and cost-effective alternatives in diagnosing and managing patients presenting with GCTs. This quality of miRNAs has demonstrated favorable performance characteristics as a reliable blood-based biomarker with high diagnostic accuracy compared to current serum tumor markers (STMs), including α-fetoprotein (AFP), beta human chorionic gonadotropin (β-hCG), and lactate dehydrogenase (LDH). The conventional STMs exhibit limited specificity and sensitivity. Potential clinical implications of miRNAs include impact on de-escalating or intensifying treatment, detecting recurrence at earlier stages, and lessening the necessity of cross-sectional imaging or invasive tissue biopsy for non-teratomatous GCTs. Here, we also highlight the outstanding issues that must be addressed prior to clinical implementation. Standards for measuring circulating miRNAs and determining ideal cutoff values are essential for integration into current clinical guidelines.

Differentiation of testicular seminomas from nonseminomas based on multiphase CT radiomics combined with machine learning: A multicenter study

BACKGROUND

Differentiating seminomas from nonseminomas is crucial for formulating optimal treatment strategies for testicular germ cell tumors (TGCTs). Therefore, our study aimed to develop and validate a clinical-radiomics model for this purpose.

METHODS

In this study, 221 patients with TGCTs confirmed by pathology from four hospitals were enrolled and classified into training (n = 126), internal validation (n = 55) and external test (n = 40) cohorts. Radiomics features were extracted from the CT images. After feature selection, we constructed a clinical model, radiomics models and clinical-radiomics model with different machine learning algorithms. The top-performing model was chosen utilizing receiver operating characteristic (ROC) curve analysis. Decision curve analysis (DCA) was also conducted to assess its practical utility.

RESULTS

Compared with those of the clinical and radiomics models, the clinical-radiomics model demonstrated the highest discriminatory ability, with AUCs of 0.918 (95 % CI: 0.870 - 0.966), 0.909 (95 % CI: 0.829 - 0.988) and 0.839 (95 % CI: 0.709 - 0.968) in the training, validation and test cohorts, respectively. Moreover, DCA confirmed that the combined model had a greater net benefit in predicting seminomas and nonseminomas.

CONCLUSION

The clinical-radiomics model serves as a potential tool for noninvasive differentiation between testicular seminomas and nonseminomas, offering valuable guidance for clinical treatment.

Testicular cancer in 2023: Current status and recent progress

Testicular germ cell tumor (GCT) is the most common solid tumor in adolescent and young adult men. Progress in the management of GCT has been made in the last 50 years, with a substantial improvement in cure rates for advanced disease, from 25% in the 1970s to nearly 80%. However, relapsed or platinum-refractory disease occurs in a proportion, 20% of whom will die from disease progression. This article reviews the current evidence-based treatments for extracranial GCT, the acute and chronic toxic effects that may result, and highlights contemporary advances and progress in the field.

A case report of challenges in distinguishing gastroesophageal junction hepatoid adenocarcinoma from testicular germ cell tumor: Insights for improved diagnosis with gene expression profiling

Gastroesophageal junction hepatoid adenocarcinoma is a rare form of gastroesophageal cancer. We present a case of a 38-year-old man with no significant medical history who was diagnosed with gastroesophageal junction hepatoid adenocarcinoma but initially misdiagnosed with a testicular germ cell tumor, given the elevated alpha-feto protein and poorly differentiated pathology. We will elaborate on the importance of gene expression profiling in modern oncology to better define the tumor of origin in patients with cancer of unknown primary origin, how it helped us to diagnose gastroesophageal junction hepatoid adenocarcinoma and how it can help identify potential additional therapeutic targets in some cases. Due to the rarity of this subtype of gastroesophageal junction cancer there is a lack of standard therapeutic options, and we will discuss the most commonly used treatment regimens. The patient underwent three lines of antineoplastic therapy and unfortunately passed after 51 weeks of follow-up.

A novel lactate dehydrogenase-based risk score model to predict the prognosis of primary central nervous system germ cell tumor treated with chemoradiotherapy

BACKGROUND

The prognostic role of lactate dehydrogenase (LDH) has been confirmed in many malignant tumors, but the role of serum LDH in primary central nervous system germ cell tumor (GCT) remains unknown. This study aimed to assess the prognostic value of LDH in GCT patients and develop a nomogram to predict prognosis in patients undergoing chemoradiotherapy.

METHODS

A total of 161 patients with GCT were included in this study. Using a restricted cubic spline (RCS) model, the optimal cutoff point for LDH was determined to be 217 U/L. The survival of GCT patients was evaluated using the Kaplan-Meier method and log-rank test to analyze the effects of LDH levels. Univariate Cox regression, multivariate Cox regression, and LASSO Cox regression were conducted to identify prognostic factors, which were incorporated into a nomogram for predicting overall survival (OS). The predictive accuracy of the nomogram was assessed using the C-index, calibration curve, area under the time-dependent receiver operating characteristic curve (time-dependent AUC), and risk group stratification. The net benefits of the nomogram at different threshold probabilities were quantified using decision curve analysis (DCA).

RESULTS

The high-LDH group had significantly shorter OS compared to the low-LDH group (P = 0.016). Based on the SYSUCC cohort, three variables were shown to be significant factors for OS and were incorporated in the nomogram: LDH, histopathology, and dissemination. It showed good discrimination ability, with C-index of 0.789 (95% CI, 0.671-0.907). Additionally, the clinical usefulness of the nomogram was confirmed by calibration curves and time-dependent AUC. DCA further highlighted the potential of the nomogram to guide clinical treatment strategies for patients. Moreover, there was a significant difference in OS among patients categorized into different risk groups (P < 0.001).

CONCLUSION

LDH levels may serve as a reliable predictor for assessing the therapeutic effect of chemoradiotherapy in GCT. The developed nomogram exhibits high accuracy in predicting survival outcomes, aiding in the classification of prognostic groups, and supporting informed clinical decision-making.

Diffusion-weighted imaging in pediatric extracranial germ cell tumors

BACKGROUND

Germ cell tumors (GCTs) comprise a rare and heterogeneous group of neoplasms presenting different clinical and histological characteristics, leading to a challenging scenario in clinical practice. Diffusion-weighted imaging (DWI) has been suggested as an indirect marker of tumor density and cellularity and could be used to monitor therapeutic response. However, its role in pediatric GCTs needs to be clarified.

PURPOSE

Here, we evaluated the features of DWI in pediatric extracranial GCTs in a reference Brazilian institution.

MATERIAL AND METHODS

We included 43 pediatric patients with primary GCTs treated between 2008 and 2022 in Hospital de Amor de Barretos. The patients' MRI images included T1-weighted without contrast, T2-weighted, DWI and apparent diffusion coefficient (ADC) maps. DWI was evaluated in the section that exhibited the greatest restricted diffusion in the largest hypersignal area of the image. The lowest ADC value was determined to define the region of interest (ROI). We used a small ROI, avoiding necrotic, adipose tissue, noisy or nonenhancing lesion voxels as recommended. ROI determination was established by visual inspection by two radiologists in accordance. We used two values of b (b = 50 mm2/s or b = 800) for ADC values.

