Global incidence and outcome of testicular cancer

Higher expression of SALL4-A isoform is correlated with worse outcomes and progression of the disease in subtype of testicular germ cell tumours

BACKGROUND

The transcription factor SALL4 is associated with embryonic pluripotency and has proposed as a novel immunohistochemistry (IHC) marker for diagnosing germ cell tumours. SALL4 comprises three isoforms, and SALL4-A being the full-length isoform. Studying its isoforms could revolutionize testicular cancer prognosis and subtype differentiation.

METHODS

The expression and clinical significance of isoform 'A' of SALL4 was evaluated in 124 testicular germ cell tumours (TGCTs) subtypes, adjacent 67 normal tissues and 22 benign tumours, using immunohistochemistry on tissue microarrays (TMA).

RESULTS

A statistically significant higher expression of nuclear and cytoplasmic SALL4-A was detected in TGCTs histological subtypes and benign tumours compared to the normal tissues. Seminoma and yolk sac tumours had the highest nuclear and cytoplasmic expression of SALL4-A. A significant correlation was detected between the higher nuclear expression of SALL4-A and increased pT stages (P = 0.026) in seminomas. Whereas in embryonal carcinomas, cytoplasmic expression of SALL4-A was associated with the tumour recurrence (P = 0.04) and invasion of the epididymis (P = 0.011).

CONCLUSIONS

SALL4-A isoform expression in the cytoplasm and nucleus of TGCTs may be associated with histological differentiation. In the seminoma subtype of TGCTs, higher expression of SALL4-A may be used as a predictive indicator of poorer outcomes and prognosis.

Synchronous Bilateral Testicular Tumors With Discordant Histopathology: A Rare Case in an Infertile Male

Testicular cancer, accounting for 1-1.5% of male malignancies, rarely presents bilaterally, with only 2-3% of cases being bilateral and a mere 10% being synchronous, typically sharing histological patterns in both testes. Discordant histological presentation is exceedingly rare, with only a few reported cases. In this report, we detail a case involving a 35-year-old infertile male with bilateral synchronous testicular tumors, each exhibiting different histopathologies. This case highlights the diagnostic intricacies and the necessity for tailored management in the face of such uncommon presentations. The implications of oncological treatment and fertility preservation significantly affect the patient's overall quality of life.

Malignant testicular tumors in children: overview on 10 years of Saudi Cancer Registry

BACKGROUND/OBJECTIVE

The aim of this study was to identify epidemiological and histopathological patterns of pediatric testicular tumor (TT) in Saudi population over 10 years.

METHODS

Retrospective data extracted from the Saudi Cancer Registry for Saudi children diagnosed with TT from 2008 to 2017. The data collected included patient's factors as age, year of diagnosis, survival status, and tumor factors as basis of diagnosis, origin of the tumor, histopathological group and subtype, and tumor behavior, stage, and laterality.

RESULTS

A total of 115 patients with a median age of 14 (IQR 1.5-17) were included. The primary tumor site was a normal descended testis in 98.3% (115). Yolk sac tumor was the most common 28.2% (33), followed by embryonal carcinoma in 27.4% (32) and mixed germ-cell tumors in 23.1% (27). Kaplan-Meier analysis revealed significant association between survival and the stage of the tumor (p = 0.002). However, there was a lack of significant association between survival and age groups, histopathological groups, and histopathological subtypes (p = 0.541, p = 0.609, and p = 0.733, respectively). The overall mortality rate of TT 5.2% with all deaths caused by non-seminomatous germ-cell tumor diagnosed with stage 3.

CONCLUSIONS

The median age of the patients was 14 years. Yolk sac tumors were the most common while testicular choriocarcinomas were the least in incidence. No increase in the incidence of TT was seen and the mortality rate over the 10-year period was 5.2%. Shorter survival was associated with higher tumor stage.

The environment and male reproductive system: the potential role and underlying mechanisms of cadmium in testis cancer

Cadmium is a known human carcinogen, and has been shown to profoundly affect male reproductive function, at multiple levels, by exerting both endocrine and non-endocrine actions. Nevertheless, the potential role of cadmium in the etiology of testis cancer has been scantly investigated in humans, and, currently, available epidemiological observational studies are insufficient to draw definitive conclusions in this regard. On the contrary, experimental studies in laboratory animals demonstrated that cadmium is a strong inducer of testis tumors, mostly represented by benign Leydig cell adenoma; moreover, malignant transformation was also reported in few animals, following cadmium treatment. Early experimental studies in animals proposed an endocrine-dependent mechanism of cadmium-induced testis tumorigenesis; however, more recent findings from cell-free assays, in vitro studies, and short-term in vivo studies, highlighted that cadmium might also contribute to testis tumor development by early occurring endocrine-independent mechanisms, which include aberrant gene expression within the testis, and genotoxic effects, and take place well before the timing of testis tumorigenesis. These endocrine-independent mechanisms, however, have not been directly investigated on testis tumor samples retrieved from affected, cadmium-treated animals so far. The present review focuses on the relationship between cadmium exposure and testis cancer, by reporting the few epidemiological observational human studies available, and by providing animal-based experimental evidences of cadmium implication in the pathogenesis and progression of testis tumor. Moreover, the relevance of experimental animal studies to human cadmium exposure and the translational potential of experimental findings will be extensively discussed, by critically addressing strengths and weaknesses of available data.

Bone marrow metastasis of testicular germ cell tumour: A rare case

Germ cell tumour (GCT) is the most common testicular tumour that commonly presents as a painless mass. Bone marrow metastasis in cases of testicular GCT is rare; only few case reports are available till date in the literature. Here an adult male presented with an intra-abdominal mass in right iliac fossa with inguinal lymphadenopathy with a deranged kidney function test. Bone marrow (BM) aspirate smear revealed metastatic tumour cells, but BM-biopsy was unremarkable. High serum Beta - HCG (38286 mIU/L) pointed towards germ cell lesion. Lymph node biopsy along with immunomarkers confirmed metastatic foci from germ cell tumor and managed as per standard protocol. Rarely BM aspirate is seen positive for malignancy, while biopsy turns out to be negative. Secondly, BM metastasis of GCT should be considered while dealing with cases like this.

Informed consent

This is certified that the informed consent has been obtained from the patient.

Differences in incidence, staging, and survival of urologic cancers in patients under 65 living in the US-Mexico border region

Objectives

To describe and compare the incidence, stage at diagnosis, and survival for genitourinary cancers in the border regions and in Hispanic-Americans.

Materials and methods

A population-based search was performed using the Surveillance, Epidemiology, and End Results Program 18 database and the Texas Cancer Registry from 2000 to 2017. Cox regression models were performed with adjusted for age, gender, race, cancer type, cancer stage, insurance status, and cause of death were used to compare cancer-specific survival.

Results

A total of 63,236 kidney and renal pelvis, 38,398 bladder, 170,640 prostate, 24,313 testicular cancer cases were identified. Cancer-specific survival was found to be improved in Hispanic-Americans in kidney and renal pelvis (hazard ratio [HR], 0.903, 95% confidence interval [CI], 0.856-0.952, p = 0.0001), and bladder cancers (HR, 0.817, 95% CI, 0.743-0.898, p < 0.001), despite a more advanced stage at diagnosis in Hispanics with bladder cancer (p < 0.0074). Testicular cancer has a survival disadvantage for individuals living in the border region (HR, 1.315, 95% CI, 1.124-1.539, p = 0.0006).

Conclusions

Disparities exist between Hispanic-Americans and Non-Hispanic White and also between individuals living in the border counties when compared to other regions. This is most significant in individuals with testicular cancer residing in the border region who demonstrate worse overall survival.

