Testis-preserving strategies in testicular germ cell tumors and germ cell neoplasia in situ

Organ-Sparing Surgery for Testicular Germ Cell Tumors: A Current Perspective

Background and Objectives: We aimed to evaluate the oncological and functional outcomes of organ-sparing surgery for testicular germ cell tumors, a procedure that seeks to strike a balance between effective cancer control and organ preservation, in the treatment of testicular tumors. We aimed to discuss the surgical technique and complications, and determine the appropriate candidate selection for this approach. Material and Methods: A comprehensive literature search was conducted to identify relevant studies on organ-sparing surgery for testicular tumors. Various databases, including PubMed, Embase, and Cochrane Library, were used. Studies reporting on surgical techniques, complications, and oncologic and functional outcomes were included for analysis. Results: Current evidence suggests that organ-sparing surgery for testicular germ cell tumors can be considered a safe and efficacious alternative to radical orchiectomy. The procedure is associated with adequate oncological control, as indicated by low recurrence rates and low complication rates. Endocrine testicular function can be preserved in around 80-90% of patients and paternity can be achieved in approximately half of the patients. Candidate selection for this surgery is typically based on the following criteria: pre-surgery normal levels of testosterone and luteinizing hormone, synchronous or metachronous bilateral tumors, tumor in a solitary testis, and tumor size less than 50% of the testis. Conclusions: Organ-sparing surgery for testicular germ cell tumors offers a promising approach that balances oncological control and preservation of testicular function. Further research, including large-scale prospective studies and long-term follow-ups, is warranted to validate the effectiveness and durability of organ-sparing surgery and to identify optimal patient selection criteria.

Adult granulosa cell tumour of the testis: an uncommon tumour

A male patient in his late 20s was admitted to the hospital after presenting with left abdominal, back and scrotal pain that had begun approximately 2 weeks earlier. He had a history of a stable left testicular mass for 3 years, and a physical exam revealed a non-tender, firm left testicular mass and a mild left varicocele. Testicular tumour markers were normal, but a scrotal ultrasound revealed a 2 cm hypoechoic left testicular lesion. Staging imaging showed no retroperitoneal adenopathy or pulmonary metastases.The patient underwent left radical inguinal orchiectomy with no evidence of extratesticular or spermatic cord involvement. His surgical pathology revealed a left pT1a 2.3 cm adult granulosa cell tumour of the testis with no lymphovascular invasion. The tumour was positive for inhibin and negative for OCT3/4, supporting the diagnosis.

The utility of cfDNA in TGCT patient management: a systematic review

Background:

Testicular germ cell tumors (TGCTs) are the most common young male malignancy with a steadily rising incidence. Standard clinical practice is radical orchidectomy of suspicious lumps followed by histopathological diagnosis and tumor subtyping. This practice can lead to complications and quality of life issues for the patients. Liquid biopsies, especially cell-free DNA (cfDNA), promised to be true surrogates for tissue biopsies, which are considered dangerous to perform in cases of testicular tumors. In this study, we have performed a systematic review on the potential of cfDNA in TGCT patient management, its potential challenges in translation to clinical application and possible approaches in further research.

Materials & Methods:

The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines on EuropePMC and PUBMED electronic databases, with the last update being on October 21, 2021. Due to the high heterogeneity in identified research articles, we have performed an overview of their efficacy.

Results:

Eight original articles have been identified on cfDNA in TGCT patients published from 2004 to 2021, of which six had more than one TGCT patient enrolled and were included in the final analysis. Three studies investigated cfDNA methylation, one has investigated mutations in cfDNA, two have investigated cfDNA amount, and one has investigated cfDNA integrity in TGCT. The sensitivity of cfDNA for TGCT was found to be higher than in serum tumor markers and lower than miR-371a-3p, with comparable specificity. cfDNA methylation analysis has managed to accurately detect teratoma in TGCT patients.

Conclusion:

Potential challenges in cfDNA application to TGCT patient management were identified. The challenges relating to the biology of TGCT with its low mutational burden and low cfDNA amounts in blood plasma make next-generation sequencing (NGS) methods especially challenging. We have also proposed possible approaches to help find clinical application, including a focus on cfDNA methylation analysis, and potentially solving the challenge of teratoma detection.

