Vascularity of Intra-testicular Lesions: Inter-observer Variation in the Assessment of Non-neoplastic Versus Neoplastic Abnormalities After Vascular Enhancement With Contrast-Enhanced Ultrasound

The aim of this study is to assess the additional benefit of contrast-enhanced ultrasound (CEUS) over conventional ultrasonography (US) in identifying intra-testicular abnormalities among observers of different experiences. In this study, 91 focal testicular lesions (46 neoplastic, 45 non-neoplastic) imaged with gray-scale US/Doppler US and CEUS were classified using a 5-point scale. Three experienced and four inexperienced observers rated each lesion using gray-scale/color Doppler US alone and then with the addition of CEUS. Improved diagnostic specificity and accuracy with the addition of CEUS was observed for both experienced (specificity: 71.1% vs. 59.3%, p = 0.005; accuracy: 83.5% vs. 76.9%, p = 0.003) and inexperienced observers (specificity: 75.6% vs. 51.7%, p = 0.005; accuracy: 80.2% vs. 72.0%, p < 0.001). Significant inter-observer variability between the experienced and inexperienced observers when assessing conventional US alone was eliminated with the addition of CEUS. CEUS improves diagnostic accuracy of focal intra-testicular lesions for both experienced and inexperienced observers and reduces inter-observer variability in inexperienced operators.

[Ultrasound characteristics of testicular Leydig cell tumors , , , 1.]

OBJECTIVE

To explore the color Doppler ultrasonic characteristics of testicular Leydig cell tumors (LCT) and improve the clinical diagnosis of the disease.

METHODS

We retrospectively analyzed 4 cases of testicular LCT diagnosed and treated in our hospital and summarized the experience in the ultrasonic diagnosis of LCT with a review of the relevant literature.

RESULTS

All the 4 testicular LCTs were solitary and quasi-round, 1 in the left and 3 in the right. The smallest mass was 1.8 × 1.5 cm and the largest 3.1 × 2.5 cm, and 2 were complicated by hydrocele of tunica vaginalis. The margins of tumors were distinct in 2 cases and indistinct in 1, and changed from distinct to indistinct in another during the follow-up. Hypoechoes were revealed in all the 4 cases in ultrasonography, 2 with abundant internal blood flow, 1 with abundant peripheral blood flow, and the other with abundant internal blood flow changed from circular blood flow surrounding the mass.

CONCLUSIONS

A typical sporadic LCT was ultrasonically manifested as an isolated hypoechoic infracentimetric mass with a clear demarcation from the adjacent pulp. It exhibited intrinsic hypervascularization associated with a typical peripheral rim pattern. Larger lesions more often presented a lobulated shape and intense hypervascularization. Although these ultrasonic characteristics do not reveal the nature of LCT with certainty, they can help the surgeon with the decision on testis-sparing surgery or perhaps even on the active monitoring for the smallest lesions in a population with impaired fertility.

Should we rely on Doppler ultrasound for evaluation of testicular solid lesions?

PURPOSE

Colour Doppler ultrasound (CDUS) is the main radiologic tool to evaluate scrotal masses and intratesticular-vascularised solid lesions are mostly considered malign lesions. Objective of this trial is determine ratio of benign lesions in patients with hypervascularised solid intratesticular lesions.

MATERIAL AND METHOD

Patients who underwent radical orchiectomy due to hypervascularised intratesticular solid lesions detected in CDUS are evaluated retrospectively. Those with previous testicular cancer history and inguinal/scrotal surgeries were excluded from the study. All patients are evaluated for age, preoperative testicular atrophy, multicentricity, echotexture and size of solid lesions, preoperative tumor markers (AFP, bHCG and LDH), and postoperative pathology results. Two tailed p value test was used to evaluate numeric parameters and Fisher's exact test was used to evaluate non-numeric parameters.

RESULTS

A total of 117 patients with a mean age of 35.9 (5-86) were included to the study. Mean size of solid lesions was 4.39 cm. Seven patients had subcentimeter (subcm) lesions. 101 patients had hypoechoic, ten patients had isoechoic and six patients hyperechoic solid lesions. Preoperatively 60 patients (51.2%) had at least one tumor marker elevated. Postoperative pathology examination resulted to; 21 patients (17.9%) had benign lesions. Elevation of tumor markers, palpability, hypoechoic texture and larger size of the solid lesion were found to be parameters that predict malignancy.