RESULTS

The highest mean ADC (mADC) value was observed in pure teratomas (1,403.50 ± 161.76 x10-3 mm2/s; mean ± SD) compared to other histologies (yolk sac, mixed teratoma, dysgerminoma and mixed GCT) of GCT (p<0.001). Furthermore, ROC analysis determined a cutoff mADC value of 1,179.00 x 10-3 mm2/s that differentiated pure teratomas from the other GCT histologies with a sensitivity of 95.8% and a specificity of 92.9% (AUC = 0.979; p<0.01). A significant increase in mADC was observed for malignant GCTs in treatment (1,197.00 ± 372.00 mm2/s; p<0.001) compared to that exhibited at the time of diagnosis (780.00 ± 168.00 mm2/s; mean ± SD. Our findings suggest that mADC assessment could be used as a tool to distinguish pure teratomas from malignant CGT histologies at diagnosis. Additionally, we demonstrated reasonable evidence that it could be used as a complementary tool to monitor treatment response in patients with malignant GCT.

Multiparametric Ultrasound for Diagnosing Testicular Lesions: Everything You Need to Know in Daily Clinical Practice

BACKGROUND

Ultrasonography (US) represents the gold standard imaging method for the assessment of testicular lesions (TL). The gray-scale (GSUS) and color-Doppler (CDUS) ultrasound examination allow sonographers to investigate the size, margins, echotexture, and vascular features of TLs with the aim to differentiate benign from malignant lesions. Recently, the use of contrast-enhanced US (CEUS) and sonoelastography (SE) has led to further improvements in the differential diagnosis of TL. Although GSUS and CDUS are often sufficient to suggest the benign or malignant nature of the TL, CEUS can be decisive in the differential diagnosis of unclear findings, while SE can help to strengthen the diagnosis. The contemporary combination of GSUS, CDUS, CEUS, and SE has led to a new diagnostic paradigm named multiparametric US (mp-US), which is able to provide a more detailed characterization of TLs than single techniques alone. This narrative and pictorial review aimed to describe the mp-US appearance of several TLs.

METHODS

An extensive Medline search was performed to identify studies in the English language focusing on the mp-US evaluation of TLs.

RESULTS

A practical mp-US "identity card" and iconographic characterization of several benign and malignant TLs is provided herein.

CONCLUSIONS

The mp-US characterization of TL reported herein can be useful in daily clinical practice.

Extragonadal Germ Cell Tumors: A Single Institution Experience with Clinicopathological Correlation

Background. Extragonadal germ cell tumors (EGCTs) are a rare heterogeneous group of tumors without evidence of primary gonadal germ cell tumors. They account for 2%-5% of overall malignancies. EGCTs are often not clinically suspected, making them challenging for pathologists. In this retrospective observational study, we describe our institutional experience among EGCTs with clinicopathological correlation. Materials and methods. All patients diagnosed as EGCTs from January 2014 to April 2023 were collected. All relevant clinical data and serum markers were retrieved from hospital medical records. Histopathology and immunohistochemistry slides were reviewed. Results. The present study included a total of 56 patients; 34 (60%) men and 22 (40%) women with a men-to-women ratio of 1.5:1. Of them, 1 patient had congenital/neonatal EGCTs, 21 patients had prepubertal EGCTs, and 34 had post-pubertal EGCTs. The common sites included are mediastinum (45%), sacrococcyx (18%), retroperitoneum (14%), and central nervous system (12%). The other rare sites were the vagina, liver, colon, and duodenum. The common germ cell tumor included mature teratoma (34%), mixed germ cell tumor (27%), seminoma/germinoma (12%), pure yolk sac tumor (11%), immature teratoma (9%), mature teratoma with somatic tumor (5%), and embryonal carcinoma (2%). All histological diagnoses of germ cell tumors were confirmed with IHC markers like PLAP, CD117 (KIT), AFP, LIN28, CD30, and β-hCG. Pre and posttreatment serum tumor marker levels were available in 37 patients. All our treated patients had a decrease or normal tumor marker levels post-therapy. Conclusion. In our study, a heterogeneous group of germ cell tumors was seen. Most of them were seen in post-pubertal adolescents and young adults. Early intervention by platinum-based combination chemotherapy in seminoma and nonseminomatous germ cell tumors has significantly improved the prognosis of malignant EGCTs similar to their germ cell counterparts.

[18F]fluorodeoxyglucose positron emission tomography/computed tomography characteristics of primary mediastinal germ cell tumors

Primary mediastinal germ cell tumor (MGCT) is an uncommon tumor. Although it has histology similar to that of gonadal germ cell tumor (GCT), the prognosis for MGCT is generally worse than that for gonadal GCT. We performed visual assessment and quantitative analysis of [18F]fluorodeoxyglucose positron emission tomography/computed tomography ([18F]FDG PET/CT) for MGCTs. A total of 35 MGCT patients (age = 33.1 ± 16.8 years, F:M = 16:19) who underwent preoperative PET/CT were retrospectively reviewed. The pathologic diagnosis of MGCTs identified 24 mature teratomas, 4 seminomas, 5 yolk sac tumors, and 2 mixed germ cell tumors. Visual assessment was performed by categorizing the uptake intensity, distribution, and contour of primary MGCTs. Quantitative parameters including the maximum standardized uptake value (SUVmax), tumor-to-background ratio (TBR), metabolic tumor volume (MTV), total lesion glycolysis (TLG), and maximum diameter were compared between benign and malignant MGCTs. On visual assessment, the uptake intensity was the only significant parameter for differentiating between benign and malignant MGCTs (p = 0.040). In quantitative analysis, the SUVmax (p < 0.001), TBR (p < 0.001), MTV (p = 0.033), and TLG (p < 0.001) showed significantly higher values for malignant MGCTs compared with benign MGCTs. In receiver operating characteristic (ROC) curve analysis of these quantitative parameters, the SUVmax had the highest area under the curve (AUC) (AUC = 0.947, p < 0.001). Furthermore, the SUVmax could differentiate between seminomas and nonseminomatous germ cell tumors (p = 0.042) and reflect serum alpha fetoprotein (AFP) levels (p = 0.012). The visual uptake intensity and SUVmax on [18F]FDG PET/CT showed discriminative ability for benign and malignant MGCTs. Moreover, the SUVmax may associate with AFP levels.

Refractory primary mediastinal malignant germ cell tumor with multiple systemic metastases: A rare case report

The incidence of extra-gonadal germ cell tumor is low. There are few reports about liver metastasis and multiple systemic metastasis of mediastinal germ cell tumor. Here, we report a case of a 42-year-old young man with mediastinal mass discovered by computed tomography, which was finally confirmed as mediastinal germ cell tumor after many pathological biopsies. After radiotherapy and chemotherapy, the mediastinal mass was stable, but a new mass appeared in the liver. Mediastinal mass remained stable after modification of treatment regimen, but multiple metastases were found throughout the body. He finally died after 8 months of treatment because of his poor health.

