Prognosis of Patients With Testicular Carcinoma Is Dependent on Metastatic Site

Testicular seminoma presenting as a large conglomerate mass in abdomen

Testicular seminoma commonly occurs in young men aged between 15 and 45 years old. Those with testicular cancer may present with a lump or swelling in the testicle. If treated and managed early, patients can expect a greater than 95% success rate. However, advanced stages of testicular seminoma can lead to eventual metastasis. We present a 45-year-old male patient with a prior history of testicular seminoma who was admitted to the emergency department with abdominal distension and acute abdominal pain. The CT identified a rather sizable abdominal mass and the biopsy confirmed metastatic testicular seminoma. Lymphoma was considered as the other differential diagnosis. Abdominal metastasis is rare in patients with testicular seminoma and usually leads to a poor survival outcome. Our patient did not attend follow-up appointments postorchidectomy, likely resulting in abdominal metastasis of testicular seminoma. This demonstrates the importance of ongoing surveillance of seminoma patients, and the challenges associated with differentiating large abdominal conglomerate mass in the CT scan. This patient is currently on active chemotherapy with bleomycin, cisplatin, and etoposide.

Robot-Assisted Laparoscopic Radical Prostatectomy for Prostatic Metastatic Recurrence from Testicular Cancer

Introduction

Treatment evidence for malignancies metastatic to the prostate in young patients is scarce. Herein, we present a case of prostatic metastasis from testicular cancer treated with induction chemotherapy followed by robot-assisted radical prostatectomy. Case Presentation. The patient is a 34-year-old male who underwent radical orchiectomy for a left testicular tumor two years ago and was diagnosed with a mixed germ cell tumor. He was followed up without adjuvant therapy, but symptoms of dysuria lead to suspicion of a prostate tumor, which was diagnosed by prostate biopsy as seminoma of the prostate. After four cycles of chemotherapy, normalization of tumor markers, and tumor shrinkage on imaging, he underwent robot-assisted radical prostatectomy. No recurrence has been observed nine months after treatment.

Conclusion

In men with a history of testicular cancer presenting with lower urinary tract symptoms, it is important to consider recurrent prostate metastases.

Metastatic Testicular Cancer Patterns and Predictors: A Contemporary Population-based SEER Analysis

OBJECTIVE

To elucidate clinical and demographic predictors of metastatic testicular cancer (TC) at presentation and study the impact of these factors on prognosis. Patients with metastatic TC experience poorer outcomes than those with localized or locoregional disease. Social determinants of health may compound this trend.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was queried to identify 16,528 patients aged ≥18 with TC diagnosed from 2010 to 2016. Descriptive statistics were analyzed using Fisher exact test and Pearson chi-square test for continuous and categorical variables. Predictors of specific metastases and factors impacting cancer-specific mortality (CSM) were evaluated using multivariate logistic regression analysis and competing risks regression, respectively.

RESULTS

Of 16,474 patients with complete data, 1877 (11.39%) had distant metastases at diagnosis. These patients more commonly featured disease-specific and demographic variables associated with worse health outcomes (all P < .001). Lung metastases were the predominant site of synchronous and solitary metastases. Disease-specific predictors of metastasis included T stage, histology, tumor size, lymphovascular invasion, and cryptorchidism. Patient-specific predictors included age, geography, ethnicity, race, marital status, and socioeconomic status. Nearly one-fourth of patients with metastases died. Poor CSM was predicted by histology, age, insurance status, and socioeconomic status. All metastatic sites except bone were associated with worse CSM, with lung metastases conferring the greatest risk.

CONCLUSION

This cross-sectional study identifies variables associated with TC metastasis and survival, particularly highlighting the importance of social determinants of health in TC mortality. These findings can facilitate a risk-stratified approach to staging and management while supporting new approaches to target disparities.

A case of prostatic metastasis from non-seminomatous testicular cancer

Introduction

Prostatic metastasis from testicular cancer is extremely rare, with only 10 reported cases, all of which were diagnosed as relapse. Herein, we report the case of a patient with concurrent testicular cancer and prostatic metastasis.

Case presentation

A 57-year-old man presented at our emergency department with urinary retention. A painless mass was found in the right scrotum, and computed tomography showed lung, mediastinal, and liver metastases, and an enlarged prostate. Tumor markers were measured in 2057 U/L lactate dehydrogenase, 2460 mIU/mL human chorionic gonadotrophin, 1303 ng/mL alpha-fetoprotein, and 1.51 ng/mL prostate specific antigen. An orchiectomy and biopsy were performed; the pathological results showed immature teratomas, embryonal carcinomas, choriocarcinomas, and seminomas in the testis, and embryonal carcinomas in the prostate, liver, and mediastinum. The patient refused chemotherapy and died 3 months following diagnosis.