Rare tumors: a blue ocean of investigation

Advances in novel drugs, therapies, and genetic techniques have revolutionized the diagnosis and treatment of cancers, substantially improving cancer patients' prognosis. Although rare tumors account for a non-negligible number, the practice of precision medicine and development of novel therapies are largely hampered by many obstacles. Their low incidence and drastic regional disparities result in the difficulty of informative evidence-based diagnosis and subtyping. Sample exhaustion due to difficulty in diagnosis also leads to a lack of recommended therapeutic strategies in clinical guidelines, insufficient biomarkers for prognosis/efficacy, and inability to identify potential novel therapies in clinical trials. Herein, by reviewing the epidemiological data of Chinese solid tumors and publications defining rare tumors in other areas, we proposed a definition of rare tumor in China, including 515 tumor types with incidences of less than 2.5/100 000 per year. We also summarized the current diagnosis process, treatment recommendations, and global developmental progress of targeted drugs and immunotherapy agents on the status quo. Lastly, we pinpointed the current recommendation chance for patients with rare tumors to be involved in a clinical trial by NCCN. With this informative report, we aimed to raise awareness on the importance of rare tumor investigations and guarantee a bright future for rare tumor patients.

Somatic mutation detection and KRAS amplification in testicular germ cell tumors

BACKGROUND

Testicular Germ Cell Tumors (TGCT) are the most common cancer among young adult men. The TGCT histopathology is diverse, and the frequency of genomic alterations, along with their prognostic role, remains largely unexplored. Herein, we evaluate the mutation profile of a 15-driver gene panel and copy number variation of KRAS in a large series of TGCT from a single reference cancer center.

MATERIALS AND METHODS

A cohort of 97 patients with TGCT, diagnosed at the Barretos Cancer Hospital, was evaluated. Real-time PCR was used to assess copy number variation (CNV) of the KRAS gene in 51 cases, and the mutation analysis was performed using the TruSight Tumor 15 (Illumina) panel (TST15) in 65 patients. Univariate analysis was used to compare sample categories in relation to mutational frequencies. Survival analysis was conducted by the Kaplan-Meier method and log-rank test.

RESULTS

KRAS copy number gain was a very frequent event (80.4%) in TGCT and presented a worse prognosis compared with the group with no KRAS copy gain (10y-OS, 90% vs. 81.5%, p = 0.048). Among the 65 TGCT cases, different variants were identified in 11 of 15 genes of the panel, and the TP53 gene was the most recurrently mutated driver gene (27.7%). Variants were also detected in genes such as KIT, KRAS, PDGFRA, EGFR, BRAF, RET, NRAS, PIK3CA, MET, and ERBB2, with some of them potentially targetable.

CONCLUSION

Although larger studies incorporating collaborative networks may shed the light on the molecular landscape of TGCT, our findings unveal the potential of actionable variants in clinical management for applying targeted therapies.

Testicular Cancer in Saudi Arabia Between 2004 and 2017

Objective

This study examines the epidemiology related to testicular cancer (TC) in the administrative regions of Saudi Arabia by looking at not only the percentage/ frequency of diagnosed cases, but also the crude incidence rate, age-specific incidence rate, and age-standardized incidence rate stratified by the age group, diagnosis year, and regions.

Methods

From 2004 to 2017, descriptive epidemiological research was carried out across all TC cases registered under the Saudi Cancer Registry (SCR). Descriptive statistics as well as the Kruskal-Wallis test, together with SPSS (version 20.0) were used to evaluate the data.

Results

The SCR received 1114 reports of TC diagnoses between January 2004 and December 2017. TC was diagnosed most frequently in Saudi men aged 15-44 years. In terms of Saudi men, Jouf, Tabuk, Hail, and the Northern region reported the highest age-specific incidence rate (ASIR) of TC at 1.1 per 100,000 men. Alternatively, Baha, Jazan, and Riyadh had the lowest overall ASIR of TC (0.1 and 0.3 per 100,000 men, respectively). The ASIR of TC exceeded its previous levels by twofold. The likelihood of TC was five times higher in Jouf, Tabuk, Hail, and Northern regions than in Baha and Jazan.

Conclusion

In Saudi Arabia, the ASIRs of TC doubled between 2004 and 2017. TC was most frequently diagnosed in younger Saudi men. Jouf, Tabuk, Hail, and Northern regions of Saudi Arabia had the highest incidence of TC among Saudi men, whereas Baha, Jazan, and Riyadh had the lowest incidence.

Clinical features and prognostic factors in patients diagnosed with lymphovascular invasion of testicular germ-cell tumors: Analysis based on the SEER database

Background

Lymphovascular invasion (LVI) is a high-risk factor for testicular germ-cell tumors (TGCT), but a prognostic model for TGCT-LVI patients is lacking. This study aimed to develop a nomogram for predicting the overall survival (OS) of TGCT-LVI patients.

Methods

A complete cohort of 3288 eligible TGCG-LVI patients (training cohort, 2300 cases; validation cohort, 988 cases) were obtained from the Surveillance, Epidemiology, and End Results database. Variables screened by multivariate Cox regression analysis were used to construct a nomogram, which was subsequently evaluated using the consistency index (C-index), time-dependent receiver operating characteristic curve (ROC), and calibration plots. The advantages and disadvantages of the American Joint Committee on Cancer (AJCC) staging system and the nomogram were assessed by integrated discrimination improvement (IDI) and net reclassification improvement (NRI). Decision-analysis curve (DCA) was used to measure the net clinical benefit of the nomogram versus the AJCC staging system. Finally, Kaplan-Meier curves were used to evaluate the ability to identify different risk groups between the traditional AJCC staging system and the new risk-stratification system built on the nomogram.

Results

Nine variables were screened by multivariate Cox regression analysis to construct the nomogram. The C-index (training cohort, 0.821; validation cohort, 0.819) and time-dependent ROC of 3-, 5-, and 9-year OS between the two cohorts suggested that the nomogram had good discriminatory ability. Calibration curves showed good consistency of the nomogram. The NRI values of 3-, 5-, and 9-year OS were 0.308, 0.274, and 0.295, respectively, and the corresponding values for the validation cohort were 0.093, 0.093, and 0.099, respectively (P<0.01). Additionally, the nomogram had more net clinical benefit as shown by the DCA curves, and the new risk-stratification system provided better differentiation than the AJCC staging system.

Conclusions

A prognostic nomogram and new risk-stratification system were developed and validated to assist clinicians in assessing TGCT-LVI patients.

Multicenter Database of Patients with Germ-Cell Tumors: A Latin American Cooperative Oncology Group Registry (LACOG 0515)

INTRODUCTION

Germ-cell tumors (GCTs) are the most common malignancy in young men. There is a paucity of data on GCTs in developing countries. LACOG 0515 study aimed to evaluate clinical characteristics and treatment outcomes in patients with GCTs from Brazilian cancer centers.

MATERIALS AND METHODS

This is a retrospective cohort study evaluating male patients diagnosed with GCTs from 2000 to 2018 in 13 Brazilian hospitals. We described baseline characteristics, progression-free survival (PFS), and overall survival (OS).

RESULTS

A total of 1232 patients were included, with a median age of 30 years. Histology was seminoma in 47.1% and non-seminoma GCT (NSGCT) in 52.9%. The primary tumor site was testis in 96.5%. At diagnosis, clinical stage I was present in 68.1% and 34.7% and clinical stages IS/II/III in 31.9% and 65.2% of patients with seminoma and NSCGT, respectively. Following orchiectomy, 55.2% of patients with clinical stage I were managed with surveillance. The 5-year disease-free survival rates among patients with stage I were 98.0% in seminoma and 92.3% in NSGCT, with 5-year OS of 99.6% and 97.6%, respectively. Among patients with advanced disease (IS, II, and III), the 5-year PFS were 88.7% in seminoma and 68.7% in NSGCT, with 5y-OS of 97.6% and 82.8%, respectively.

CONCLUSION

This is the largest Brazilian cohort of GCTs. Our results show a high rate of adjuvant chemotherapy in patients with clinical stage I. Although our data demonstrate slightly inferior PFS compared with the International Germ Cell Cancer Collaborative Group and other contemporary series, the OS rates were similar.

Awareness of testicular cancer among adult Polish men and their tendency for prophylactic self-examination: conclusions from Movember 2020 event

BACKGROUND

Testicular cancer (TC), due to its non-specific symptoms and occurrence in young men, is particularly dangerous. A critical point for early diagnosis is awareness of the disease and the willingness to perform a testicular self-examination (TSE). The main aim of the study was to assess the knowledge of 771 adult men about testicular cancer. Additionally, the sources of information on TC and TSE were analyzed and the influence of demographic factors on the willingness to join preventative programs was examined.