MicroRNA-371a-3p-The Novel Serum Biomarker in Testicular Germ Cell Tumors

INTRODUCTION

Testicular germ cell tumors (TGCTs) are a paradigm for the use of serum tumor markers in clinical management. However, conventional markers such as alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH) have quite limited sensitivities and specificities. Within the last decade, the microRNA-371a-3p (miR371) emerged as a possible new biomarker with promising features.

AREAS COVERED

This review covers the typical features as well as possible clinical applications of miR371 in TGCT patients, such as initial diagnosis, therapy monitoring, and follow-up. Additionally, technical issues are discussed.

EXPERT OPINION

With a sensitivity of around 90% and specificity >90%, miR371 clearly outperforms the classical serum tumor markers in TGCTs. The unique features of the test involve the potential of modifying recent standards of care in TGCT. In particular, miR371 is expected to aid clinical decision-making in scenarios such as discriminating small testicular TGCT masses from benign ones prior to surgery, assessing equivocal lymphadenopathies, and monitoring chemotherapy results. Likewise, it is expected to make follow-up easier by reducing the intensity of examinations and by sparing imaging procedures. Overall, the data presently available are promising, but further prospective studies are required before the test can be implemented in standard clinical care.

How [18F]-FDG-PET/CT Affects Clinical Management of Patients with Germ Cell Tumors in the Real World

OBJECTIVE

The aim of this study was to evaluate the impact of PET/CT on clinical management of patients with germ cell tumors (GCTs) conducted in a real-world setting, including avoidance of invasive procedures, additional diagnostic imaging, and changes in treatment.

METHODS

Patients with GCTs were prospectively enrolled into a PET/CT registry study between May 2013 and April 2021. Intended patient management prior and after PET/CT was documented using standardized questionnaires. Changes in oncologic staging and clinical management after PET/CT were recorded, including planned treatment and planned additional diagnostics.

RESULTS

Forty-three male patients with GCTs were included consecutively in this study. After PET/CT, oncologic staging changed in 22/43 patients (51%), with upstaging in seven cases (16%), downstaging in ten cases (23%), and cancer relapse in five cases (11%). The number of patients with intended curative treatment remained stable, while a considerable change in intended therapeutic intervention was noted after PET/CT, with an increase in planned chemotherapy from three to eleven patients and a decrease in planned surgical resection from eleven to two patients. In addition, PET/CT contributed to preventing patients from intended invasive procedures including biopsy and surgery in 8/43 (19%) cases and from additional diagnostic procedures in 25 (58%) cases.

CONCLUSION

With the use of FDG-PET/CT as a tool to guide patient management in GCTs, we observed a notable impact on clinical staging and a consequent reduction in the need for additional invasive and diagnostic procedures. These findings are expected to be even more consequential in the future as treatment modalities improve and the life expectancy of GCT patients further increases.

KEY POINTS

PET/CT considerably influences the clinical stage of GCT patients. PET/CT has remarkable influence on the choice of therapeutic interventions and reduces additional diagnostic procedures.

The Value of Tumour Markers in the Detection of Relapse-Lessons Learned from the Swiss Austrian German Testicular Cancer Cohort Study

The tumour markers alpha-fetoprotein (AFP), beta human chorionic gonadotropin (βHCG), and lactate dehydrogenase (LDH) have established roles in the management and follow-up of testicular cancer. While a tumour marker rise can serve as an indicator of relapse, the frequency of false-positive marker events has not been studied systematically in larger cohorts. We assessed the validity of serum tumour markers for the detection of relapse in the Swiss Austrian German Testicular Cancer Cohort Study (SAG TCCS). This registry was set up to answer questions on the diagnostic performance and impact of imaging and laboratory tests in the management of testicular cancer, and has included 948 patients between January 2014 and July 2021.A total of 793 patients with a median follow-up of 29.0 mo were included. In total, 71 patients (8.9%) had a proven relapse, which was marker positive in 31 patients (43.6%). Of all patients, 124 (15.6%) had an event of a false-positive marker elevation. The positive predictive value (PPV) of the markers was limited, highest for βHCG (33.8%) and lowest for LDH (9.4%). PPV tended to increase with higher levels of elevation. These findings underline the limited accuracy of the conventional tumour markers to indicate or rule out a relapse. Especially, LDH as part of routine follow-up should be questioned.

Patient summary

With the diagnosis of testicular cancer, the three tumour markers alpha-fetoprotein, beta human chorionic gonadotropin, and lactate dehydrogenase are routinely measured during follow-up to monitor for relapse. We demonstrate that these markers are often falsely elevated, and, by contrast, many patients do not have marker elevations despite a relapse. The results of this study can lead to improved use of these tumour markers during follow-up of testis cancer patients.

Real-world histopathological approach to malignancy of undefined primary origin (MUO) to diagnose cancers of unknown primary (CUPs)

The aim of this study is to envisage a streamlined pathological workup to rule out CUPs in patients presenting with MUOs. Sixty-four MUOs were classified using standard histopathology. Clinical data, immunocytochemical markers, and results of molecular analysis were recorded. MUOs were histologically subdivided in clear-cut carcinomas (40 adenocarcinomas, 11 squamous, and 3 neuroendocrine carcinomas) and unclear-carcinoma features (5 undifferentiated and 5 sarcomatoid tumors). Cytohistology of 7/40 adenocarcinomas suggested an early metastatic cancer per se. In 33/40 adenocarcinomas, CK7/CK20 expression pattern, gender, and metastasis sites influenced tissue-specific marker selection. In 23/40 adenocarcinomas, a "putative-immunophenotype" of tissue of origin addressed clinical-diagnostic examinations, identifying 9 early metastatic cancers. Cell lineage markers were used to confirm squamous and neuroendocrine differentiation. Pan-cytokeratins were used to confirm the epithelial nature of poorly differentiated tumors, followed by tissue and cell lineage markers, which identified one melanoma. In total, 47/64 MUOs (73.4%) were confirmed CUP. Molecular analysis, feasible in 37/47 CUPs (78.7%), had no diagnostic impact. Twenty CUP patients, mainly with squamous carcinomas and adenocarcinomas with putative-gynecologic-immunophenotypes, presented with only lymph node metastases and had longer median time to progression and overall survival (< 0.001), compared with patients with other metastatic patterns. We propose a simplified histology-driven workup which could efficiently rule out CUPs and identify early metastatic cancer.

Carcinoembryonic Antigen, Carbohydrate Antigen 19-9, Cancer Antigen 125, Prostate-Specific Antigen and Other Cancer Markers: A Primer on Commonly Used Cancer Markers

Cancer markers are molecules produced by cancer cells which may serve to identify the presence of cancer. Cancer markers can be differentiated as serum-based, radiology-based and tissue-based, and are one of the most important tools in diagnosing, staging and monitoring of treatment of many cancers. The most used cancer markers are serum cancer markers due to its relative ease and lower cost of testing. However, serum cancer markers have poor mass screening utilization due to poor positive predictive value. Several markers such as prostate-specific antigen (PSA), beta-human chorionic gonadotropin (B-hCG), alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH) are used to aid in diagnosis of cancer in cases of high suspicion. Serum markers such as carcinoembryonic antigen (CEA), AFP, carbohydrate antigen 19-9 (CA 19-9), and 5-hydroxyindoleacetic acid (5-HIAA) play a significant role in assessing disease prognosis as well as response to treatment. This work reviews the role of some of the biomarkers in the diagnosis and treatment of cancer.