CONCLUSION

Benign incidence of vascular testicular solid lesions detected with scrotal ultrasound with colour Doppler is greater than expected. In patients with smaller, non-palpable lesions without elevated tumor markers, treatment options other than radical orchiectomy such as testicular sparing surgery should be considered.

Straight Vessel Pattern and Rapid Filling Time: Characteristic Findings on Contrast-Enhanced Sonography of Testicular Lymphoma

Six patients with 7 lesions that were histologically confirmed as primary testicular lymphoma were preoperatively investigated with a standardized sonographic protocol including contrast-enhanced sonography. Duplex and contrast-enhanced sonography showed marked hypervascularization in all 7 lesions. On contrast-enhanced sonography, the filling time of lymphomatous lesions was significantly shorter than the filling time of a size-matched sample of 10 patients with seminomas (P < .0001). The sonographic hallmarks of testicular lymphoma in our case series were as follows: (1) sharply demarcated homogeneous hypoechoic testicular lesions with marked hypervascularization; (2) a rapid (<7 seconds) filling time of contrast bubbles; and (3) a straight and parallel course of intralesional vessels on contrast-enhanced sonography.

CEUS Time Intensity Curves in the Differentiation Between Leydig Cell Carcinoma and Seminoma: A Multicenter Study

PURPOSE

Ultrasound (US) is the main imaging technique in the assessment of testicular masses, as it has proved to be highly accurate in the visualization of these pathologies. Identification of a Leydig cell tumor is essential since the lesion is benign in 90% of cases. The aim of this multicenter study is to assess the effectiveness of contrast-enhanced ultrasound (CEUS) in differentiating Leydig cell tumors from seminoma using qualitative and quantitative features.

MATERIALS AND METHODS

From February 2011 to December 2013, 31 patients (mean age: 34 years; range: 25 - 52) were recruited for this prospective study. Three of them were monorchid. Therefore, a total of 59 testicles were assessed. All patients underwent grayscale US, color Doppler ultrasound (CDUS), CEUS and orchiectomy. The paired one-tailed Student's t-test was carried out to differentiate between Leydig cell tumors and seminomas.

RESULTS

31 lesions suspicious for malignancy were hypoechoic on grayscale US while they did not show a typical pattern on CDUS. CEUS qualitative analysis, based on contrast enhancement pattern, during the arterial and venous phases, did not allow discrimination of Leydig cell tumors from seminoma. Quantitative analysis of time-intensity curves (TICs) demonstrated that only three parameters presented statistical significance, i. e. wash-in rate (WiR) p = 0.014, peak enhancement (PE) p = 0.001 and time to peak (TTP) p = 0.003.

CONCLUSION

The vascular bed of a Leydig cell tumor is wider and the blood flow velocity is higher than that of a seminoma due to more regular neovascularization. In contrast, a seminoma presents large areas of necrosis due to irregular neovascularization. This explains the different PE and WiR values. Further studies involving larger patient populations are mandatory to confirm these encouraging preliminary results.

Diagnosis of Testicular Adrenal Rest Tumors on Ultrasound: A Retrospective Study of 15 Cases Report

The aim of this study was to evaluate the imaging features of testicular adrenal rest tumors (TARTs) on baseline ultrasound (BUS).The imaging features of 30 TART lesions pathologically or clinically confirmed in 15 patients who had undergone BUS were evaluated, and the sonographic characteristics of the lesions were analyzed.All 15 cases were bilateral and located near the testicular mediastinum. Approximately 56.7% (17/30) of the TART lesions exhibited homogeneous hypoechogenicity, 36.7% (11/30) of the lesions exhibited heterogeneous hypoechogenicity, and 6.6% (2/30) of the lesions exhibited heterogeneous isoechogenicity. In addition, 76.7% (23/30) of the lesions exhibited a rich blood supply, whereas 23.3% (7/30) of the lesions exhibited a scarce blood supply.The sonographic characteristics of the TARTs were bilateral growth, location adjacent to the testicular mediastinum, hypoechogenicity, and rich blood supply, which may play important roles in early clinical diagnosis.