MATERIALS AND METHODS

The study was carried out during the Movember2020 campaign, where a testicular ultrasound was performed on participants. They were asked to complete a questionnaire with 26 questions to assess their knowledge.

RESULTS

The results obtained in the study indicate a low level of knowledge (average 3.5 points out of 18) about TC. Living in a large city (OR = 1.467; p = 0.03), as well as an earlier conversation about TC (OR = 1.639; p = 0.002), increased the awareness about the disease. Additionally it showed that many participants do not perform TSE at all (52.4%) and that only few perform TSE frequently (18.4%). Relationship status (OR = 2.832; p < 0.001) and previous conversations about TC (OR = 1.546; p = 0.02) was reported to be the main contributing factors in males deciding to have TSE.

CONCLUSIONS

Our research indicates large educational neglect in terms of knowledge about TC and reluctance in performing TSE. It is worth carrying out preventative actions periodically on an increasing scale, not only for the screening of testicular cancer, but also to expand knowledge on this subject.

Long Noncoding RNA LINC00467: Role in Various Human Cancers

Intricate genetic mutations promote the progression of different cancer types. Long noncoding RNAs (lncRNAs) have been widely demonstrated to participate in the genomic activities of various human cancers. Long intergenic non-coding RNA 467 (LINC00467) is an upregulated lncRNA in diverse diseases, especially in several types of cancers. Functional experiments of LINC00467 revealed that LINC00467 overexpression enhanced cell chemoresistance, proliferation, migration, and invasion in several types of cancers. Moreover, overexpressed LINC00467 was associated with a poor clinical prognosis. The present evidence suggests that LINC00467 may serve as a promising prognostic indicator and become a novel cancer therapeutic target. In this review, we introduce the biologic functions of lncRNAs and describe the molecular mechanism and clinical significance of LINC00467 in detail.

Long Non-Coding RNA RFPL3S Functions as a Biomarker of Prognostic and Immunotherapeutic Prediction in Testicular Germ Cell Tumor

The incidence of testicular germ cell tumor (TGCT) is currently on the rise worldwide, of which 15%-30% of patients have occur recurrence and metastasis. However, clinical methods for diagnosing TGCT and judging its prognosis remained inadequate. In this study, we aimed to explore the possibility of testis-specific long-chain non-coding RNA (lncRNA) Ret finger protein-like 3S (RFPL3S) as a biomarker for TGCT diagnosis, prognosis, and treatment response by reviewing the TGCT gene expression data in Gene Expression Omnibus (GEO) and The Cancer Genome Atlas (TCGA) databases. The cohort data and DNA methylation data of TGCT in TCGA were downloaded from TGCA, UCSC XENA, and GEO. The bioinformatic tools were used, including GEPIA2, Kaplan-Meier Plotter, LinkedOmics, UCSC XENA, Sangerbox Tools, GSCA, and Tumor Immune Dysfunction and Exclusion. Compared with normal testicular tissues, the RFPL3S expression was significantly reduced in TGCT, and was significantly negatively correlated with the patient’s Tumor, Node, Metastasis stage. Hypermethylation and low copy number of RFPL3S were present in TGCT, and low RFPL3S was associated with short disease-free and progression-free intervals. Silencing RFPL3S significantly enhanced the invasion ability and proliferation ability of TGCT cells as evaluated by Transwell and CCK-8 experiments. Additionally, RFPL3S expression was positively correlated with the infiltration of immune-activating cells such as B cells, CD8+ T cells, cytotoxic T cells, and natural killer cells, and negatively correlated with the infiltration of immunosuppressive cells such as Th17 and Th2. Higher RFPL3S expression was present in patients with immunotherapy benefits. In conclusion, we determined that the testis-specific lncRNA RFPL3S functioned as a tumor suppressor in TGCT and could be used as a prognostic predictor of TGCT, as well as a marker to predict the effect of TGCT immunotherapy.

Epigenetics and Testicular Cancer: Bridging the Gap Between Fundamental Biology and Patient Care

Testicular cancer is the most common solid tumor affecting young males. Most testicular cancers are testicular germ cell tumors (TGCTs), which are divided into seminomas (SGCTs) and non-seminomatous testicular germ cell tumors (NSGCTs). During their development, primordial germ cells (PGCs) undergo epigenetic modifications and any disturbances in their pattern might lead to cancer development. The present study provides a comprehensive review of the epigenetic mechanisms–DNA methylation, histone post-translational modifications, bivalent marks, non-coding RNA–associated with TGCT susceptibility, initiation, progression and response to chemotherapy. Another important purpose of this review is to highlight the recent investigations regarding the identification and development of epigenetic biomarkers as powerful tools for the diagnostic, prognostic and especially for epigenetic-based therapy.

Diverse Roles and Targets of miRNA in the Pathogenesis of Testicular Germ Cell Tumour

Testicular germ cell tumour (TGCT) is the most common cancer type among young adults in many parts of the world. Although the pathogenesis of TGCT is not well understood, the involvement of heritable components is evident, and the risk is polygenic. Genome-wide association studies have so far found 78 susceptibility loci for TGCT, and many of the loci are in non-coding regions indicating the involvement of non-coding RNAs in TGCT pathogenesis. MicroRNAs (miRNAs), a class of non-coding RNAs, have emerged as important gene regulators at the post-transcriptional level. They are crucial in controlling many cellular processes, such as proliferation, differentiation, and apoptosis, and an aberrant miRNA expression may contribute to the pathogenesis of several cancers, including TGCT. In support of this notion, several studies reported differential expression of miRNAs in TGCTs. We previously demonstrated that miRNAs were the most common group of small non-coding RNAs in TGCTs, and several functional studies of miRNAs in TGCTs suggest that they may act as either oncogene or tumour suppressors. Moreover, individual miRNA targets and downstream pathways in the context of TGCT development have been explored. In this review, we will focus on the diverse roles and targets of miRNAs in TGCT pathogenesis.

Burned-Out Testicular Tumor Presenting as a Retroperitoneal Mass: A Case Report

Spontaneous primary tumor regression, or burned-out tumors, refers to the presence of a metastatic tumor with the histological regression of the primary lesion. The burned-out phenomenon has been reported in various malignancies, with testicular germ cell tumors (GCTs) accounting for a significant share of these cases. However, burned-out testicular tumors are a rare clinical phenomenon and are generally difficult to diagnose, as there is no evidence of primary testicular cancer. Here, we describe the case of a 42-year-old male who presented to our hospital complaining of right abdomen and groin pain for several months. On physical exam, the patient had normal genital and rectal exams. An abdominal-pelvic computed tomography (CT) scan of his abdomen and pelvis revealed a large retroperitoneal mass with radiographic characteristics of a sarcoma. Given his groin pain, the patient had a testicular ultrasound, which revealed scar tissue in the right testicle. His testicular tumor markers showed elevated β-human chorionic gonadotropin (β-hCG) and lactate dehydrogenase (LDH) but normal α-fetoprotein (AFP). He underwent right radical inguinal orchiectomy, with pathologic examination of the testicle revealing a burned-out testicular tumor. The patient was then treated with four cycles of bleomycin, etoposide, and cisplatin (BEP). His post-treatment tumor markers were normalized; however, his abdomen-pelvic CT scan showed a persistent mass. The patient underwent retroperitoneal lymph node dissection (RPLND) with the removal of 12 lymph nodes. However, pathologic evaluation of the lymph nodes revealed no evidence of neoplastic cells. The patient has remained disease-free after five years of follow-up.

This report highlights the potential of burned-out testicular tumors in young and middle-aged men presenting with a retroperitoneal mass. Furthermore, it underscores the importance of obtaining testicular ultrasound in these patients to rule out regressed testicular tumors.

Synchronous Bilateral Primary Testicular Tumors With Discordant Histopathology

Concomitant presentation of histologically distinct bilateral testicular tumors is exceedingly rare. Here we report the case of a 20-year-old male who presented with a left testicular mass. He was found to have bilateral testicular masses on ultrasound and underwent bilateral orchiectomy. Left testicular pathology revealed a mixed germ cell tumor consisting of teratoma, seminoma, and germ cell neoplasia in situ; right testicular pathology revealed two foci of pure seminomas. He is currently on active surveillance and remains in remission at 18-month follow-up. Our case demonstrates the rare occurrence of bilateral primary synchronous testicular tumors with different histopathology in each testis. Despite the rarity of this condition, its treatment is based on standard management of unilateral testicular carcinoma, with the added element of prioritization of one tumor over the other. It is important for clinicians to tailor management for bilateral testicular germ cell tumors according to the most aggressive component.