Integrated Microarray-Based Data Analysis of miRNA Expression Profiles: Identification of Novel Biomarkers of Cisplatin-Resistance in Testicular Germ Cell Tumours

Testicular germ cell tumours (TGCTs) are the most common solid malignancy among young men, and their incidence is still increasing. Despite good curability with cisplatin (CDDP)-based chemotherapy, about 10% of TGCTs are non-responsive and show a chemoresistant phenotype. To further increase TGCT curability, better prediction of risk of relapse and early detection of refractory cases is needed. Therefore, to diagnose this malignancy more precisely, stratify patients more accurately and improve decision-making on treatment modality, new biomarkers are still required. Numerous studies showed association of differential expressions of microRNAs (miRNAs) with cancer. Using microarray analysis followed by RT-qPCR validation, we identified specific miRNA expression patterns that discriminate chemoresistant phenotypes in TGCTs. Comparing CDDP-resistant vs. -sensitive TGCT cell lines, we identified miR-218-5p, miR-31-5p, miR-125b-5p, miR-27b-3p, miR-199a-5p, miR-214-3p, let-7a and miR-517a-3p as significantly up-regulated and miR-374b-5p, miR-378a-3p, miR-20b-5p and miR-30e-3p as significantly down-regulated. In patient tumour samples, we observed the highest median values of relative expression of miR-218-5p, miR-31-5p, miR-375-5p and miR-517a-3p, but also miR-20b-5p and miR-378a-3p, in metastatic tumour samples when compared with primary tumour or control samples. In TGCT patient plasma samples, we detected increased expression of miR-218-5p, miR-31-5p, miR-517a-3p and miR-375-5p when compared to healthy individuals. We propose that miR-218-5p, miR-31-5p, miR-375-5p, miR-517-3p, miR-20b-5p and miR-378a-3p represent a new panel of biomarkers for better prediction of chemoresistance and more aggressive phenotypes potentially underlying metastatic spread in non-seminomatous TGCTs. In addition, we provide predictions of the targets and functional and regulatory networks of selected miRNAs.

Identification of novel potential genes in testicular germ cell tumors: A transcriptome analysis

OBJECTIVE

Testicular germ cell tumors (TGCTs), containing pure seminoma and non-seminoma, occupy the most majority of testicular cancers in adolescents and young men, which has increased dramatically in recent decades. Therefore, it is important to find crucial genes for improving diagnosis and prognosis in TGCTs. However, the diagnostic and prognostic markers of TGCTs are limited.

METHODS

In this study, our main objective is to explore novel potential genes that can be used as diagnostic and prognostic biomarkers in TGCTs. Our study detected 732 differentially expressed genes (DEGs) using three microarray expression profiling datasets from Gene Expression Omnibus (GEO). Multiple analysis was performed to identify the roles of DEGs, including pathway and functional enrichment analysis, protein-protein interaction (PPI) network analysis, module analysis, and survival analysis.

RESULT

In total, 322 upregulated genes and 406 downregulated genes were identified as DEGs The functional and pathway enrichment analysis shows that DEGs were highly enriched in multiple biological attributes such as T cell activation, reproduction in multicellular organism, sperm flagellum, antigen processing and presentation Then, seven potential crucial genes were identified via PPI network analysis, module analysis, and survival analysis. Furthermore, 7 potential crucial genes had shown to play a key role in regulating immune cell infiltration level in patients with TGCTs.

CONCLUSION

We identified seven potential crucial genes (LAPTM5, NCF2, PECAM1, CD14, COL4A2, ANPEP and RGS1), which may be molecular markers in improving the way of diagnosis and prognosis in TGCTs.

Immune-related mechanisms and immunotherapy in extragonadal germ cell tumors

Purpose of review

Extragonadal germ cell tumors (EGCTs) are relatively rare tumors, accounting for 1%-5% of all GCTs. In this review, we summarize the current research progress regarding the pathogenesis, diagnosis, and treatment of EGCTs from an immunology perspective.

Recent findings

The histological origin of EGCTs is related to a gonadal origin, but they are located outside the gonad. They show great variation in morphology and can occur in the cranium, mediastinum, sacrococcygeal bone, and other areas. The pathogenesis of EGCTs is poorly understood, and their differential diagnosis is extensive and challenging. EGCT behavior varies greatly according to patient age, histological subtype, and clinical stage.

Summary

This review provides ideas for the future application of immunology in the fight against such diseases, which is a hot topic currently.

A Nonseminomatous Germ Cell Tumor Presenting as a Mixed Cryoglobulinemic Vasculitis

Background

Mixed cryoglobulinemia syndrome (MCS) is a rare entity with a variety of causes but has not been associated with testicular germ cell tumors. We present here a case of a patient with a nonseminomatous germ cell tumor (NSGCT) presenting as a type III mixed cryoglobulinemic vasculitis. Case Presentation. A 58-year-old male exhibited typical clinical features of vasculitis, including weakness, fatigue, palpable purpura, multiple mononeuropathy, and a low C4 level. An MCS diagnosis was confirmed by the presence of cryoglobulins (6%) with polyclonal IgM and IgG components and biopsy proven leukocytoclastic vasculitis. Concomitantly, a stage IIIC (TxNxM1bS1) germ tumor with marked elevation of serum beta-human chorionic gonadotropin (2764 mUI/mL) was diagnosed. An aggressive treatment was needed, including methylprednisolone pulses, plasmapheresis, rituximab, followed by orchiectomy, and chemotherapy (bleomycin/etoposide/cisplatin). After tumor resection and treatment, cryoglobulins decrease to 0%, suggesting a paraneoplastic origin of the vasculitis.

Conclusion

To the best of our knowledge, this is the first case of MCS possibly attributable to a NSGCT. This case further elaborates on the presentation of mixed cryoglobulinemia vasculitis and adds to the published literature on the topic.

Impact of differing methodologies for serum miRNA-371a-3p assessment in stage I testicular germ cell cancer recurrence

Introduction

Current evidence shows that serum miR-371a-3p can identify disease recurrence in testicular germ cell tumour (TGCT) patients and correlates with tumour load. Despite convincing evidence showing the advantages of including miR-371a-3p testing to complement and overcome the classical serum tumour markers limitations, the successful introduction of a serum miRNA based test into clinical practice has been impeded by a lack of consensus regarding optimal methodologies and lack of a universal protocol and thresholds. Herein, we investigate two quantitative real-time PCR (qRT-PCR) based pipelines in detecting disease recurrence in stage I TGCT patients under active surveillance, and compare the sensitivity and specificity for each method.

Methods

Sequential serum samples collected from 33 stage I TGCT patients undergoing active surveillance were analysed for miR-371a-3p via qRT-PCR with and without an amplification step included.

