Very Late Recurrence in Germ Cell Tumor of the Testis: Lessons and Implications

Germ Cell Tumor of the Testis: Lethal Subtypes of a Curable Cancer

Germ cell tumor of the testis (GCT) is a curable cancer even when it is widely metastatic; however, outcomes can differ based on tumor histology. Chemo-resistance in certain phenotypes, such as teratoma and yolk sac tumor, contributes to poor clinical outcomes in some patients with GCT. Despite this resistance to S-YSTemic therapy, many of these tumor subtypes remain amenable to surgical resection and possible cure. In this study, we report on a series of seven patients highlighting two chemo-resistant subtypes of nonseminomatous germ cell tumor (NSGCT), sarcomatoid yolk sac tumor (S-YST), and epithelioid trophoblastic tumor (ETT) for which early resection rather than additional salvage chemotherapy or high-dose intense chemotherapy might provide a superior clinical outcome and enhance cure rate.

Impact of teratoma on survival probabilities of patients with metastatic non-seminomatous germ cell cancer: Results from the IGCCCG Update Consortium

AIMS

To resolve the ongoing controversy surrounding the impact of teratoma (TER) in the primary among patients with metastatic testicular non-seminomatous germ-cell tumours (NSGCT).

PATIENTS AND METHODS

Using the International Germ Cell Cancer Collaborative Group (IGCCCG) Update Consortium database, we compared the survival probabilities of patients with metastatic testicular GCT with TER (TER) or without TER (NTER) in their primaries corrected for known prognostic factors. Progression-free survival (5y-PFS) and overall survival at 5 years (5y-OS) were estimated by the Kaplan-Meier method.

RESULTS

Among 6792 patients with metastatic testicular NSGCT, 3224 (47%) had TER in their primary, and 3568 (53%) did not. In the IGCCCG good prognosis group, the 5y-PFS was 87.8% in TER versus 92.0% in NTER patients (p = 0.0001), the respective 5y-OS were 94.5% versus 96.5% (p = 0.0032). The corresponding figures in the intermediate prognosis group were 5y-PFS 76.9% versus 81.6% (p = 0.0432) in TER and NTER and 5y-OS 90.4% versus 90.9% (p = 0.8514), respectively. In the poor prognosis group, there was no difference, neither in 5y-PFS [54.3% in TER patients versus 55.4% (p = 0.7472) in NTER], nor in 5y-OS [69.4% versus 67.7% (p = 0.3841)]. NSGCT patients with TER had more residual masses (65.3% versus 51.7%, p < 0.0001), and therefore received post-chemotherapy surgery more frequently than NTER patients (46.8% versus 32.0%, p < 0.0001).

CONCLUSION

Teratoma in the primary tumour of patients with metastatic NSGCT negatively impacts on survival in the good and intermediate, but not in the poor IGCCCG prognostic groups.

An insight into metastatic Leydig cell tumors: A case report

Sex cord-stromal tumors comprise approximately 5% of all testicular tumors, while the remainder are of germ cell origin. Leydig cell tumors are the most common subtype of testicular sex cord-stromal tumors and account for 1%-2% of all testicular tumors. Leydig cell tumors are mostly benign but approximately 5%-10% of them have malignant potential. The commonest metastatic sites are regional lymph nodes, lung, liver, and bones. Here, we report a case of late metastatic relapsed Leydig cell disease in a 73-year-old male. The goal of this care report was to better understand manifestation and management of patients with late relapsed Leydig cell tumors and low-volume disease. Patients with metastatic Leydig cell tumors (or sex cord-stromal tumors) have poor prognosis, and standard treatment recommendations do not exist. Surgical resection of metastasis and/or chemotherapy with bleomycin, etoposide, and cisplatin should be discussed with patients, as some were reported to have complete remission after these interventions. Although there are few literature studies and data to support ideal management, this case has shown that there may be utility for local radiation therapy in unresectable low-volume metastatic Leydig cell disease. A limitation in this report is that we will need long-term follow-up regarding this case. Given the rare occurrence of this malignancy, more data collection going forward will assist in the optimal management of future patients, given this diagnosis.

A case of testicular cancer with retroperitoneal lymph node metastasis of teratoma with somatic-type malignancy 18 years after initial treatment

Introduction

In testicular cancer, late relapse of teratoma with somatic-type malignancy is rare and associated with a poor survival. A case of retroperitoneal lymph node metastasis of teratoma with somatic-type malignancy 18 years after initial treatment for testicular cancer is reported.

Case presentation

A 46-year-old man had a 15-mm-sized mass in the para-aortic region 18 years after initial treatment for testicular cancer, without elevated serum alfa-fetoprotein or human chorionic gonadotropin levels. Laparoscopic retroperitoneal lymph node dissection was performed. The pathological findings showed teratoma with somatic-type malignancy, and the findings of primary testicular cancer reported a yolk sac tumor, not teratoma.

Conclusion

Late relapse of teratoma with somatic-type malignancy was resected by laparoscopic retroperitoneal lymph node dissection. Therefore, long-term follow-up should be considered if patients with small retroperitoneal masses did not undergo retroperitoneal lymph node dissection, and early detection and surgical resection for relapse might be effective.