The tumour suppressor CCDC6 is involved in ROS tolerance and neoplastic transformation by evading ferroptosis

Coiled-coil domain containing 6 (CCDC6) is a tumour suppressor gene involved in apoptosis and DNA damage response. CCDC6 is known to be functionally impaired upon gene fusions, somatic mutations, and altered protein turnover in several tumours. Testicular germ cell tumours are among the most common malignancies in young males. Despite the high cure rate, achieved through chemotherapy and/or surgery, drug resistance can still occur. In a human cellular model of testis Embryonal Carcinoma, the deficiency of CCDC6 was associated with defects in DNA repair via homologous recombination and sensitivity to PARP1/2 inhibitors. Same data were obtained in a panel of murine testicular cell lines, including Sertoli, Spermatogonia and Spermatocytes. In these cells, upon oxidative damage exposure, the absence of CCDC6 conferred tolerance to reactive oxygen species affecting regulated cell death pathways by apoptosis and ferroptosis. At molecular level, the loss of CCDC6 was associated with an enhancement of the xCT/SLC7A11 cystine antiporter expression which, by promoting the accumulation of ROS, interfered with the activation of ferroptosis pathway. In conclusion, our data suggest that the CCDC6 downregulation could aid the testis germ cells to be part of a pro-survival pathway that helps to evade the toxic effects of endogenous oxidants contributing to testicular neoplastic growth. Novel therapeutic options will be discussed.

Autologous Stem Cell Transplantation in Testicular Germ Cell Tumor-Preliminary Experience from a Single Center

Background Germ cell tumor (GCT) of the testis is one of the highly curable solid organ malignancies. Those who experience relapse after platinum-based chemotherapy can be salvaged with systemic therapy followed by high-dose chemotherapy (HDCT) and autologous stem cell transplantation (ASCT). Complete remission can be obtained in approximately 50 to 60% of patients treated with HDCT. Our experience reports the efficacy and safety of HDCT followed by ASCT in relapsed GCT.

Methods Analysis of patient records (2012–2019) showed that three patients had received HDCT and ASCT.

Results All the three patients were treated with BEP (bleomycin, etoposide, and cisplatin) as first-line therapy. HDCT was done in Case 1 after third-line salvage and in other two patients after second-line salvage chemotherapies. High-dose carboplatin and etoposide were used as conditioning regimen. Granulocyte colony-stimulating factor was used for the mobilization of stem cells. After ASCT, complete remission was documented in all the patients. All were alive and disease-free till the last follow-up. Grade ¾ toxicities including myelosuppression, diarrhea, and mucositis were observed in all three patients.

Conclusion This is the first report from India on HDCT with ASCT in GCT. HDCT/ASCT seems to be feasible, safe, and effective in relapsed testicular GCTs.

Small Bowel Metastasis as a Presentation of Testicular Seminoma

Testicular germ cell tumors account for 95% of testicular cancers in men with approximately 71,000 patients being diagnosed with testicular cancer every year. The overall survival of testicular germ cell tumors is approximately 95%. However, the prognosis becomes less favorable when distant metastasis is present. Gastrointestinal (GI) tract metastasis occurs in less than 5% of patients with non-seminomatous tumors, and in less than 1% in patients with pure seminomas. GI metastasis usually involves the colon, esophagus, and stomach with the most common symptoms of GI metastasis being diarrhea, nausea, vomiting, and obstruction. We discuss the case of a 42-year-old male patient with GI manifestations as the first presentation of testicular seminoma with metastasis to the small bowel. Computed tomography of the abdomen and pelvis revealed a small bowel mass, and the diagnosis was confirmed with histopathologic examination of endoscopic biopsy samples. The patient subsequently underwent chemotherapy treatment with close surveillance. Clinicians should maintain a high index of suspicion in the differential diagnosis of abdominal pain in young male patients, especially when associated with symptoms like unexplained weight loss, constitutional symptoms, and testicular pain or swelling. Metastasis to the GI tract from the testis should be promptly diagnosed and managed, as the overall survival rates can significantly decrease with the delay of diagnosis.

Integrated analysis of high-throughput sequencing data reveals the key role of LINC00467 in the invasion and metastasis of testicular germ cell tumors

Long noncoding RNAs (lncRNAs) are involved in various physiological and pathological processes. However, the role of lncRNAs in testicular germ cell tumor (TGCT) has been rarely reported. Our purpose is to comprehensively survey the expression and function of lncRNAs in TGCT. In this study, we used RNA sequencing to construct the lncRNA expression profiles of 13 TGCT tissues and 4 paraneoplastic tissues to explore the function of lncRNAs in TGCT. The bioinformatics analysis showed that many lncRNAs are differentially expressed in TGCT. GO and KEGG enrichment analyses revealed that the differentially expressed lncRNAs participated in various biological processes associated with tumorigenesis in cis and trans manners. Further, we found that the expression of LINC00467 was positively correlated with the poor prognosis and pathological grade of TGCT using WGCNA analysis and GEPIA database data mining. In vitro experiments revealed that LNC00467 could promote the migration and invasion of TGCT cells by regulating the expression of AKT3 and influencing total AKT phosphorylation. Further analysis of TCGA data revealed that the expression was negatively correlated with the infiltration of immune cells and the response to PD1 immunotherapy. In summary, this study is the first to construct the expression profile of lncRNAs in TGCT. It is also the first study to identify the metastasis-promoting role of LNC00467, which can be used as a potential predictor of TGCT prognosis and immunotherapeutic response to provide a clinical reference for the treatment and diagnosis of TGCT metastasis.

METTL3 May Regulate Testicular Germ Cell Tumors Through EMT and Immune Pathways

Testicular germ cell tumors (TGCTs) are highly prevalent in young men aged 20–40 years and are one of the most common lethal solid tumors in men of this age. Due to the current unclear mechanism of tumor development, there is a lack of effective treatment, and therefore in-depth research of the molecular mechanism of the occurrence and development of TGCT and the search for suitable and effective therapeutic targets and molecular markers are of great significance for achieving effective treatment. METTL3 is a very important methylase, which has been implicated in the progression of many cancers, but the role of METTL3 in TGCT has not been fully elucidated. In this article, we found that METTL3 expression was significantly downregulated in TGCT tissues, and patients with low expression levels had lower overall survival and relapse-free survival rates. After overexpressing METTL3, cell proliferation, invasion, and migration ability significantly increased, while influencing the expression of epithelial–mesenchymal transition (EMT)-related proteins. In addition, we observed that the expression level of METTL3 positively correlated with molecular markers and infiltration level of CD8+ and CD4+ T cells and natural killer cells. In sum, our findings identified that METTL3 can be used as an independent prognostic marker in patients with TGCT. METTL3 participates in the proliferation, migration, and invasion of TGCT cells by regulating the expression of EMT-related genes and may also play a role in activating the tumor immune response in TGCT.

Outcome of testicular non-seminomatous germ cell tumours: report from a tertiary cancer centre in eastern India

Non-seminomatous germ cell tumour (NSGCT) is a rare but highly curable malignancy. The literature on the management and outcomes of NSGCT is scarce from India. Here, we report the demography and treatment outcomes of NSGCT treated at our centre. This is a retrospective analysis of testicular and retroperitoneal NSGCT patients treated from March 2011 to December 2019. Patients were staged appropriately with imaging, pre- and post-operative tumour marker. Patients received stage adjusted adjuvant treatment after high inguinal orchiectomy. Patients with advanced disease were risk stratified as per International Germ Cell Cancer Collaborative Group (IGCCCG) classification. A total of 100 patients were treated with a median age of 28 years (Range: 18–51). Primary site was testis in 92 and retroperitoneum in 8 patients. Testicular violation was present in 17 (18%) patients. The stage of the disease was I in 32, II in 19 and III in 49 patients, respectively. IGCCCG risk groups were good in 29 (46%), intermediate in 13 (21%) and poor in 21 (33%) patients. Eleven patients (24%) underwent retroperitoneal lymph node dissection amongst 45 with post-chemotherapy residual disease. After a median follow-up of 26.6 months (range: 2.2–100.7), 3-year event-free survival and overall survival (OS) were 70.7% ± 5.6% and 78.2% ± 5.4%, respectively. S3 tumour marker (p = 0.01) and non-pulmonary visceral metastasis (p < 0.001) emerged as independent poor prognostic factors for OS in multivariate analysis. To conclude, testicular NSGCT has very high cure rate. Two-third patients present with advanced disease and one-third of them had poor risk disease. S3 tumour marker and non-pulmonary visceral metastasis are poor risk factors for OS.