Results

Using a pre-amplified protocol, all known recurrences were detected via elevated miR-371a-3p expression, while without pre-amplification, we failed to detect recurrence in 3/10 known recurrence patients. For pre-amplified analysis, sensitivity and specificity was 90% and 94.4% respectively. Without amplification, sensitivity dropped to 60%, but exhibited 100% specificity.

Discussion

We conclude that incorporating pre-amplification increases sensitivity of miR-371a-3p detection, but produces more false positive results. The ideal protocol for quantification of miR-371a-3p still needs to be determined. TGCT patients undergoing active surveillance may benefit from serum miR-371a-3p quantification with earlier detection of recurrences compared to current standard methods. However, larger cross-institutional studies where samples are processed and data is analysed in a standardised manner are required prior to its routine clinical implementation.

Testicular Cancer: Contemporary Updates in Staging

Testicular tumors are the most common solid tumors in young men, the vast majority of which are of germ cell origin. The staging of human cancers is paramount to correct patient management. Staging systems have passed through several developments leading to the release of the most recent 8th edition of the American Joint Committee for Cancer (AJCC) staging manual, which is based on the current understanding of tumor behavior and spread. In this review, the authors summarize the current AJCC staging of the germ cell tumors, highlight essential concepts, and provide insight into the most important parameters of testicular tumors.

A new biomarker for lung metastasis in non-seminomatous testicular cancer: De Ritis Ratio

PURPOSE

We aimed to show that the De Ritis Ratio (DRR) may be a new biomarker for lung metastasis in non-seminomatous Testicular Cancers (TC).

MATERIAL AND METHODS

Patients who underwent radical orchiectomy due to TC between January 2010 and January 2021 were included in the study. Demographic characteristics, preoperative laboratory and radiological findings and pathological data of the patients were recorded. The DRR was calculated from preoperative peripheral blood analysis.

RESULTS

A total of 124 patients with non-seminomatous TC were included. Mean patient age was 30.67±7.45 years, and the mean tumour diameter was 4.69±2.55 cm. 61 patients had T1, 51 had T2, and 12 had T3 disease. 42 of them had lung metastasis; 82 of them had no lung metastasis. The optimal DRR threshold was 1.21 for lung metastasis. [Area Under the Curve (AUC): 0.724 with a sensitivity of 81% and specificity of 74%]. DRR was determined as an independent prognostic factor for lung metastasis in univariate and multivariate analyses (p=0.002).

CONCLUSIONS

A high preoperative DRR can be used to detect the presence of lung metastases in non-seminomatous TCs.

Clinical usefulness of circulating tumor markers

Tumor markers are a heterogeneous group of substances released by cancer cells into bloodstream, but also expressed by healthy tissues. Thus, very small concentrations can be present in plasma and serum from healthy subjects. Cancer patients tend to show increased levels correlating with tumor bulk, but false positive results could be present in patients with benign conditions. The correct interpretation of TM results could be challenging and many factors should be considered, from pre-analytical conditions to patient concomitant diseases. In this line, the Clinical Chemistry and Laboratory Medicine journal has made important contributions though several publications promoting the adequate use of TM and therefore improving patient safety. TM measurement offers valuable information for cancer patient management in different clinical contexts, such as helping diagnosis, estimating prognosis, facilitating early detection of relapse and monitoring therapy response. Our review analyzes the clinical usefulness of tumor markers applied in most frequent epithelial tumors, based on recent evidence and guidelines.

Human Chorionic Gonadotropin-A Review of the Literature

Importance

The measurement of human chorionic gonadotropin (hCG) levels in different body fluids is a commonly utilized tool in obstetrics and gynecology, as well as other fields. It is often one of the first steps in the medical workup of female patients, and the results and interpretation of this test can have significant downstream ramifications. It is essential to understand the uses and limitations of hCG as a testing and therapeutic measure to appropriately evaluate, counsel, and treat patients.

Objective

The purpose of this article is to review the current literature on hCG, including its origins, structure, pharmacokinetics, metabolism, and utility in testing and medical treatment.

Evidence Acquisition

Original research articles, review articles, and guidelines on hCG use were reviewed.

Conclusions and Relevance

While the primary function of hCG is to maintain early pregnancy, testing for hCG demonstrates that this molecule is implicated in a multitude of different processes where results of testing may lead to incorrect conclusions regarding pregnancy status. This could affect patients in a myriad of settings and have profound emotional and financial consequences. In addition, hCG testing may be revealing of alternative pathology, such as malignancy. It is imperative to understand the nuances of the physiology of hCG and testing methods to effectively use and interpret this test for appropriate patient management.

Biomarkers in Urological Cancers

Urological tumours have become one of the most common cancers in the last decade. It is important to apply an approach that evaluates many factors related to the patient and the disease carefully to minimize cancer-associated morbidity and mortality. The clinical use of cancer biomarkers is a valuable part of the clinical management of urological cancers. These biomarkers may lead to optimized detection, treatment, and follow-up of urological cancers. With the development of molecular research, newly developed biomarkers and next-generation sequencing have also contributed to patient management. In this chapter, we will present biomarkers in the most common urological cancers under subheadings of bladder cancer, prostate cancer, kidney cancer, and testicular cancer. Additionally, due to the development that occurred in the next-generation sequencing (NGS), all the above-mentioned malignancies are evaluated with regard to NGS.

The Role of CT in the Staging and Follow-Up of Testicular Tumors: Baseline, Recurrence and Pitfalls

Simple Summary

Testicular cancer (TC) is an uncommon group of tumors affecting predominantly younger males between 15 and 40 years, and accounting for less than 1% of malignancies in men, albeit in the context of an increasing incidence rate over recent decades. Testicular germ cell tumors (TGCT) are the most frequent (90%), and most cases of TGCT are organ-confined at diagnosis. The majority of patients with TGCT have an excellent prognosis, with a 5-year survival rate greater than 95%, and expect to be cured thanks to different risk-adapted treatments such as cisplatin-based chemotherapy, even at advanced stages. It is for this reason that both initial staging and follow-up are essential for appropriate management in initiating adapted therapy as well as treating cases of recurrence, most frequent during the first 5 years.

Abstract

Ultrasound imaging of the testis represents the standard-of-care initial imaging for the diagnosis of TGCT, whereas computed tomography (CT) plays an integral role in the initial accurate disease staging (organ-confined, regional lymph nodes, or sites of distant metastases), in monitoring the response to therapy in patients who initially present with non-confined disease, in planning surgical approaches for residual masses, in conducting follow-up surveillance and in determining the extent of recurrence in patients who relapse after treatment completion. CT imaging has also an important place in diagnosing complications of treatments. The aims of this article are to review these different roles of CT in primary TGCT and focus on different pitfalls that radiologists need to be aware of.

A Machine Learning Algorithm for Predicting the Risk of Developing to M1b Stage of Patients With Germ Cell Testicular Cancer

Objective

Distant metastasis other than non-regional lymph nodes and lung (i.e., M1b stage) significantly contributes to the poor survival prognosis of patients with germ cell testicular cancer (GCTC). The aim of this study was to develop a machine learning (ML) algorithm model to predict the risk of patients with GCTC developing the M1b stage, which can be used to assist in early intervention of patients.