Application of Mass Spectrometry Imaging in Uro-Oncology: Discovering Potential Biomarkers

A growing need is emerging worldwide for new molecular markers which could enhance the accuracy of diagnostic and therapeutic methods for detecting urogenital cancers. Mass spectrometry imaging (MSI) is a very promising tool in this regard. In this review, we attempt to provide a subjective summary of the latest publications on potential biomarkers of renal, bladder, prostate, and testicular malignancies detected with MSI through the eyes of a clinical urologist.

Incidental Findings and How to Manage Them: Testis- A WFUMB Position Paper

Testicular incidentalomas are non-palpable, asymptomatic lesions, most frequently detected on ultrasound examinations. Each incidentaloma should undergo a standardized diagnostic workup to exclude malignancy and recognize other potentially significant non-malignant conditions that may first present with an incidental finding on scrotal ultrasound. This position statement of the World Federation of Ultrasound in Medicine and Biology (WFUMB) summarizes the available evidence on management of testicular incidentalomas and describes efficient management strategies with particular reference to the role of ultrasound techniques.

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

INTRODUCTION

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

CASE PRESENTATION

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

CONCLUSION

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

Oncological and functional outcomes of testis sparing surgery in small testicular mass: a systematic review

INTRODUCTION

The prevalence of testicular tumor is constantly increasing, with an estimated incidence rate of about 3-10 new cases per 100,000 males/per year. Radical orchiectomy or testis sparing surgery (TSS) are recognized therapeutic approaches in these cases. However, the risk for hypogonadism and infertility is higher with the former compared with the latter. The aim of this systematic review is to evaluate the oncological outcome and testicular function (endocrine and reproductive aspects) in patients who had undergone TSS for small testicular lesions.

EVIDENCE ACQUISITION

To accomplish this, 684 articles were retrieved and screened; 24 retrospective and two prospective studies were selected and finally included in this systematic review.

EVIDENCE SYNTHESIS

Overall the TSS attempts were 1096 but TSS was definitively performed in 603 cases (55%). Frozen section examination was performed in 996 TSS attempts (22 out of the 26 studies selected) and showed a benign histology in 37-100% of cases, a malignant histology in 0-63%, and an inconclusive result in 0-16%, respectively. Five studies reported that a total of 22 patients were able to father after conservative surgery. None of these studies reported cases of hypotestosteronemia after surgery and a low prevalence (1.66%) of complications was associated with this type of surgery.

CONCLUSIONS

In conclusion, TSS showed to be safe and practicable if used according to the specific guidelines. It can be safely performed to treat recurrence eventually associated to local adjuvant radiotherapy when an intra-tubular neoplasia is present. Urologists can therefore consider TSS as an important means against testicular tumor in selected and well-informed patients.

Testis Sparing Surgery in Pediatric Testicular Tumors

Simple Summary

Testis sparing surgery (TSS) is a safe treatment option in selected cases of testicular tumors in adults, focusing on technical feasibility, oncologic safety, preserving of testicular function, and long-term outcome. This surgical technique is also increasingly being considered in children, as benign tumors are more common in this population. With this systematic review, we aim to evaluate outcome of TSS and to investigate under which circumstances TSS can be considered safe in boys with testicular tumors. Based on the current practice described in this systematic review, combined with the outcome of TSS, we would like to suggest an algorithm to guide clinicians in determining the appropriate surgical treatment in prepubertal patients less than 12 years of age with a testicular tumor. TSS may lead to improved testicular function and quality of life in boys with testicular tumors.

Abstract

Objective: The purpose of this review is to evaluate the outcomes of testis sparing surgery (TSS) and to investigate under which circumstances TSS can be considered a safe treatment option in pediatric patients with testicular tumors. Methods: A database search was performed in Cochrane, Pubmed, and Embase for studies that focused on TSS as treatment for testicular tumors in the pediatric population, excluding reviews and single case reports. Results: Twenty studies, describing the surgical treatment of 777 patients with testicular tumors, were included in the analysis. The majority of pediatric patients with benign germ cell tumors (GCTs) (mean age: 3.7 years) and sex cord-stromal tumors (SCSTs) (mean age: 6.6 years) were treated with TSS, 61.9% and 61.2%, respectively. No cases of testicular atrophy occurred. Four of the benign GCTs, i.e., three teratomas and one epidermoid cyst, recurred. No cases of recurrence were reported in patients with SCSTs. Of the 243 malignant GCTs (mean age: 4.2 years), only one patient had TSS (0.4%). Conclusion: TSS is a safe treatment option for prepubertal patients less than 12 years of age with benign GCTs and low grade SCSTs.