Treatment of clinical stage I non-seminoma

Germ cell cancers are the most common solid tumors among men between 15 and 40 years. Non-seminomatous germ cell tumors (NSGCTs) represent a unique and exclusive cohort of germ cell tumor patients. Non-seminoma can harbor different histologic components. The most commonly found histologies are embryonal cell cancer, teratoma, yolk sack tumor and choriocarcinoma, as well as teratocarcinoma and seminoma, in combination with non-seminomatous germ cell tumors histologic types. The clinical definition of stage I non-seminoma is the absence of metastatic lesions on imaging and normal tumor markers. The cure rate for clinical stage I NSGCT is 99% and this can be achieved by three therapeutic strategies: Active surveillance with treatment at the time of relapse, retroperitoneal lymph node dissection or adjuvant chemotherapy. The balancing of these various strategies should always be based on an individual risk profile of NGSCG patient depending on the lymphovascular invasion of the tumor.

International trends in ovarian cancer incidence from 1973 to 2012

PURPOSE

Ovarian cancer is the 7th leading cancer diagnosis and the 8th leading cause of cancer death in women worldwide. We conducted this study to investigate the incidence of ovarian cancer internationally.

METHODS

The trends in ovarian cancer incidence were analyzed through the latest data of CI5 over the 40-year period from 21 populations in 4 continents using Joinpoint analysis, ASRs and proportions of different histological subtypes in those populations were also analyzed using volume XI of CI5.

RESULTS

ASRs of ovarian cancer were from 7.0 to 11.6 per 100,000 in non-Asia populations during 2008-2012. In Asia, the ASR in Israel (Jews) were the highest, up to 8.1 per 100,000 in the same period. The international trends from 1973 to 2012 showed that ASRs of ovarian cancer were decreasing in 8 of 21 selected populations, whereas ASRs in Slovakia, Spain (Navarra) and China (Shanghai) were increasing. Meanwhile, there are certain differences in the main pathological classification patterns within different regions. In Asia, China (Hong Kong) and Japan both have a higher ASRs and proportions for clear cell and endometrioid carcinomas, while Japan has the highest ASRs and proportions for mucinous carcinomas.

CONCLUSION

Although the reasons for those trends were not entirely clear, environmental, reproductive and genetic factors were likely to have led to these patterns. Meanwhile, more attention and further study should be given to the etiological factors of histology-specific ovarian cancer.

Trends of Testicular Cancer Mortality-to-Incidence Ratios in Relation to Health Expenditure: An Ecological Study of 54 Countries

Favorable testicular cancer mortality-to-incidence ratios (MIRs) are associated with health care disparities, including health care expenditures, but the trends of testicular MIR and health care disparity remain unclear. We evaluated changes in MIR as the difference between 2012 and 2018, termed delta MIR (δMIR). Health care expenditures and the human development index (HDI) were obtained from the World Health Organization and the Human Development Report Office of the United Nations Development Programme. The association between the variables was analyzed by Spearman's rank correlation coefficient. A total of 54 countries were included in the criteria of data quality reports and missing data. By continent, the most favorable MIR was in Oceania (0.03) while it was 0.36 in Africa. In these areas, the incidence rates were positively correlated to health care expenditure, but the mortality rates showed a reversed correlation. The MIR ranged from 0.01 to 0.34 and the δMIR ranged from -0.05 to 0.34. The favorable MIRs are correlated to high health care expenditure and HDI (all p < 0.001). Interestingly, favorable δMIRs tend to be seen in countries with relatively low health care expenditure and HDI (all p < 0.001). In conclusion, favorable testicular cancer MIRs are associated with high HDI and health care expenditure, but the improvement in MIR between 2012 and 2018 (δMIR) is negatively correlated with HDI and health care expenditure.

Assessing Health-Related Quality of Life Among Survivors of Testicular Cancer: A Systematic Review

This study aimed to determine if the current health-related quality of life (HRQoL) tools created for survivors of testicular cancer are collecting the highest quality of data via a two-step methodological critique of both the seminal studies that produced a survivor of testicular cancer HRQoL tool (Phase 1) and the actual tool itself (Phase 2). It is the goal of this current article to present and discuss Phase 1.

A systematic review aimed to assess the methodological quality of studies conducted to create instruments used to measure survivors of testicular cancer HRQoL. Five reviewers independently assessed each study with the 20-item Appraisal Tool for Cross-Sectional Studies (AXIS). Inter-rater agreement and Fleiss’ kappa was also assessed to ensure consistency in reported scores. Assessments for the EORTC QLQ-TC 26 and CAYA-T studies were low (AXIS 52.5%; IRA 95%; κ = 0.779) and fair (AXIS 65%; IRA 80%; κ = 0.599), respectively. Critical appraisal of the scales included issues within the three core AXIS domains. Primary concerns related to sampling methodology and the lack of a qualitative component of their core conceptual development phase.

Both reviewed seminal studies have significant methodological concerns that question the tools’ quality. Next steps include extensive appraisal of the psychometric properties of the EORTC QLQ TC-26 and the CAYA-T to complete the comprehensive review. Accurate and reliable data are necessary to understand survivor of testicular cancer HRQoL and assist in building the bridge of communication between health care professionals and survivors to help to improve patient outcomes.

The Good, the Bad and the Ugly of Testicular Immune Regulation: A Delicate Balance Between Immune Function and Immune Privilege

The testis is one of several immune privilege sites. These sites are necessary to decrease inflammation and immune responses that could be damaging to the host. For example, inflammation in the brain, eye or placenta could result in loss of cognitive function, vision or rejection of the semi-allogeneic fetus, respectively. In the testis, immune privilege is "good" as it is necessary for protection of the developing auto-immunogenic germ cells. However, there is also a downside or "bad" part of immune privilege, where pathogens and cancers can take advantage of this privilege and persist in the testis as a sanctuary site. Even worse, the "ugly" of privilege is how re-emerging viruses, such as Ebola and Zika viruses, can establish persistence in the testes and be sexually transmitted even months after they have been cleared from the bloodstream. In this review, we will discuss the delicate balance within the testis that provides immune privilege to protect the germ cells while still allowing for immune function to fight off pathogens and tumors.

Cancer education matters: a report on testicular cancer knowledge, awareness, and self-examination practice among young Polish men

The objective of the study was to assess the level of testicular cancer (TC) knowledge and awareness as well as the altitude and practice towards testicular self-examination (TSE) among Polish male high school and medical students. An original questionnaire survey was conducted in SE Poland with a representative sample of 1077 male students: 335 from high school and 742 medical students. The results indicate the knowledge about TC epidemiology and the awareness of risk factors responsible for the TC was low. The knowledge of the signs and symptoms of TC was significantly higher among the medical students, compared to the high school students. The level of education was associated with the awareness of methods for early detection and symptoms of TC. A satisfactory level of awareness of the TSE practice was exhibited only by the medical students. The main reason for not performing self-examination was the lack of knowledge and practical skills. The deficits of knowledge of TC in young men should motivate the education policy makers in Poland to implement education in the field of TC issues more widely in high schools. Moreover, cancer prevention modules and/or teaching methods should be improved in medical schools.