Methods

The clinical and pathological data of patients with GCTC were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Combing the patient's characteristic variables, we applied six machine learning (ML) algorithms to develop the predictive models, including logistic regression(LR), eXtreme Gradient Boosting (XGBoost), light Gradient Boosting Machine (lightGBM), random forest (RF), multilayer perceptron (MLP), and k-nearest neighbor (kNN). Model performances were evaluated by 10-fold cross-receiver operating characteristic (ROC) curves, which calculated the area under the curve (AUC) of models for predictive accuracy. A total of 54 patients from our own center (October 2006 to June 2021) were collected as the external validation cohort.

Results

A total of 4,323 patients eligible for inclusion were screened for enrollment from the SEER database, of which 178 (4.12%) developing M1b stage. Multivariate logistic regression showed that lymph node dissection (LND), T stage, N stage, lung metastases, and distant lymph node metastases were the independent predictors of developing M1b stage risk. The models based on both the XGBoost and RF algorithms showed stable and efficient prediction performance in the training and external validation groups.

Conclusion

S-stage is not an independent factor for predicting the risk of developing the M1b stage of patients with GCTC. The ML models based on both XGBoost and RF algorithms have high predictive effectiveness and may be used to predict the risk of developing the M1b stage of patients with GCTC, which is of promising value in clinical decision-making. Models still need to be tested with a larger sample of real-world data.

Addressing the diagnostic and therapeutic dilemmas of ovarian immature teratoma: Report from a clinicopathologic consensus conference

Ovarian immature teratoma is a rare subtype of germ cell tumour that can be pure or associated with non-teratomatous germ cell tumour elements and is graded based on extent of the immature neuroectodermal component. Immature teratoma (IT) can also be associated with somatic differentiation in the form of sarcoma, carcinoma, or extensive immature neuroectodermal elements and may produce low levels of serum alpha-fetoprotein. Variable interpretation of these issues underlies diagnostic and management dilemmas, resulting in substantial practice differences between paediatric and adult women with IT. The Malignant Germ Cell International Consortium (MaGIC) convened oncologists, surgeons, and pathologists to address the following crucial clinicopathologic issues related to IT: (1) grading of IT, (2) definition and significance of 'microscopic' yolk sac tumour, (3) transformation to a somatic malignancy, and (4) interpretation of serum tumour biomarkers. This review highlights the discussion, conclusions, and suggested next steps from this clinicopathologic conference.

Potential role of biochemical markers in the prognosis of COVID-19 patients

The global pandemic due to coronavirus disease 2019 (COVID-19) has posed an overall threat to modern medicine. The course of the disease is uncertain with varying forms of presentation that cannot be managed solely with clinical skills and vigor. Since its inception, laboratory medicine forms a backbone for the proper diagnosis, treatment, monitoring, and prediction of the severity of the disease. Clinical biochemistry, an integral component of laboratory medicine, has been an unsung hero in the disease prognosis and severity assessment in COVID-19. This review attempts to highlight the biomarkers which have shown a significant role and can be used in the identification, stratification, and prediction of disease severity in COVID-19 patients. It also highlights the basis of the use of these biomarkers in the disease course and their implications.

Stage migration of testicular germ cell tumours in Alberta, Canada, during the COVID-19 pandemic: a retrospective cohort study

BACKGROUND

An absence of screening recommendations and the rapid progression of testicular germ cell tumours (TGCTs) offer a perspective on the potential impact of the COVID-19 pandemic on cancer presentations. We evaluated the presenting cancer stages of TGCTs in a real-world population before and during the pandemic to assess stage migration.

METHODS

We performed a retrospective review of all new patients with TGCT diagnoses in Alberta, Canada, from Dec. 31, 2018, to Apr. 30, 2021, using the Alberta Cancer Registry. Because potential changes in staging should not occur instantaneously, we used a 6-month lag time from Apr. 1, 2020, for seminomas, and a 3-month lag time for nonseminomas, to compare initial cancer stages at presentation before and during the pandemic. We evaluated monthly rates of presentation by stage and histology. Exploratory outcomes included the largest tumour dimension, tumour markers and, for advanced disease, risk category and treatment setting.

RESULTS

Of 335 patients with TGCTs, 231 were diagnosed before the pandemic and 104 during the pandemic (using a lag time). In total, 18 (7.8%) patients diagnosed before the pandemic presented with stage III disease, compared to 16 (15.4%) diagnosed during the pandemic (relative risk 1.97, 95% confidence interval [CI] 1.05-3.72). We observed no significant differences for secondary outcomes. Without a lag time, the rate ratio for a stage II presentation decreased significantly during the pandemic (0.40, 95% CI 0.21-0.72).

INTERPRETATION

We observed signs of TGCT stage migration during the COVID-19 pandemic, driven by a decline in stage II disease and a potential rise in stage III disease. Management of TGCTs should remain a priority, even during a global pandemic.

Urothelial carcinoma of the prostate with raised β-hCG levels: a case report

Background

Trophoblastic differentiation in primary urothelial carcinoma of the prostate is extremely rare. An increased level of β-subunit human chorionic gonadotropin in serum in urothelial carcinoma is detected in approximately 30% of cases. To our knowledge, increased concentration of β-subunit human chorionic gonadotropin in serum in prostatic urothelial carcinoma has never been reported and its clinical significance is not evaluated yet.

Case report

Here we present the case of a 67-year-old European patient who was admitted to the hospital with hematuria, dysuria, and enlarged painful testis. Ultrasonographic examination of the testis did not reveal any focal lesion. Magnetic resonance imaging of the pelvis showed a tumor of 62 mm diameter mainly located in the posterior part of the prostatic gland. A pathological examination from cystoscopy biopsy allowed us to set the diagnosis of high-grade invasive urothelial carcinoma with trophoblastic differentiation. The patient received neoadjuvant treatment. Nonetheless, after a short period of disease stabilization, he developed progression and brain metastasis. He died 9 months after diagnosis. During the disease course, his β-human chorionic gonadotropin level was measured repeatedly and analyzed in relation to disease progression. The level of serum β-human chorionic gonadotropin corresponded with the therapy response; it was at its lowest during stabilization and the highest in the metastatic stage.

Conclusion

Our case study provides the first report of urothelial cancer of the prostate, with a concomitant increase of β-subunit human chorionic gonadotropin level with testis enlargement. Besides its rarity, it constitutes an interesting observation of increasing β-subunit human chorionic gonadotropin concentration with concomitant disease progression.

Oncological outcomes of testicular cancer patients: 10 years of experiences resulting from a single university-based hospital

Purpose

To explore clinical and pathological characteristics of testicular cancer and also identify factors associated with its oncological outcomes. Testicular cancer has a very good prognosis. Actually, we aim to report on 10 years of experience in the real-world practice of treating testicular cancer in a university-based hospital.