Conclusion

Prostatic metastasis should be considered in cases of dysuria or prostate enlargement in testicular cancers.

Development and validation of a nomogram to predict lung metastasis in patients with testicular germ cell tumors

Background

Lung metastatic tumor (LM) is one of testicular germ cell tumors' most common metastatic sites. Our study aimed to develop a nomogram for predicting the risk of LM among patients with testicular germ cell tumors (TGCTs).

Methods

Clinicopathological information of 4078 patients with TGCT between 2010 and 2015 was obtained from SEER. Univariate and multivariate logistic regression analyses were performed to identify risk factors for LM, and a nomogram was developed based on these factors. Calibration curves, area under the receiver operating curve (AUC), and decision curve analysis (DCA) were used to evaluate the accuracy and discrimination of the model.

Results

Study participants included 4078 people with TGCTs, including 305 people with LM. They were randomly divided into two groups (training cohort = 2854 and validation cohort = 1224) at a ratio of 7:3. The following variables were incorporated in the nomogram: marital status, tumor histological type, T stage, brain metastasis, liver metastasis, lactate dehydrogenase (LDH), and chemotherapy. Besides, the AUC of it was 0.922 in the training cohort, while was 0.930 in the validation cohort. Training and validation cohort calibrations showed that the nomogram had excellent predictive abilities. DCA suggested it was more clinically relevant than the traditional TN staging.

Conclusion

We have established a nomogram to predict the risk of LM in patients with TGCTs. Doctors and patients can use this nomogram to monitor and identify lung metastasis of tumors through active monitoring and follow-up.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

KEY POINTS

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

Risk analysis of subsequent therapies after first-line chemotherapy in advanced testicular cancer patients

BACKGROUND

Testicular cancer is the most common solid cancer diagnosed among young men. Despite good response to chemotherapy and a high survival rate, subsequent salvage therapies may still be required for some patients in advanced stages. The predictive and prognostic markers are crucial unmet needs.

METHODS

We retrospectively analyzed advanced testicular cancer patients who had received first-line chemotherapy between January 2002 and December 2020. The associations between baseline characteristics and clinical outcomes were evaluated.

RESULTS

Of the 68 included patients, the median age was 29 years. Among them, 40 patients received only first-line chemotherapy while the remaining 28 received subsequent chemotherapy or surgeries. Data reveal that 82.5% (33/40) of the patients in the chemotherapy-only group were recorded as a good prognostic risk using the International Germ Cell Cancer Collaborative Group classification when compared with 35.7% (10/28) in the second-line therapy group. In the chemotherapy-only group, 53.8% of patients were presented with lymph node metastasis compared with 78.6% in the second-line therapy group ( p = 0.068). Fifteen percent of patients (6/40) were recorded as S stage 2-3 in the chemotherapy-only group, whereas 85.2% (23/28) were recorded as such in the second-line therapy group ( p < 0.001). The 5-year overall survival estimation was 92.9% in the chemotherapy-only group and 77.3% in the second-line therapy group. Univariate analysis for overall survival revealed that those patients at the S 2-3 stage and those receiving second-line therapies showed a trend of having an increased death risk (hazard ratio [HR] = 8.26, 95% confidence interval (CI), 0.99-68.67, p = 0.051; HR = 7.76, 95% CI, 0.93-64.99, p = 0.059, respectively). The S 2-3 stage was also independently associated with the risk of subsequent therapy (HR = 33.13; 95% CI, 2.55-430.64, p = 0.007).

CONCLUSION

Our real-world data show the predictive role of serum tumor marker stage 2-3 to be associated with any subsequent therapies after first-line chemotherapy. This can facilitate clinical decision making during the testicular cancer treatment process.

A population-based study of synchronous distant metastases and prognosis in patients with PDAC at initial diagnosis

Objective

Cancer of the pancreas is a life-threatening condition and has a high distant metastasis (DM) rate of over 50% at diagnosis. Therefore, this study aimed to determine whether patterns of distant metastases correlated with prognosis in pancreatic ductal adenocarcinoma (PDAC) with metastatic spread, and build a novel nomogram capable of predicting the 6, 12, 18-month survival rate with high accuracy.