Prognostic factors and outcomes of nonseminomatous germ cell tumours of testis-experience from a tertiary cancer centre in India

Germ cell tumour of the testis is the most common cancer in young men in the western world. India has the lowest incidence globally, and hence Indian data are sparse. We report the outcomes of patients with nonseminomatous germ cell tumours of testis treated at a tertiary cancer centre in South India over a period of 10 years. Patients with a histopathological diagnosis of nonseminomatous germ cell tumours of the testis from 1 January 2006 to 31 December 2016 were included in the study. Patient demographics, tumour characteristics and treatment details were retrieved from case records. Kaplan–Meier method was used to estimate progression-free survival (PFS) and overall survival (OS). Cox regression model was used to analyse the prognostic factors.

One hundred and nineteen patients with nonseminomatous germ cell tumours of the testis were included in the study. The median follow-up was 81 months. The estimated 4-year OS and progression-free survival were 87.1% and 84.5%, respectively. The four-year OS for good, intermediate and poor-risk groups was 93.6%, 87.5% and 52.6%, respectively. The PFS at 4 years was 91.4%, 87.8% and 47.4% for good, intermediate and poor-risk groups, respectively. The presence of nonpulmonary visceral metastasis and biochemical response after chemotherapy were significant predictors for OS and PFS in multivariate cox proportional hazards regression. The survival figures are comparable to the rest of the world except in the poor prognostic risk group. The inferior survival noticed in this group of patients may be due to the lack of good salvage procedures. High-dose chemotherapy with stem-cell support may be considered more often for this group of patients.

Development and validation of prognostic nomogram for germ cell testicular cancer patients

The purpose of our study was to establish a reliable and practical nomogram based on significant clinical factors to predict the overall survival (OS) and cancer-specific survival (CSS) of patients with germ cell testicular cancer (GCTC). Patients diagnosed with GCTC between 2004 and 2015 were obtained from the SEER database. Nomograms were constructed using the R software to predict the OS and CSS probabilities and the constructed nomograms were validated and calibrated. A total of 22,165 GCTC patients were enrolled in the study, including the training cohort (15,515 patients) and the validation cohort (6,650 patients). In the training cohort, multivariate Cox regression showed that age, race, AJCC stage, SEER stage and surgery were independent prognostic factors for OS, while age, race, AJCC stage, TM stage, SEER stage and radiotherapy were independent prognostic factors for CSS. Based on the above Cox regression results, we constructed prognostic nomograms of OS and CSS in GCTC patients and found that the OS nomograms had higher C-index and AUC compared to TNM stage in the training and validation cohorts. In addition, in the training and external validation cohorts, the calibration curves showed a good consistency between the predicted and actual 3-, 5- and 10-year OS and CSS rates of the nomogram. The current prognostic nomogram can provide a personalized risk assessment for the survival of GCTC patients.

Distinct Proteomic Profile of Spermatozoa from Men with Seminomatous and Non-Seminomatous Testicular Germ Cell Tumors

Testicular germ cell tumors (TGCTs) are predominant in young males (15–44 years). Seminomatous and non-seminomatous TGCTs account for about 98% of all TGCTs cases. In this study, we aimed to compare the sperm proteome of patients with seminomatous and non-seminomatous TGCTs to identify possible protein biomarkers that could help distinguish between them in a non-invasive manner. We analyzed semen samples from patients with seminomatous or non-seminomatous TGCTs (n = 15/group) that were cryopreserved before the start of cancer treatment. Quantitative proteomic analysis was conducted on pooled samples (n = 3/group) and a total of 258 differentially expressed proteins (DEPs) were identified. The overexpression of acrosin precursor (ACR) and chaperonin containing TCP1 subunit 6B (CCT6B) as well as the underexpression of S100 calcium-binding protein A9 (S100A9) in the spermatozoa of patients with non-seminomatous TGCTs were validated by western blotting conducted on individual samples (n = 6 for seminomatous group and n = 6 for non-seminomatous group). Our overall results suggest an association between the higher and faster invasiveness of non-seminomatous TGCTs and the altered protein expressions, providing important information for future studies.

SPANXN2 functions a cell migration inhibitor in testicular germ cell tumor cells

Background

SPANX family members are thought to play an important role in cancer progression. The SPANXN2 is a gene expressed mainly in normal testis, but its role in testicular germ cell tumors (TGCTs) has yet to be investigated. TGCT is one of the most common solid tumors in young men and is associated with poor prognosis; however, effective prognostic indicators remain elusive. Therefore, we investigated the role of SPANXN2 in TGCT development.

Methods

SPANXN2 expression levels were validated by quantitative real-time polymerase chain reaction (qRT-PCR) analyses of 14 TGCT samples and five adjacent normal tissue samples. SPANXN2 was transiently overexpressed in TGCT cells to study the consequences for cell function. The effects of SPANXN2 on cell migration were evaluated in transwell and wound healing assays. The effects on cloning ability were evaluated in colony formation assays. MTT assays and cell cycle analysis were used to detect the effects of SPANXN2 on cell proliferation. The expression levels of EMT- and AKT-related proteins in cells overexpressing SPANXN2 were analyzed by Western blotting.

Results

Compared with adjacent normal tissues, the Gene Expression Profiling Interactive Analysis database showed SPANXN2 expression was downregulated in TGCTs which was consistent with the qRT-PCR analysis. SPANXN2 overexpression reduced cell migration and colony formation capability and downregulated expression of EMT- and AKT-related proteins, Vimentin, Snail, AKT, and p-AKT.

Conclusion

Our results suggest that SPANXN2 regulates TGCT cell migration via EMT- and AKT-related proteins although its role in the occurrence and development of TGCT remains to be fully elucidated.

A scoping review and proposed workflow for multi-omic rare disease research

BACKGROUND

Patients with rare diseases face unique challenges in obtaining a diagnosis, appropriate medical care and access to support services. Whole genome and exome sequencing have increased identification of causal variants compared to single gene testing alone, with diagnostic rates of approximately 50% for inherited diseases, however integrated multi-omic analysis may further increase diagnostic yield. Additionally, multi-omic analysis can aid the explanation of genotypic and phenotypic heterogeneity, which may not be evident from single omic analyses.

MAIN BODY

This scoping review took a systematic approach to comprehensively search the electronic databases MEDLINE, EMBASE, PubMed, Web of Science, Scopus, Google Scholar, and the grey literature databases OpenGrey / GreyLit for journal articles pertaining to multi-omics and rare disease, written in English and published prior to the 30th December 2018. Additionally, The Cancer Genome Atlas publications were searched for relevant studies and forward citation searching / screening of reference lists was performed to identify further eligible articles. Following title, abstract and full text screening, 66 articles were found to be eligible for inclusion in this review. Of these 42 (64%) were studies of multi-omics and rare cancer, two (3%) were studies of multi-omics and a pre-cancerous condition, and 22 (33.3%) were studies of non-cancerous rare diseases. The average age of participants (where known) across studies was 39.4 years. There has been a significant increase in the number of multi-omic studies in recent years, with 66.7% of included studies conducted since 2016 and 33% since 2018. Fourteen combinations of multi-omic analyses for rare disease research were returned spanning genomics, epigenomics, transcriptomics, proteomics, phenomics and metabolomics.

CONCLUSIONS

This scoping review emphasises the value of multi-omic analysis for rare disease research in several ways compared to single omic analysis, ranging from the provision of a diagnosis, identification of prognostic biomarkers, distinct molecular subtypes (particularly for rare cancers), and identification of novel therapeutic targets. Moving forward there is a critical need for collaboration of multi-omic rare disease studies to increase the potential to generate robust outcomes and development of standardised biorepository collection and reporting structures for multi-omic studies.

Evaluation of Serum Biomarkers (FGF-2, HGF, MIF and PTN) in Patients With Testicular Germ Cell Cancer

BACKGROUND/AIM

FGF-2, HGF, MIF and PTN have been suggested as biomarkers for testicular germ cell cancer patients in earlier studies. Our study was designed to validate these potential novel tumor markers.

MATERIALS AND METHODS

Serum FGF-2, HGF, MIF and PTN levels were analysed using an ELISA technique in a screening cohort of 20 testicular germ cell cancer patients and 10 healthy men. MIF levels were measured in a validation cohort of 84 patients with testicular cancer, 24 with non-malignant testicular tumors and 64 healthy men.