Methods

This is a retrospective cohort study of testicular cancer patients in Songklanagarind hospital; from January 2007 and December 2016, all eligible testicular cancer patients were included. Clinical characteristics (age, physical examination findings, tumour markers, histopathology, clinical stage, and initial treatment) and clinical outcomes were collected. These patients were divided into two groups: seminoma patients (seminomas) and non-seminoma patients (non-seminomas). Clinical characteristics and outcomes of treatment were analysed, and factors associated with oncological outcomes were identified.

Results

In 45 patients, median age 33 years, with diagnosis of testicular cancer, seminomas and non-seminomas were responsible for 23 (52.8%) and 22 (49%) of the cases, respectively. The median time of follow-up was 80.6 months (range: 1.8 to 120 months). The five-year OS was 94.7% and 57.1% in the seminoma and non-seminoma groups, respectively. For non-seminomas, five-year OS were 71.4%, 50%, and 42.9% in stage Ib–IIIa, IIIb, and IIIc, respectively, and for seminoma they were 92.3% and 100% in stage Ib–IIIa and IIIb, respectively. Multivariable analysis showed that non-seminoma, higher staging, and higher IGCCC risk were associated with poorer survival, significantly (p < 0.05).

Conclusions

Seminoma has a good prognosis and survival at all stages, whereas, in the non-seminoma group, higher staging and IGCCC risk were independent factors associated with a poorer prognosis.

Testicular Germ Cell Tumours and Proprotein Convertases

Simple Summary

Despite the high survival rate of the most common neoplasia in young Caucasian men: Testicular Germ Cell Tumors (TGCT), the quality of life of these patients is impaired by the multiple long-term side effects of their treatment. The study of molecules that can serve both as diagnostic biomarkers for tumor development and as therapeutic targets seems necessary. Proprotein convertases (PC) are a group of proteases responsible for the maturation of inactive proproteins with very diverse functions, whose alterations in expression have been associated with various diseases, such as other types of cancer and inflammation. The study of the immune tumor microenvironment and the substrates of PCs could contribute to the development of new and necessary immunotherapies to treat this pathology.

Abstract

Testicular Germ Cell Tumours (TGCT) are widely considered a “curable cancer” due to their exceptionally high survival rate, even if it is reduced by many years after the diagnosis due to metastases and relapses. The most common therapeutic approach to TGCTs has not changed in the last 50 years despite its multiple long-term side effects, and because it is the most common malignancy in young Caucasian men, much research is needed to better the quality of life of the many survivors. Proprotein Convertases (PC) are nine serine proteases responsible for the maturation of inactive proproteins with many diverse functions. Alterations in their expression have been associated with various diseases, including cancer and inflammation. Many of their substrates are adhesion molecules, metalloproteases and proinflammatory molecules, all of which are involved in tumour development. Inhibition of certain convertases has also been shown to slow tumour formation, demonstrating their involvement in this process. Considering the very established link between PCs and inflammation-related malignancies and the recent studies carried out into the immune microenvironment of TGCTs, the study of the involvement of PCs in testicular cancer may open up avenues for being both a biomarker for diagnosis and a therapeutic target.

Case report: Challenges, treatment, prognosis and outcome of a patient with partially treated seminomatous testicular carcinoma

Background

Testicular carcinoma is a rare malignancy in men. It is ranked the 18th most common male cancer in Malaysia with seminoma representing 40% of the primary testicular neoplasms. Early detection of the tumour and the immediate initiation of treatment and disease management provide high possibilities of positive outcomes for patients.

Case presentation

A 36-year-old male was initially diagnosed with a left cryptorchidism and metastatic testicular seminoma. However, due to socioeconomic circumstances and the Coronavirus-19 (COVID-19) pandemic, he defaulted on his chemoradiotherapy follow-up treatments. He returned to us four years later with a progressively enlarging testicular mass with normal tumour marker values and subsequently underwent a successful radical left orchidectomy. Histopathological examination revealed features of regressed germ cell tumour (GCT). He successfully underwent chemoradiotherapy treatment and surveillance follow-ups did not show tumor recurrences.

Discussion

Seminoma is the commonest type of testicular carcinoma with good prognosis among young patients. In huge masses, as seen in our patient, early chemoradiotherapy with the intention to reduce tumor bulk and invasiveness after which will be followed by radical orchidectomy. Residual mass post chemotherapy for patients with seminomas should be properly assessed for viability of tumor cells within it.

Conclusion

Undescended testis and cryptorchidism present key risk factors for developing testicular carcinomas which are uncommon among men. Early detection, surgery and chemoradiotherapy on seminomas would usually lead to positive outcomes. The remarkable chemosensitivity of a seminomatous type tumour towards a platinum-based regiment in combination with radical resection entails good prognosis and effective local disease control.

•

Testicular carcinoma is an extremely rare malignancy among men which affects the young age groups.

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Ectopic testis should be surgically corrected prior to puberty to hinder germ cell insult.

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Extensive metastatic disease requires urgent chemotherapy initiation followed by orchidectomy later.

A Multi-institutional Pooled Analysis Demonstrates That Circulating miR-371a-3p Alone is Sufficient for Testicular Malignant Germ Cell Tumor Diagnosis

BACKGROUND

Circulating microRNAs have clear potential for improving malignant germ-cell-tumor (MGCT) diagnosis. Here, we address the central issue of whether measurement of a single microRNA is sufficient for detecting testicular MGCTs, or whether there is added benefit in quantifying other members of the 4-microRNA panel previously identified (miR-371a-3p/miR-372-3p/miR-373-3p and miR-367-3p).

PATIENTS AND METHODS

We performed a pooled analysis of available published raw data where all 4 panel miRNAs had been assessed using pre-amplification PCR technology (4 studies; total 329 patients). Two studies using identical methodology (and identical normalization using endogenous miR-30b-5p) were used in the discovery phase (n = 51 patients: 17 MGCT, 34 controls). The 2 other studies (n = 278 patients: 140 MGCT, 138 controls), which assessed the same test panel but with different normalization approaches (endogenous miR-93-5p, exogenous cel-miR-39-3p), were used for the validation phase. We derived sensitivity, specificity, positive- and negative-predictive-values (PPV/NPV) for the detection thresholds that maximised the Youden Index (YI).

RESULTS

In the discovery-phase, the YI was 0.97 for miR-371a-3p (sensitivity = 1, specificity = 0.97), 0.71 (miR-367-3p), 0.68 (miR-372-3p), and 0.50 (miR-373-3p). These findings were confirmed in the validation-phase, with YI of 0.75 for miR-371a-3p (sensitivity = 0.90, specificity 0.85), 0.55 (miR-367-3p), 0.47 (miR-372-3p), and 0.51 (miR-373-3p). Importantly, no combination of markers added additional diagnostic benefit to miR-371a-3p alone, in either the discovery or the validation phase.

CONCLUSION

Quantifying circulating miR-371a-3p alone is sufficient for testicular MGCT diagnosis. PCR measurement of this single miRNA marker will be more cost-effective and easier to interpret, facilitating future incorporation into routine clinical practice.