Contrast-enhanced ultrasound and real-time elastography for the diagnosis of benign Leydig cell tumors of the testis - a single center report on 13 cases

PURPOSE

To describe sonomorphological features in testicular Leydig cell tumors (LCTs) with a special focus on contrast-enhanced ultrasonography (CEUS) and real-time elastography (RTE).

PATIENTS AND METHODS

In a series of 186 patients with testicular surgery for neoplastic disease, 13 benign LCTs (in 12 patients) were histopathologically diagnosed. Preoperatively, all patients had been examined with a standardized protocol (high-resolution grayscale and color-coded ultrasonography, CEUS). 5 patients underwent RTE. In CEUS, the filling time of the lesion was compared to that of 14 size-matched germ cell tumors (GCT).

RESULTS

10/13 LCTs had a size of < 10 mm, and a sharply demarcated hypoechoic appearance was typical (10/13). Color-coded ultrasonography detected signals in 8 lesions, while CEUS showed clear hypervascularization in all. LCTs had a significantly shorter filling time than GCTs (p < 0.0005), with 9/13 LCTs being completely filled within 4 s. In RTE, all 5 examined lesions were clearly "harder" than the surrounding testicular tissue.

CONCLUSION

Contrary to some earlier reports, we could demonstrate marked hypervascularization in LCTs. This feature clearly allows for the differentiation of a small LCT from focal scars. However, it may only be visible on CEUS. In CEUS, LCT is suggested by the findings of a short filling time or by a circumferential vessel with a rapid centripetal filling, combined with a "harder" appearance in RTE. These features along with the findings of a small and peripherally situated hypoechoic tumor would justify an operative strategy with frozen section examination and possibly organ sparing surgery instead of orchiectomy.

High expression of NPY receptors in the human testis

NPY receptors represent novel molecular therapeutic targets in cancer and obesity. However, the extent of NPY receptor expression in normal human tissues is poorly investigated. Based on the role of NPY in reproductive functions, the NPY receptor expression was studied in 25 normal human testes and, additionally, 24 testicular tumors using NPY receptor autoradiography. In the normal testis, Leydig cells strongly expressed NPY receptor subtype Y2, and small arterial blood vessels Y1. Y2 receptors were found to be functional with agonist-stimulated [(35)S]GTPγS binding autoradiography. Full functional integrity of the NPY system was further suggested by the immunohistochemical detection of NPY peptide in nerve fibers directly adjacent to Leydig cells and arteries. Germ cell tumors expressed Y1 and Y2 on tumor cells in 33% and Y1 on intratumoral blood vessels in 50%. Based on its strong NPY receptor expression in Leydig cells and blood vessels, the normal human testis represents a potentially important physiological and pharmalogical NPY target.

Epithelial versus endothelial CEACAM1 expression and angiogenesis in epididymal adenomatoid tumor

BACKGROUND/AIM

To study the expression of the pro-angiogenic factor carcinoembryonic antigen-related cell adhesion molecule-1 (CEACAM1) in epididymal adeno-matoid tumor tissue, a very rare benign neoplasia, in relation to its vascularization.

MATERIALS AND METHODS

Immunohistochemistry for CEACAM1 and for both endothelial markers CD31 and CD34 was performed in normal human epididymal and epididymal adenomatoid tumor tissue. The vessel density was calculated in four tumor regions with different degrees of vascularization in comparison to the vascularization of the normal epididymal tissue.

RESULTS

CEACAM1 was found in normal epididymal epithelium, while the epithelium of tumor glands was mostly negative. Only few blood vessels and lymphatics in adenomatoid tumor tissue expressed CEACAM1. The assessment of vascularization revealed either equal or a significantly lower vessel density in some adenomatoid tumor regions in comparison to normal epididymal tissue.

DISCUSSION

These data demonstrate that despite its epithelial down-regulation, CEACAM1 is not present in the majority of adenomatoid tumor blood vessels, which might be related to the lower angiogenic activity and benign behaviour of this tumor.

Metronomic dosing enhances the anti-angiogenic effect of epothilone B

BACKGROUND

High doses (10 nM) of epothilone B, a microtubule stabilizer, will inhibit the development of human tumor-derived angiogenesis following short (14 d) drug exposure times. Metronomic dosing regimes use lower drug doses and prolonged drug exposure times in an attempt to decrease toxicity compared with standard dosing schedules. We hypothesized that epothilone B would be an effective anti-angiogenic agent when administered at very low doses over an extended period of time.