RESULTS

Serum FGF-2, HGF and PTN levels did not differ in cancer patients and healthy males within the screening cohort, whereas MIF was significantly increased among cancer patients. Within the validation cohort, a modest but insignificant increase of serum MIF was observed in TGCT patients compared to healthy men. MIF levels were not correlated with adverse clinical-pathological parameters.

CONCLUSION

FGF-2, HGF, MIF and PTN are not suitable as non-invasive biomarkers for testicular germ cell cancer patients.

Systemic therapy for primary and extragonadal germ cell tumors: prognosis and nuances of treatment

Testicular germ cell tumors are the most common solid tumors in young men. These cancers represent a success story of modern medicine in our ability to cure young patients and offer decades of life, with a 5-year survival rate of approximately 95%. This review outlines the staging and risk classification of testicular cancers, and reviews the current state of knowledge and standard of care for the systemic treatment of testicular germ cell tumors with chemotherapy, focusing on the relevant clinical data supporting each treatment regimen. This review also briefly highlights current areas of active investigation, notably in the relapsed and refractory setting, including ongoing clinical trials.

The role of diagnostic imaging in the primary testicular cancer: initial staging, response assessment and surveillance

Testicular cancers are a group of uncommon malignancies that account for less than 1% of new cancer cases per year in the United States and globally. The disease typically affects men between the ages of 20-44, and the overwhelming majority of tumors are germ cell in origin. Most cases of testicular cancer are organ confined at diagnosis and have a good overall prognosis. Testicular cancers are staged by the tumor, node, metastasis, serum markers (TNMS) classification set forth by the American Joint Commission on Cancer staging. Diagnostic imaging plays a crucial role in initial staging, specifically in assessing the primary tumor prior to orchiectomy and evaluating for regional and/or distant metastasis. Multimodality imaging is used for initial staging, with ultrasound and computed tomography (CT) most commonly utilized. Diagnostic imaging is also important in evaluating response in patients who initially present with metastatic disease as well as in patients who are undergoing surveillance. Typically, CT is used for response assessment and surveillance, with magnetic resonance imaging (MRI) and positron emission tomography (PET) serving as adjunct modalities. This article reviews the role of various diagnostic imaging modalities and how they are employed in the diagnosis, staging, response assessment and surveillance of primary testicular cancer.

Correlations between Mortality-to-Incidence Ratios and Health Care Disparities in Testicular Cancer

The mortality-to-incidence ratio (MIR) is associated with the clinical outcomes of different types of cancer as well as the ranking of health care systems. However, the association between MIRs for testicular cancer and health care disparities, including differences in expenditures and health system rankings, has not yet been reported. We used the Spearman’s rank correlation coefficient (CC) to analyze the correlation between testicular cancer MIRs and both total expenditures on health/gross domestic product (e/GDP) and the World Health Organization’s (WHO) health system rankings. After screening the data for quality and missing information, 57 countries were chosen for analysis. Generally, developed countries and regions had relatively high rates of incidence/mortality, but with a favorable MIR. Among the continents, Europe had the highest incidence rates, whereas the highest MIRs were in Africa. Globally, favorable testicular cancer MIRs were observed in countries with both a high e/GDP and a good WHO ranking (R² = 0.325, p < 0.001 and CC = −0.568, p < 0.001; R² = 0.367, p < 0.001 and CC = 0.655, p < 0.001, respectively). In conclusion, the MIR for testicular cancer varies in countries and regions based on both their total health expenditure and their health care system ranking.

Environmental Pollution as a Risk Factor in Testicular Tumour Development: Focus on the Interaction between Bisphenol A and the Associated Immune Response

Bisphenol A (BPA) is an endocrine disruptor to which animals and humans are highly exposed. Many reports have established a relationship between BPA exposure and breast cancer incidence, especially during critical periods of development. However, its effects on the immune response in testicular tumour growth have not yet been described. Thus, we wanted to analyse the effect of perinatal BPA exposure in pregnant female mice and the immune response modulation and tumour growth in an intratesticular cancer model in offspring male mice. Pregnant female mice were exposed to a dose of 250 mg/kg/day/body weight of BPA in their drinking water. In adulthood, male offspring underwent intrascrotal inoculation with 4T1 cancer cells. On day 21 after inoculation, mice were euthanised, and serum was obtained to measure BPA levels using HPLC coupled to mass spectrometry. The percentages of immune cell populations in peripheral lymph nodes (PLN), the spleen and tumours were evaluated by flow cytometry. In addition, the tumour expression of IL-10, TNF-α and TGF-β was analysed by RT-PCR. Of note, we found detectable circulating levels of BPA in the offspring of mothers exposed to it while pregnant. Remarkably, BPA treatment promoted tumour growth by about 75% compared to mice coming from female mice that did not receive the compound. Perinatal exposure to BPA modulated the percentages of different immune cells in the spleen and PLN. In addition, the expression of inflammatory-related cytokines (IL-10 and TNF-α) in the tumours was significantly enhanced compared to control and vehicle groups. In conclusion, the perinatal BPA administration in pregnant female mice modulated different cellular and molecular immune components that resulted in outstanding testicular tumour size in male offspring.

Can Smartphones Promote Cancer Prevention Behaviours in Healthy Young Adults? A Prospective Study

Cancer prevention should start as early as possible. Young adults would benefit largely from the use of a smartphone app aiming at promoting cancer prevention behaviours. The aims of the study described in this paper are to (1) examine the user participation and engagement with a cancer prevention app in real-life settings and (2) assess changes in the users' cancer prevention behaviours. A cancer prevention smartphone app called Happy was developed and released to the general population. Data from registered app users' (N = 3326) demographics and baseline cancer prevention behaviours was analysed. App engagement was measured and all behaviour data logged through the app was analysed to assess the effectiveness of the app in the promotion of cancer prevention behaviours. User demographics and baseline behaviour assessment show that the app reached its intended target population: young adults that generally do not comply with cancer prevention guidelines. Logged behavioural data showed an increased frequency in several cancer prevention behaviours and a significant increase in the overall putative cancer prevention level (p < 0.001). However, user engagement with the app was limited and might condition the long-term impact of such changes. Happy reached its intended population and seems to be an effective tool to promote cancer prevention. Further research is needed to fully assess its long-term persuasive potential.

Clinical Benefit of Sorafenib Combined with Paclitaxel and Carboplatin to a Patient with Metastatic Chemotherapy-Refractory Testicular Tumors

Testicular cancer is one of the few tumor types that have not yet benefited from targeted therapy. Still no new active agents for treating this cancer have been identified over the past 15 years. Once patients are refractory to cisplatin-based chemotherapy, they will be expected to die from testicular cancer. This report describes a 21-year-old man who was refractory to chemotherapy and immunotherapy. Whole exome sequencing and low-depth whole genome sequencing confirmed the KRAS gene amplification, which may lead to the tumor cells' progression and proliferation. After discussion at the molecular tumor board, the patient was offered paclitaxel, carboplatin, and sorafenib (CPS) based on a phase III clinical trial of melanoma with KRAS gene copy gains. After treatment with CPS, the patient achieved excellent curative effects. Because of a nearly 50% frequency of KRAS amplification in chemotherapy-refractory testicular germ cells, CPS regimen may provide a new therapy, but it still warrants further validation in clinical studies. KEY POINTS: Chemotherapy-refractory testicular cancer has a very poor prognosis resulting in a lack of effective targeted therapies. KRAS gene amplification occurs in nearly 20% of testicular cancer and 50% of chemotherapy-refractory testicular cancer. KRAS amplification may activate the MAPK signaling pathway, and inhibition of MAPK by sorafenib combined with paclitaxel and carboplatin could be a viable option based on a phase III clinical trial of melanoma.To the authors' knowledge, this is the first report of response to sorafenib-based combination targeted therapy in a patient with chemotherapy-refractory testicular cancer.Clinical genomic profiling can confirm copy number variation of testicular cancer and provide insights on therapeutic options.