Examination of clinical data and semen analysis results of patients undergoing orchiectomy for testicular tumor

OBJECTIVE

Testicular tumor constitutes 1% of male neoplasms. Infertility can be determined in patients with testicular tumors before orchiectomy due to the deterioration of spermatogenesis. The aim of this study was to show the clinical, radiological, and pathological characteristics and spermiogram results of patients with testicular tumor and their relationship with each other.

METHODS

The data of patients who underwent orchiectomy due to testicular tumor between 2016 and 2019 were reviewed retrospectively. These data included sociodemographic data of the patients, pretreatment spermiogram characteristics, level of serum tumor markers, characteristics of the ultrasonography, type of orchiectomy, and histopathological examination.

RESULTS

This study included 53 male patients, with a mean age of 33.51±12.86 years. The mean levels of all tumor markers were above the reference levels. The mean tumor size was 34.68±23.32 mm. Multiple localizations and microlithiasis were detected in 11.3 and 13.2% of the tumors, respectively. The most common masses were hypoechoic (n=37; 69.8%) and hypervascular (n=47; 81%). Spermiogram and cryopreservation were performed in 29 (54.7%) of 53 patients preoperatively. The mean sperm concentration before orchiectomy was 24.21×106 /mL and group A sperm motility 0.79%, group B sperm motility 39.10%, group C sperm motility 9.83%, and group D sperm motility 22.69% in testicular tumors.

CONCLUSION

Spermatogenesis adversely affected before the treatment due to local and systemic effects of testicular cancer. Fertility expectations can be increased in the subsequent years by semen analysis and referral to cryopreservation.

Recent advances in testicular germ cell tumours

Testicular germ cell tumours (TGCTs) are the most common solid tumours in young men and have an excellent overall cure rate and prognosis. In most patients, localised disease is cured by surgery alone, and a minority of patients receive short-course adjuvant chemotherapy to reduce the risk of further relapse. Also, in about 80% of patients, metastatic disease can be cured by systemic cisplatin-based chemotherapy. Unfortunately, for a proportion of patients, the disease exhibits platinum resistance and relapse occurs. Despite further lines of systemic treatment, cure can be difficult to achieve in these patients and ultimately about 20% of them will die from disease progression. Addressing the mechanisms underpinning platinum resistance is critical to improving the survival and chances of cure for these patients. This review describes the latest advances in TGCT research, focusing on the identification of novel biomarkers, genetic characteristics and exploring novel treatments.

Tumor markers and 18F-FDG PET/CT after orchiectomy in seminoma: Is there any correlation?

OBJECTIVE

The aim of our study was to analyze the potential relationship between tumor markers and ¹⁸F-fluorodoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) results in patients affected by seminoma.

MATERIAL AND METHODS

65 ¹⁸F-FDG PET/CT scans of 41 patients with diagnosis of seminoma were analyzed and compared to alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG). PET/CT studies were analyzed qualitatively and measuring the maximum and mean standardized uptake value body weight max (SUVbwmax, SUVbwmean), maximum SUV lean body mass (SUVlbm), maximum SUV body surface area (SUVbsa), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) of hypermetabolic lesions. All values were compared with serum markers.

RESULTS

31 PET/CT studies were true negative, 28 true positive, 6 false positive and 0 false negative with sensitivity of 100%, specificity of 84%, negative predictive value of 100%, positive predictive value of 82% and accuracy of 91%. No correlation between PET results and tumor marker levels was found and also between AFP and PET/CT semiquantitive parameters. All semiquantitative PET parameters were significantly related to hCG level.

CONCLUSIONS

¹⁸F-FDG PET/CT has good accuracy in evaluating patients with relapsed seminoma. HCG levels were significantly correlated with metabolic PET/CT parameters.

When is a seminoma not a seminoma? The incidence, risk factors and management of patients with testicular seminoma with discordant elevated serum alpha-fetoprotein

OBJECTIVE

To describe the incidence, clinical and demographic factors, and treatment patterns associated with discordant elevated AFP findings in patients with pure seminomatous histology.

METHODS

We queried the National Cancer Database to identify patients with testicular GCT diagnosed in 2011-2015. Patients were grouped based on histologic diagnosis and pre-operative serum AFP level.

RESULTS

Of 18,616 patients diagnosed with testicular GCT, 53% (N=9,849) had pure seminomatous histology, of whom 8.3% (N=821) had an elevated serum AFP pre-operatively. Non-white patients with seminoma were more likely to have a pre-op elevated AFP (OR 1.42; 95% CI: 1.10-1.83); patients treated at higher volume centers were less likely to have a pre-op elevated AFP (0.66, 95% CI: 0.53-0.83). Patients with seminoma with elevated AFP received adjuvant radiation more frequently than those with NSGCT (Stage I: 15% vs 0.2%, p < 0.01; Stage II: 21.9% vs 0.1%, p <0.01) and less frequently underwent retroperitoneal lymph node dissection (RPLND) (Stage 1: 1.9% vs 11.1% p <0.01; Stage II: 8.8% vs 17.4%, p <0.01).

CONCLUSION

The detection of elevated serum alpha-fetoprotein (AFP) in patients with pure seminomatous testicular germ cell tumors (GCT) is a discordant finding that implies the presence of occult non-seminomatous GCT (NSGCT) elements. 8% of patients with pure seminomatous GCTs had diagnostically discordant elevated pre-operative AFP levels. Despite recommendations to manage these patients as NSGCT, patients with seminoma and elevated AFP were managed in a fashion comparable to those with seminoma and normal AFP levels.

HFE variants in colorectal cancer and their clinicopathological correlations

The study aimed to screen mutation of human homeostatic iron regulator (HFE) in colorectal carcinoma (CRC) and detect their associations with clinicopathological parameters. Expression of HFE was determined by quantitative polymerase chain reaction in matched CRC and non neoplastic colorectal mucosal tissue of 76 patients. Genomic DNA extracted were subjected to high high-resolution melt curve analysis and Sanger sequencing to detect mutations in HFE. The associations of the identified mutations with a variety of clinical features were determined. Approximately 60% of CRC showed low HFE expression. Of the ten 10 mutations identified in exons 2 and 4, c.187C>G (H63D), c845G>A (C282Y), c.193A>T (S65C), g.3828T>C, g.5795T>C, and g.5728G>A were known mutations. Four novel mutations were discovered; : c.184G>A, c.220T>G, c.322A>C, and c.324T>C. Heterozygous H63D and C282Y mutations were seen in 71% and 49% of cancer tissue, respectively. Tumour site (p = 0.048) and gender (p = 0.039) were significantly associated with H63D and C282Y mutation status, respectively. Local spread of cancer was significantly associated with C282Y mutations in CRC cancer and adjacent non-neoplastic tissue (p = 0.029 & and p = 0.004, respectively). There was a statistically significant association between H63D and C282Y negativity in matched non-neoplastic colorectal mucosa tissue and pathological staging of cancer (p = 0.047 & and p = 0.001, respectively). Patients with H63D and C282Y mutations in cancer tissue tend to have higher survival rates. Hence HFE mutations are common in CRC and are associated with clinicopathological parameters, implying the potential clinical significance of HFE mutations in colorectal carcinogenesis.