False‐Positive Serum Human Chorionic Gonadotropin (hCG) in a Male Patient with a Malignant Germ Cell Tumor of the Testis: A Case Report and Review of the Literature

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

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

Pituitary as a Source of HCG: Residual Levels After Bilateral Testicular Tumor Removal

Context. Challenging clinical scenario in which elevated β-human chorionic gonadotropin (HCG, subsequently termed HCG) levels suggested occult tumor metastases after removal of bilateral testicular cancers and metastases from them and as well as after chemotherapy. Case Report. A 22-year-old male, post excision of bilateral testicular tumors, who had no imaging or clinical evidence of residual tumor but an elevated HCG raising the question of the presence and location of occult tumor metastases. Clinical Questions. Does luteinizing hormone (LH) cross-react with HCG in current assays? What levels of testosterone and estradiol are necessary to suppress LH and follicle-stimulating hormone (FSH) in a male patient with bilateral orchiectomy, and therefore lacking inhibin? Does the pituitary secrete HCG and under what circumstances? Assessment. Current HCG assays no longer cross-react with LH as did prior assays, but the presence of heterophile antibodies and other factors such as biotin can still cause false positive HCG levels. In the chronic post-orchiectomy state, the pituitary is relatively resistant to LH and FSH suppression by testosterone. The pituitary secretes HCG in very small amounts unless interruption of negative feedback results in high LH and FSH whereupon HCG levels become elevated. Clinical Conclusion. A GnRH antagonist suppressed both LH and HCG in this patient indicating that the elevated HCG was secreted by the pituitary and not by occult tumor metastases. Further credence for this conclusion resulted from the lack of a progressive increase in HCG levels over a 4-year period of follow-up and from no evidence of metastatic tumors on serial imaging.

Pregnancy, malignancy or mother nature? Persistence of high hCG levels in a perimenopausal woman

Despite the fact that a small percentage of peri en postmenopausal women have mild elevations in human chorionic gonadotrophin (hCG) concentrations (<14 IU/L) besides high levels of gonadotrophins, a considerable number of clinicians are not aware of this phenomenon. We report a case of a 53-year-old woman with an unusually high hCG concentration (>40 IU/L) given her menopausal state. Although a pregnancy or a malignancy was unlikely on the basis of stable hCG levels, elevated gonadotrophins and a negative transvaginal ultrasound, her physicians were uncertain and chose an expectant approach by repeated testing. Ultimately, after consulting the laboratory, analytical interference was ruled out and pituitary origin of unusual high hCG level could be confirmed after conduction of a suppression test by oestrogen-progesterone hormone replacement therapy. Until that time, the patient had undergone a vast amount of laboratory tests and gynaecology consultations, resulting in an enormous amount of confusion, anxiety and overdiagnosis.

Human Chorionic Gonadotropin Assays for Testicular Tumors: Closing the Gap between Clinical and Laboratory Practice

BACKGROUND

Clinical practice guidelines recommend the measurement of human chorionic gonadotropin (hCG) and/or hCGβ in serum for management of testicular germ cell tumors (GCTs). These guidelines, however, disregard relevant biochemical information on hCG variants to be detected for oncological application. We set out to provide a critical review of the clinical evidence together with a characterization of the selectivity of currently marketed hCG immunoassays, identifying assays suitable for management of GCTs.

CONTENT

Evidence sources in the available literature were critically appraised. Most instances of misdiagnosis and mismanagement of testicular GCTs have been associated with hCG results. According to the clinical evidence, 36% of patients with seminoma show an exclusive hCGβ increase, and 71% of patients with nonseminomatous GCTs (NSGCTs) show an increase of intact hCG and/or hCG + hCGβ, whereas the hCGβ increase in NSGCTs is variable according to the tumor stage and histology.

SUMMARY

hCG + hCGβ assays that display an equimolar recognition of hCG and hCGβ, or at least do not overtly underestimate hCGβ, may be employed for management of testicular GCTs. Assays that underestimate hCGβ are not recommended for oncological application. In addition to the hCG + hCGβ assay in service, an additional assay with broader selectivity for other hCG variants should be considered when false-negative or false-positive results are suspected on the basis of clinical data.

β-HCG Elevation in Wilms Tumor: An Uncommon Presentation

Wilms tumor (nephroblastoma) is a readily diagnosed common abdominal tumor in children. Rarely, it may present with factors that may confound the diagnosis. We report a 6-year-old female child who presented with a rapidly growing and invasive abdominal mass with the histopathologic features of Wilms tumor associated with an elevated serum beta human chorionic gonadotropin, which has not been previously reported in this condition.