Reprint of: somatic-type malignancies in testicular germ cell tumors

The development of somatic-type malignancy (SM) in testicular germ cell tumor represents a major challenge in the diagnosis and treatment of testicular cancer. Most SMs are derived from teratoma, and the remainder is associated with yolk sac tumor. They occur more frequently in metastases than in primary testicular tumors. SMs demonstrate a variety of histologic types, including sarcoma, carcinoma, embryonic-type neuroectodermal tumor, nephroblastoma-like tumor, and hematologic malignancy. Sarcoma, particularly rhabdomyosarcoma, accounts for the majority of SMs in the primary testicular tumors, whereas carcinoma, particularly adenocarcinoma, is the most common SM in metastases. Although SMs derived from testicular germ cell tumors mimic their histologic counterparts in other organs with overlapping immunohistochemical profiles, isochromosome 12p is present in most SMs, which can be useful in the differential diagnosis. The presence of SM in the primary testicular tumor may not worsen the outcome, but the development of SM in metastasis is associated with a poor prognosis. Furthermore, somatic-type carcinoma is likely associated with a worse prognosis than somatic-type sarcoma. Although SMs respond poorly to the cisplatin-based chemotherapy, timely surgical resection is an effective treatment for most patients.

Somatic-Type Malignancies in Testicular Germ Cell Tumors

The development of somatic-type malignancy (SM) in testicular germ cell tumor represents a major challenge in the diagnosis and treatment of testicular cancer. Most SMs are derived from teratoma, and the remainder is associated with yolk sac tumor. They occur more frequently in metastases than in primary testicular tumors. SMs demonstrate a variety of histologic types, including sarcoma, carcinoma, embryonic-type neuroectodermal tumor, nephroblastoma-like tumor, and hematologic malignancy. Sarcoma, particularly rhabdomyosarcoma, accounts for the majority of SMs in the primary testicular tumors, whereas carcinoma, particularly adenocarcinoma, is the most common SM in metastases. Although SMs derived from testicular germ cell tumors mimic their histologic counterparts in other organs with overlapping immunohistochemical profiles, isochromosome 12p is present in most SMs, which can be useful in the differential diagnosis. The presence of SM in the primary testicular tumor may not worsen the outcome, but the development of SM in metastasis is associated with a poor prognosis. Furthermore, somatic-type carcinoma is likely associated with a worse prognosis than somatic-type sarcoma. Although SMs respond poorly to the cisplatin-based chemotherapy, timely surgical resection is an effective treatment for most patients.

Ultrasonic misdiagnosis of giant pediatric testicular yolk sac tumor: A case report and literature review

BACKGROUND

Yolk sac tumor is the most common malignant nonseminomatous germ-cell tumor in children characterized by elevated level of α-fetoprotein (AFP), accounting for 70%-80% of all cases. However, giant yolk sac tumors that involve the entire testicle may be misdiagnosed by color Doppler ultrasonography as orchitis. Therefore, we described a case of a 2-year-old pediatric patient with a giant testicular yolk sac tumor that was misdiagnosed by ultrasonography as orchitis, in order to evaluate the role of measuring AFP levels in the initial diagnosis to aid in the accuracy of the definitive diagnosis of testicular yolk sac tumor.

CASE PRESENTATION

A 2-year-old boy received outpatient visits for unintentional swelling of the right scrotum for 7 days. Physical examination showed a rubbery swelling of the right scrotum with rejective touch. Then, the patient underwent perineal color Doppler ultrasonography in outpatient visits. The result showed a right testicle size of 29 mm × 22 mm × 20 mm with heterogeneous echogenicity and abundant blood flow, supporting the initial diagnosis of orchitis. However, the initial surgeon was skeptical of the ultrasonography diagnosis. Thus, the patient was admitted to the Department of Andrology on day 2 for further serological and imaging examination. The serum AFP level on day 3 was 323.77 ng/ml. The results of CT and MRI showed a giant tumor of the right testis (26 mm × 21 mm × 29.6 mm) with multiple lymphoid hyperplasia in the inguinal region bilaterally. The patient received radical orchidectomy without lymph node dissection on day 9. The results of postoperative pathological examination confirmed giant testicular yolk sac tumor (T1N0M0S1, Stage Is) and was positive for AFP and SALL4 in immunohistochemistry staining. The patient received three courses of bleomycin-etoposide-cisplatin chemotherapy in the Department of Pediatrics after multidisciplinary team meeting on postoperative days 14, 37, and 58, respectively. During chemotherapy and follow-up, the patient's AFP and lactate dehydrogenase levels continued to decline, and eventually remained within normal range on postoperative day 84.

CONCLUSION

Measuring the AFP level was necessary for initial diagnosis and follow-up in pediatric cases of testicular enlargement. Radical orchidectomy combined with postoperative bleomycin-etoposide-cisplatin adjuvant chemotherapy was an effective treatment strategy for pediatric giant testicular yolk sac tumors.