Methods

We analyzed data from the Surveillance, Epidemiology, and End Results (SEER) database for cases of PDAC with DM. Kaplan-Meier analysis, log-rank tests and Cox-regression proportional hazards model were used to assess the impact of site and number of DM on the cancer-specific survival (CSS) and over survival (OS). A total of 2709 patients with DM were randomly assigned to the training group and validation group in a 7:3 ratio. A nomogram was constructed by the dependent risk factors which were determined by multivariate Cox-regression analysis. An assessment of the discrimination and ability of the prediction model was made by measuring AUC, C-index, calibration curve and decision curve analysis (DCA). In addition, we collected 98 patients with distant metastases at the time of initial diagnosis from Ningbo University Affiliated LiHuili Hospital to verify the efficacy of the prediction model.

Results

There was a highest incidence of liver metastases from pancreatic cancer (2387,74.36%), followed by lung (625,19.47%), bone (190,5.92%), and brain (8,0.25%). The prognosis of liver metastases differed from that of lung metastases, and the presence of multiple organ metastases was associated with poorer prognosis. According to univariate and multivariate Cox-regression analyses, seven factors (i.e., diagnosis age, tumor location, grade of tumor differentiation, T-stage, receipt of surgery, receipt of chemotherapy status, presence of multiple organ metastases) were included in our nomogram model. In internal and external validation, the ROC curves, C-index, calibration curves and DCA were calculated, which confirmed that this nomogram can precisely predict prognosis of PDAC with DM.

Conclusion

Metastatic PDAC patients with liver metastases tended to have a worse prognosis than those with lung metastases. The number of DM had significant effect on the overall survival rate of metastatic PDAC. This study had a high prediction accuracy, which was helpful clinicians to analyze the prognosis of PDAC with DM and implement individualized diagnosis and treatment.

Characteristics of lung metastasis in testicular cancer: A large-scale population analysis based on propensity score matching

Background

This study aims to systematically evaluate predictive factors for lung metastasis (LM) in patients with testicular cancer (TC) and to investigate cancer-specific survival (CSS) and overall survival (OS) of LM in TC patients based on a large population-cohort.

Methods

A total of 10,414 patients diagnosed with TC during 2010–2015 were adopted from the Surveillance, Epidemiology, and End Results (SEER). After propensity score matching (PSM), 493 patients with LM were included for subsequent analysis. Univariate and multivariate logistic regression analyses were employed to identify risk factors, a nomogram was developed, and the receiver operating characteristic (ROC) curve was utilized to confirm the validation of the nomogram. Prognostic factors for OS and CSS among TC patients with LM were estimated via Cox proportional hazards models.

Results

Postmatching indicated that 11 parameters were successfully balanced between both groups (P &gt; 0.05). After PSM, TC patients with LM presented an undesirable prognosis in both CSS and OS than those without LM (P &lt; 0.001). The logistic regression model showed that tumor size; T stage; N stage; liver, brain, and bone metastases; and histology were positively associated with LM (P &lt; 0.05). A nomogram was developed to predict diagnostic possibilities based on the independent risk variables, and the ROC curve verified the predictive capacity of the logistic regression model [area under the curve (AUC) = 0.910].

Conclusion

The selected variates in the nomogram can be predictive criteria for TC patients with LM. Brain metastasis, liver metastasis, and larger tumor size were prognostic factors for CCS and OS among TC patients with LM.

The predictors and surgical outcomes of different distant metastases patterns in upper tract urothelial carcinoma: A SEER-based study

The purpose of this study was to investigate the predictors of metastatic patterns of upper tract urothelial carcinoma (UTUC) and to analyze the surgical outcomes of different metastatic patterns of UTUC. Data on patients with UTUC from 2010 to 2017 were retrieved from the Surveillance, Epidemiology, and End Results Program (SEER) database. Kaplan-Meier analysis was applied to compare the patients' survival distributions. Univariate and multivariate logistic regression was used to assess the specific predictors of site-specific metastases, while competitive risk regression was applied to estimate the predictors of cancer-specific mortality in patients with metastases. A total of 9,436 patients were enrolled from the SEER database, of which 1,255 patients had distant metastases. Lung metastasis (42.5%) was most common and patients with single distant lymph node metastasis had a better prognosis. Clinical N stage (N1, N2, N3) was the strongest predictors of the site specific metastatic sites. Renal pelvis carcinoma was more prone to develop lung metastases (OR = 1.67, P < 0.01). Resection of the primary tumor site is beneficial for the prognosis of patients with metastatic UTUC, whether local tumor resection (HR = 0.72, P < 0.01) or nephroureterectomy (HR = 0.64, P < 0.01). Patients with single distant lymph node metastasis have the greatest benefit in nephroureterectomy compared to other specific-site metastases (median survival 19 months vs. 8 months). An understanding of distant metastatic patterns and surgical outcomes in patients with UTUC is important in clinical settings and helpful in the design of personalized treatment protocols.

