Testicular Germ Cell Tumours—The Role of Conventional Ultrasound

French AFU Cancer Committee Guidelines - Update 2024-2026: Testicular germ cell cancer

OBJECTIVE

To update the recommendations for the management of germ cell tumours of the testis.

MATERIALS AND METHODS

Comprehensive PubMed review from 2022 on the diagnosis, treatment and follow-up of testicular germ cell tumours (TGT), as well as safety of treatments. The level of evidence of the studies was assessed.

RESULTS

The initial assessment of a patient with a germ cell tumour of the testis is based on a clinical examination, biological evaluation (by measuring the serum markers AFP, total hCG, and LDH) and radiological evaluation (scrotal ultrasound and thoraco-abdomino-pelvic computed tomography [TAP]). Inguinal orchiectomy is the first therapeutic step, as it allows histological diagnosis and defines the local stage and risk factors for progression in stage I nonseminomatous germ cell tumours (NSGCTs). For patients with pure stage I seminoma, the risk of progression is between 15 and 20%, so surveillance is preferred in compliant patients; adjuvant chemotherapy with carboplatin AUC 7 is an option; and the indications for lumbo-aortic radiotherapy are limited. For patients with stage I NSGCT, various options exist, namely, surveillance or a risk-adapted strategy (surveillance or 1 cycle of bleomycin etoposide cisplatin [BEP] depending on the presence or absence of vascular emboli within the tumour). Retroperitoneal lymph node dissection for staging has a very limited role. Treatment of metastatic GCT consists of chemotherapy with BEP in the absence of contraindication to bleomycin, the number of cycles of which is defined according to the prognostic groups of the International Germ Cell Cancer Consortium Group (IGCCCG). Lumbo-aortic radiotherapy is still the standard treatment for stage IIA seminomatous germ cell tumours (SGCTs). At the end of chemotherapy, the size of any residual mass should be assessed via a TAP scan for SNGCTs, with retroperitoneal lymph node dissection recommended for any residual mass greater than 1cm, along with removal of all other metastatic sites. For SGCT, reassessment via 18FDG PET scans is necessary to determine the surgical indication for residual masses>3cm. Surgery remains rare in these situations.

CONCLUSION

Adherence to the recommendations for the management of GCT results in excellent specific survival rates of 99% for patients with stage I disease and over 85% for patients with metastatic disease.

Ultrasound-based deep learning radiomics nomogram for risk stratification of testicular masses: a two-center study

OBJECTIVE

To develop an ultrasound-driven clinical deep learning radiomics (CDLR) model for stratifying the risk of testicular masses, aiming to guide individualized treatment and minimize unnecessary procedures.

METHODS

We retrospectively analyzed 275 patients with confirmed testicular lesions (January 2018 to April 2023) from two hospitals, split into training (158 cases), validation (68 cases), and external test cohorts (49 cases). Radiomics and deep learning (DL) features were extracted from preoperative ultrasound images. Following feature selection, we utilized logistic regression (LR) to establish a deep learning radiomics (DLR) model and subsequently derived its signature. Clinical data underwent univariate and multivariate LR analyses, forming the "clinic signature." By integrating the DLR and clinic signatures using multivariable LR, we formulated the CDLR nomogram for testicular mass risk stratification. The model's efficacy was gauged using the area under the receiver operating characteristic curve (AUC), while its clinical utility was appraised with decision curve analysis(DCA). Additionally, we compared these models with two radiologists' assessments (5-8 years of practice).

RESULTS

The CDLR nomogram showcased exceptional precision in distinguishing testicular tumors from non-tumorous lesions, registering AUCs of 0.909 (internal validation) and 0.835 (external validation). It also excelled in discerning malignant from benign testicular masses, posting AUCs of 0.851 (internal validation) and 0.834 (external validation). Notably, CDLR surpassed the clinical model, standalone DLR, and the evaluations of the two radiologists.

CONCLUSION

The CDLR nomogram offers a reliable tool for differentiating risks associated with testicular masses. It augments radiological diagnoses, facilitates personalized treatment approaches, and curtails unwarranted medical procedures.

Research Progress of PD 1/PD L1 Inhibitors in the Treatment of Urological Tumors

Immune checkpoint inhibitors (ICIs) offer significant advantages for the treatment of urologic tumors, enhancing the immune function of anti-tumor T cells by inhibiting PD-1 and PDL1 binding. They have been shown to be well tolerated and remarkably effective in clinical practice, offering hope to many patients who are not well treated with conventional drugs. Clinical trials in recent years have shown that anti-PD-1 and PD-L1 antibodies have good efficacy and safety in the treatment of urologic tumors. These antibodies can be applied to a variety of urologic tumors, such as bladder cancer, renal cell carcinoma, and prostate cancer. They have been approved for the first-line treatment or as an option for follow-up therapy. By blocking the PD-1/PD-L1 signaling pathway, ICIs can release immune functions that are suppressed by tumor cells and enhance T-cell killing, thereby inhibiting tumor growth and metastasis. This therapeutic approach has achieved encouraging efficacy and improved survival for many patients. Although ICIs have shown remarkable results in the treatment of urologic tumors, some problems remain, such as drug resistance and adverse effects in some patients. Therefore, further studies remain important to optimize treatment strategies and improve clinical response in patients. In conclusion, PD-1/PD-L1 signaling pathway blockers have important research advances for the treatment of urologic tumors. Their emergence brings new hope for patients who have poor outcomes with traditional drug therapy and provides new options for immunotherapy of urologic tumors. The purpose of this article is to review the research progress of PD-1 and PD-L1 signaling pathway blockers in urologic tumors in recent years.