Transient false-positive urine human chorionic gonadotropin in septic shock

Point-of-care testing for urine human chorionic gonadotropin (hCG) allows rapid diagnosis of pregnancy and pregnancy-related disorders at the bedside. Urine hCG test kits use enzyme-linked immunosorbent assay technology and incorporate 2 types of monoclonal antibody in a sandwich structure. There have been case reports in a variety of disease states reporting interference with this method leading to false-positive results. We describe the case of a nonpregnant female presenting to the emergency department with septic shock secondary to severe colitis. Three sequential urine tests using the Clearview hCG test kit (Alere Limited, Stockport, United Kingdom) yielded positive results, whereas quantitative serum analysis was negative for hCG. This initial test result reverted to a true-negative result after 48 hours, suggesting the transient passage of an interferent into the urine at the time of initial testing. This may have been a molecule produced as part of the host inflammatory response or from bacterial synthesis of an interferent with hCG-like antigenic structure. It is important that clinicians are aware of the mechanisms and limitations of urine hCG testing and maintain a low threshold to undertake early serum hCG testing to confirm diagnosis.

Granulosa cell tumor of the testis in a newborn

Testicular neoplasms are uncommon tumors of childhood. These tumors comprise the germ cell tumors, and other tumors that may originate from histological testicular components, which are unrelated to the germinal lineage. Among the latter are the sex cord-stromal tumors (SCST), an important entity in newborns. SCSTs comprise, among others, granulosa cell tumors, which are more common in the ovary, but in rare cases may develop in the testis. The prognosis is excellent since it is universally benign. Diagnosis, which is sometimes challenging, is usually made after orchiectomy and pathological examination, which is characterized by morphological features and positive expression of inhibin, calretinin, and vimentin, and negative for alpha-fetoprotein. The authors present the case of a newborn with a right enlarged testis detected during the first examination after birth. Ultrasonography showed a heterogeneous solid/cystic mass in the right testis, without retroperitoneal lymphadenopathy. A right inguinal orchiectomy was performed 21 hours after birth. Pathologic examination revealed a juvenile granulosa cell tumor of the right testicle. After 4 years of follow-up, as expected, the child presented an uneventful outcome.

CGB and GNRH1 expression analysis as a method of tumor cells metastatic spread detection in patients with gynecological malignances

BACKGROUND

Metastasis is a common feature of many advanced stage cancers and metastatic spread is thought to be responsible for cancer progression. Most cancer cells are localized in the primary tumor and only a small population of circulating tumor cells (CTC) has metastatic potential. CTC amount reflects the aggressiveness of tumors, therefore their detection can be used to determine the prognosis and treatment of cancer patients.The aim of this study was to evaluate human chorionic gonadotropin beta subunit (CGB) and gonadoliberin type 1 (GNRH1) expression as markers of tumor cells circulating in peripheral blood of gynecological cancer patients, indicating the metastatic spread of tumor.

METHODS

CGB and GNRH1 expression level in tumor tissue and blood of cancer patients was assessed by real-time RT-PCR. The data was analyzed using the Mann-Whitney U and Spearman tests. In order to distinguish populations with homogeneous genes' expression the maximal likelihood method for one- and multiplied normal distribution was used.

RESULT

Real time RT-PCR results revealed CGB and GNRH1 genes activity in both tumor tissue and blood of gynecological cancers patients. While the expression of both genes characterized all examined tumor tissues, in case of blood analysis, the transcripts of GNRH1 were found in all cancer patients while CGB were present in 93% of patients. CGB and GNRH1 activity was detected also in control group, which consisted of tissue lacking cancerous changes and blood of healthy volunteers. The log-transformation of raw data fitted to multiplied normal distribution model showed that CGB and GNRH1 expression is heterogeneous and more than one population can be distinguished within defined groups.Based on CGB gene activity a critical value indicating the presence of cancer cells in studied blood was distinguished. In case of GNRH1 this value was not established since the results of the gene expression in blood of cancer patients and healthy volunteers were overlapping. However one subpopulation consists of cancer patient with much higher GNRH1 expression than in control group was found.

CONCLUSIONS

Assessment of CGB and GNRH1 expression level in cancer patients' blood may be useful for indicating metastatic spread of tumor cells.