A Call to Action to Review the USPSTF's Recommendation for Testicular Self-Examination

We urge the United States Preventive Services Task Force (USPSTF) to call for a formal review of the evidence regarding testicular self-examination (TSE). Twelve years have since passed since the evidence was last formally analyzed where normally re-reviews occur in 5-year cycles. If they would decide to move forward with this action, we ask for the USPSTF to review their methods for establishing recommendations to optimize their rating system operationalization process. Finally, emerging evidence demonstrates a net positive effect of TSE. This stands in contrast to the assertions of TSE's supposed harm that is prevalent in the literature as well as the rationale behind the USPSTF's "D" rating of TSE.

Vision Loss as Presenting Symptom in Testicular Cancer: A Morbid Case Report

Testicular cancer is the most common malignancy in men 20-40 years old and most commonly metastasizes to the lung, liver, and brain. Choroidal metastasis from testicular cancer is exceedingly rare, and only few cases have been described in the literature. We report a patient who presented with painful unilateral vision loss as the initial presenting symptom of metastatic testicular germ cell tumor (GCT). A 22-year-old Latino man presented with a 3-week history of progressive central vision loss and dyschromatopsia, accompanied by intermittent, throbbing ocular, and periocular pain, in the left eye. Associated symptom was remarkable for abdominal pain. Examination of the left eye disclosed light perception vision and a large choroidal mass in the posterior pole involving the optic disk and the macula with associated hemorrhages. Neuroimaging showed a 2.1-cm lesion in the posterior globe of the left eye, and B-scan and A-scan ultrasonography findings were consistent with choroidal metastasis. Systemic workup revealed a mass in the left testicle with metastasis to the retroperitoneum, lungs, and liver. Biopsy of a retroperitoneal lymph node showed a GCT. Visual acuity worsened from light perception to no light perception 5 days following initial presentation. Several cycles of chemotherapy were completed, including salvage therapy; however, these treatments were unsuccessful. While vision loss due to choroidal metastasis as the initial presenting symptom of testicular cancer is rare, clinicians should consider metastatic testicular cancer in the differential diagnoses in patients with choroidal tumors, especially in young men.

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

Objective

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

Methods

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

Results

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

Conclusion

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

18F-FDG PET/CT for primary staging of patients with testicular germ cell tumors: the predictors of 18F-FDG PET positivity and prognostic value of PET derived metabolic parameters

PURPOSE

The aim of this study was to investigate the role of histopathologic and biochemical parameters for predicting F-FDG PET positivity for primary staging in patients with newly diagnosed testicular germ cell tumors (TGCT). It was also aimed to evaluate the prognostic value of PET derived metabolic features in this patient group.

MATERIALS AND METHODS

The imaging findings of 51 patients who were diagnosed as TGCT and underwent F-FDG PET/CT for primary staging after surgery between 2009 and 2019 were evaluated retrospectively. In terms of the presence of F-FDG uptake consistent with metastasis, the patients were divided into two groups as 'PET-positive' and 'PET-negative'. In 'PET-positive' patients, highest maximum standardized uptake values of metastatic lesions, whole-body total metabolic tumor volumes (wb-TMTV) and total lesion glycolysis (wb-TLG) were extracted. Pathological tumor types, pathological T stages (pT), tumor marker (TM) levels (AFP, hCG, LDH) after orchiectomy and overall survival (OS) times in months were also recorded. The predictive value of variables for OS was evaluated using the Kaplan-Meier survival analysis.

RESULTS

PET positivity was observed in 28% of pT1 and in 83.3% in pT2-T3 tumors (P < 0.001). In the logistic regression analysis to predict 'PET positivity', pT stage and ≥2 elevated TMs were found as independent significant predictors. Survival analysis demonstrated that wb-TMTV, wb-TLG and TMs were significantly associated with prognosis for OS.

CONCLUSION

The likelihood of PET positivity was significantly higher in patients with elevated TMs and pT2-T3 stages compared to those with normal TMs and pT1 tumors. PET derived quantitative metabolic-volumetric parameters can be used as biomarkers to identify patients with poor prognosis in TGCT.

Choroidal Metastasis Secondary to Testicular Mature Teratoma: A Case Report

We report a case of a choroidal metastasis secondary to testicular mature teratoma, a subtype of non-seminoma germ cell tumours, in a young adult male. The choroidal metastasis was treated successfully with bleomycin, etoposide, and cisplatin chemotherapy without the need for adjuvant radiotherapy. This represents a rare case of mature teratoma metastasizing to the choroid and one of very few reported testicular germ cell tumours to achieve normal or near normal visual acuity with chemotherapy alone despite severe macular disease at presentation.