Case report: Misdiagnosis of primary mucinous cystadenoma of the testicle by ultrasound

Testicular mucinous cystadenoma is a rare benign testicular tumor with the characteristics of being potentially malignant and showing atypical clinical symptoms; this article reports a case of a primary testicular mucinous cystadenoma misdiagnosed as testicular teratoma by ultrasound. A 69-year-old man was admitted to the hospital because of a 1-year history of left-sided testicular enlargement with scrotal swelling and no obvious abnormalities on laboratory tests. Ultrasound examination revealed solid-mass lesions in the left testicle, suggesting a high probability of teratoma, and contrast-enhanced magnetic resonance imaging (MRI) examination suggested an increased possibility of epidermoid cysts. Contrast-enhanced computed tomography (CT) and contrast-enhanced MRI of the preoperative abdomen and pelvis showed no other primary adenocarcinoma. Doctors performed radical resection of the left testicle. The postoperative pathological diagnosis was mucinous cystadenoma, and calcification as well as partially mildly atypical epithelial cells were discovered. Furthermore, there were no neoplastic lesions in the epididymis or spermatic cord. No metastatic lesions were found after 6 months postoperative follow-up, and the patient's prognosis remains good.

Sonoelastography for Testicular Tumor Identification: A Systematic Review and Meta-Analysis of Diagnostic Test Accuracy

The objective of this review was to summarize the applications of sonoelastography in testicular tumor identification and inquire about their test performances. Two authors independently searched English journal articles and full conference papers from CINAHL, Embase, IEEE Xplore®, PubMed, Scopus, and Web of Science from inception and organized them into a PIRO (patient, index test, reference test, outcome) framework. Eleven studies (n = 11) were eligible for data synthesis, nine of which (n = 9) utilized strain elastography and two (n = 2) employed shear-wave elastography. Meta-analyses were performed on the distinction between neoplasm (tumor) and non-neoplasm (non-tumor) from four study arms and between malignancy and benignity from seven study arms. The pooled sensitivity of classifying malignancy and benignity was 86.0% (95%CI, 79.7% to 90.6%). There was substantial heterogeneity in the classification of neoplasm and non-neoplasm and in the specificity of classifying malignancy and benignity, which could not be addressed by the subgroup analysis of sonoelastography techniques. Heterogeneity might be associated with the high risk of bias and applicability concern, including a wide spectrum of testicular pathologies and verification bias in the reference tests. Key technical obstacles in the index test were manual compression in strain elastography, qualitative observation of non-standardized color codes, and locating the Regions of Interest (ROI), in addition to decisions in feature extractions. Future research may focus on multiparametric sonoelastography using deep learning models and ensemble learning. A decision model on the benefits-risks of surgical exploration (reference test) could also be developed to direct the test-and-treat strategy for testicular tumors.

An Aberrant Seminoma as a Complication in an Undescended Testis: A Case Report and Review of Literature

Testicular germ cell tumors are testicular neoplasms in young and middle-aged men. Undescended testis dramatically increases the risk of testicular germ cell tumors. We report the case of a 33-year-old male who complained of swelling and pain in his lower abdomen. The patient also had an undescended left testis. An intrabdominal mass was detected on ultrasound that was further characterized using contrast-enhanced CT. Imaging findings suggested testicular germ cell tumor, developing as a complication in the undescended testis. The patient was operated and the diagnosis was confirmed on histopathological examination.

Testicular Neoplasms: Primary Tumour Size Is Closely Interrelated with Histology, Clinical Staging, and Tumour Marker Expression Rates-A Comprehensive Statistical Analysis

The role of primary tumour size (TS) in the clinical course of testicular tumours is incompletely understood. We retrospectively evaluated 641 consecutive patients with testicular neoplasms with regard to TS, histology, clinical stage (CS), serum tumour marker (STM) expression and patient age using descriptive statistical methods. TS ≤ 10 mm was encountered in 13.6% of cases. Median TS of 10 mm, 30 mm, 35 mm, and 53 mm were found in benign tumours, seminomas, nonseminomas, and other malignant tumours, respectively. In cases with TS ≤ 10 mm, 50.6% had benign tumours. Upon receiver operating characteristics analysis, TS of > 16 mm revealed 81.5% sensitivity and 81.0% specificity for detecting malignancy. In subcentimeter germ cell tumours (GCTs), 97.7% of cases had CS1, and CS1 frequency dropped with increasing TS. Expression rates of all STMs significantly increased with TS. MicroRNA-371a-3p (M371) serum levels had higher expression rates than classical STMs, with a rate of 44.1% in subcentimeter GCTs. In all, TS is a biologically relevant factor owing to its significant associations with CS, STM expression rates and histology. Importantly, 50% of subcentimeter testicular neoplasms are of benign nature, and M371 outperforms the classical markers even in subcentimeter tumours.