Molecular Basis of Cisplatin Resistance in Testicular Germ Cell Tumors

The emergence of cisplatin (CDDP) resistance is the main cause of treatment failure and death in patients with testicular germ cell tumors (TGCT), but its biologic background is poorly understood. To study the molecular basis of CDDP resistance in TGCT we prepared and sequenced CDDP-exposed TGCT cell lines as well as 31 primary patients' samples. Long-term exposure to CDDP increased the CDDP resistance 10 times in the NCCIT cell line, while no major resistance was achieved in Tera-2. Development of CDDP resistance was accompanied by changes in the cell cycle (increase in G1 and decrease in S-fraction), increased number of acquired mutations, of which 3 were present within ATRX gene, as well as changes in gene expression pattern. Copy number variation analysis showed, apart from obligatory gain of 12p, several other large-scale gains (chr 1, 17, 20, 21) and losses (chr X), with additional more CNVs found in CDDP-resistant cells (e.g., further losses on chr 1, 4, 18, and gain on chr 8). In the patients' samples, those who developed CDDP resistance and died of TGCT (2/31) showed high numbers of acquired aberrations, both SNPs and CNVs, and harbored mutations in genes potentially relevant to TGCT development (e.g., TRERF1, TFAP2C in one patient, MAP2K1 and NSD1 in another one). Among all primary tumor samples, the most commonly mutated gene was NSD1, affected in 9/31 patients. This gene encoding histone methyl transferase was also downregulated and identified among the 50 most differentially expressed genes in CDDP-resistant NCCIT cell line. Interestingly, 2/31 TGCT patients harbored mutations in the ATRX gene encoding a chromatin modifier that has been shown to have a critical function in sexual differentiation. Our research newly highlights its probable involvement also in testicular tumors. Both findings support the emerging role of altered epigenetic gene regulation in TGCT and CDDP resistance development.

Testicular Cancer at the University of Port Harcourt Teaching Hospital: A 10-year Retrospective Review

BACKGROUND

Testicular cancers are rare malignancies. They are however very common in males aged 15-40 years. Reports of increasing incidence of testicular cancer in western countries have been noted. Despite the increasing incidence, mortality has remained low in these countries. There are few publications on the management of testicular tumors in Nigeria.

AIM

The aim of this study was to determine the hospital prevalence and highlight our experience in the management of patients with testicular cancer.

MATERIALS AND METHODS

This was a 10-year retrospective study on patients diagnosed with histologically confirmed testicular cancer from January 2009 to December 2018. The case records were retrieved. Data obtained included biodata, clinical presentation, investigations, treatment received and outcomes. Data analysis was carried out using SPSS version 20.0.

RESULTS

Eleven patients with testicular cancer were managed during the study period, constituting 0.01% of new cases seen in the hospital. Peak age was 20-29 years (54.55%), with a mean age of 29.27 ± 9.51yrs. The most common presentation was painless scrotal swelling, observed in nine (81.8%) patients. Nine (81.8%) patients presented six months or more after onset of symptoms with advanced disease. Distant metastasis was seen in two (18.2%) patients. Right sided disease was found in seven (63.6%) and left sided disease in four (36.4%). All had radical inguinal orchidectomy. The most common histological diagnosis was seminoma in 8 (72.7%) patients. All the subjects were offered four courses of chemotherapy with bleomycin, etoposide and cisplatin. However, only four (36.4%) completed the chemotherapy. A statistically significant association was observed between the duration of symptoms and the disease stage (P = 0.003), and between number of chemotherapy sessions and survival (P = 0.02).

CONCLUSION

Testicular cancer was an uncommon condition in the catchment area of the University of Port Harcourt Teaching Hospital, affecting relatively young men. The commonest presenting complaint was painless scrotal swelling. Most patients presented with Stage II disease, with seminoma being the commonest histopathology. All had surgical treatment; adjuvant chemotherapy improved 5-year survival. Public education is necessary to surmount sociocultural barriers to effective management of testicular tumors in our environment.

miRNA-302s may act as oncogenes in human testicular germ cell tumours

Testicular germ cell tumour (TGCT) represents the most common malignancy in young men in large parts of the world, but the aetiology is yet unclear. Multiple TGCT susceptibility loci have been identified, and we have shown that one of these, SPRY4, may act as a TGCT oncogene. Furthermore, many of the loci are in non-coding regions of the genome. miRNAs, a class of non-coding RNAs may play a crucial role in cell proliferation, differentiation, and apoptosis, and alteration in their expression may lead to oncogenesis. Differential expression of miRNAs in TGCT and normal testis has been reported in previous studies. In this study, we used qPCR to analyse, in normal and malignant testis tissue, the expression of the ten miRNAs that we had previously identified by sequencing to be the most upregulated in TGCT. We found high expression of these miRNAs also by qPCR analysis. The levels of miR-302a-3p, miR-302b-3p, and miR-302c-3p were downregulated after treatment of the TGCT cell lines NT2-D1 and 833 K with the chemotherapy drug cisplatin. By using miRNA inhibitor-mediated transient transfection, we inhibited the expression of the three members of miR-302 family (miR-302s). Inhibition of miR-302s resulted in a decreased cell proliferation in NT2-D1 cells, but not in 833 K cells. In both cell lines, inhibition of miR-302s resulted in decreased expression of SPRY4, which we have previously shown to regulate MAPK/ERK and PI3K/Akt signalling pathways in these cells. Inhibition of miR-302b-3p and miR-302c-3p decreased phosphorylation of ERK1/2, whereas inhibition of miR-302a-3p and miR-302b-3p led to decreased expression of the apoptosis inhibitor, survivin. Our findings suggest that miR-302s act as TGCT oncogenes by inducing the expression of SPRY4 and activating MAPK/ERK pathway while inhibiting apoptosis via increased survivin expression.

Testicular mixed germ cell tumor presenting with seizure as the initial symptom: a case report and literature review

Most patients with testicular germ cell tumor present with a painless scrotal mass. We report a 19-year-old patient who presented with neurological complains. Rapid clinical progression to coma was noted during the staging work up. A diagnosis of testicular mixed germ cell tumor with multiorgan metastasis (lymph node, lung, liver and brain) was made. Patients with brain metastasis should receive chemotherapy alone or combined with surgery or radiotherapy. Because the clinical symptoms deteriorated quickly, surgery was used upfront followed by chemotherapy and radiotherapy for the brain tumor. After the first stage of treatment, the clinical symptoms, tumor markers and imaging findings were improved. The residual brain tumor was eliminated by chemotherapy, and only sparse degenerated tumor cells were noted in the brain tissue. Longer follow up is required to assess the impact of our treatment strategy.

Pluripotent Very Small Embryonic-Like Stem Cells in Adult Testes - An Alternate Premise to Explain Testicular Germ Cell Tumors

Developmental exposure to endocrine disruptors has resulted in the increased incidence of infertility and testicular germ cell tumors (T2GCT) in young men residing in developed countries. Unlike T1GCT (infants and young children) and T3GCT (aged men), T2GCT arise from CIS/GCNIS that develops from pre-CIS. Pre-CIS represents undifferentiated, growth-arrested gonocytes that persist in fetal testes due to endocrine disruption. However, whether pre-CIS truly exist, do CIS develop into T2GCT, why no CIS in T1GCT/T3GCT, why germ cell tumors (GCT) also occur along midline at extra-gonadal sites, why T1GCT show partial erasure and T2GCT show complete erasure of genomic imprints are open questions that are awaiting answers. We propose that rather than pre-CIS, pluripotent, very small embryonic-like stem cells (VSELs) get affected by exposure to endocrine disruption. Since VSELs are developmentally equivalent to primordial germ cells (PGCs), T2GCT cells show complete erasure of genomic imprints and CIS represents growth-arrested clonally expanding stem/progenitor cells. PGCs/VSELs migrate along the midline to various organs and this explains why GCT occur along the midline, T1GCT show partial erasure of imprints as they develop from migrating PGCs. T3GCT possibly reflects effects of aging due to compromised differentiation and expansion of pre-meiotic spermatocytes. Absent spermatogenesis in pre-pubertal and aged testes explains absence of CIS in T1GCT and T3GCT. Endocrine disruptors possibly alter epigenetic state of VSELs and thus rather than maintaining normal tissue homeostasis, VSELs undergo increased proliferation and compromised differentiation resulting in reduced sperm count, infertility and TGCT. This newly emerging understanding offers alternate premise to explain TGCT and warrants further exploration.