METHODS

Fragments of four fresh human tumors were cultured in a fibrin-thrombin matrix and maintained in nutrient media plus 20% fetal bovine serum (FBS) for 56 d. Tumor fragments (n=40-60 per group) were exposed to weekly doses of epothilone B at concentrations of 10, 5, 1, 0.5, or 0.1 nM. All of these concentrations are clinically achievable. Tumor angiogenesis was assessed weekly on d 14-56 using a validated visual grading system. This system rates neovessel growth, density, and length on a 0-16 scale [angiogenic index, (AI)]. The average change in AI between d 14 and 56 was calculated for all samples and used to evaluate the metronomic response.

RESULTS

Epothilone B produced a dose-dependent anti-angiogenic response in all tumors. Two of the four tumors demonstrated a clear and significant metronomic anti-angiogenic effect over time.

CONCLUSIONS

Epothilone B, when dosed by a metronomic schedule may have a significant anti-angiogenic effect on human solid tumors. This study provides evidence for the potential use of epothilone B on a metronomic dosing schedule.

Serum human chorionic gonadotropin is associated with angiogenesis in germ cell testicular tumors

BACKGROUND

Germ cell testicular tumors have survival rate that diminishes with high tumor marker levels, such as human chorionic gonadotropin (hCG). hCG may regulate vascular neoformation through vascular endothelial growth factor (VEGF). Our purpose was to determine the relationship between hCG serum levels, angiogenesis, and VEGF expression in germ cell testicular tumors.

METHODS

We conducted a retrospective study of 101 patients. Serum levels of hCG, alpha-fetoprotein (AFP), and lactate dehydrogenase were measured prior to surgery. Vascular density (VD) and VEGF tissue expression were determined by immunohistochemistry and underwent double-blind analysis.

RESULTS

Histologically, 46% were seminomas and 54%, non-seminomas. Median follow-up was 43 +/- 27 months. Relapse was present in 7.5% and mortality in 11.5%. Factors associated with high VD included non-seminoma type (p = 0.016), AFP > or = 14.7 ng/mL (p = 0.0001), and hCG > or = 25 mIU/mL (p = 0.0001). In multivariate analysis, the only significant VD-associated factor was hCG level (p = 0.04). When hCG levels were stratified, concentrations > or = 25 mIU/mL were related with increased neovascularization (p < 0.0001). VEGF expression was not associated with VD or hCG serum levels.

CONCLUSION

This is the first study that relates increased serum hCG levels with vascularization in testicular germ cell tumors. Hence, its expression might play a role in tumor angiogenesis, independent of VEGF expression, and may explain its association with poor prognosis. hCG might represent a molecular target for therapy.

Response to antiangiogenesis therapy in a patient with advanced adult-type testicular granulosa cell tumor

As granulosa cell tumors of the adult type are extremely uncommon testicular neoplasms, relatively few case reports and case series have been published. Treatment for localized, small-volume, or oligometastatic disease is generally surgical resection alone. Visceral or widely metastatic disease is relatively rare, so there is no consensus approach to treatment. We report the case of an advanced granulosa cell tumor of the testis with a confirmed partial response to an angiogenesis inhibitor after initial resistance to cytotoxic chemotherapy.

Angiogenesis and vascular network of teratocarcinoma from embryonic stem cell transplant into seminiferous tubules

BACKGROUND

Carcinoma in situ (CIS) of the testis is considered to be a precancerous germinal cell lesion, but the precise cellular and molecular mechanisms underlying transformation of CIS into invasive pluripotent cancer cells remain to be elucidated. Moreover, a satisfactory animal model for the experimental study of germinal tumours has not been developed to date.

METHODS

We have developed a tumour model that involves the microinjection of green fluorescent protein-labelled embryonic stem (ES) cells (which are functionally equivalent to CIS cells) into syngenic mouse seminiferous tubules, a unique cell microenvironment in which germinal cells mature and CIS arise. To characterise the vascularisation of teratocarcinomas, which arise after cell transplant, we used immunohistochemistry, together with a qualitative and quantitative analysis of scanning electron microscopy images of corrosion casting samples.

RESULTS

Embryonic stem cells transplanted into seminiferous tubules did not differentiate into germinal cells, but rather they behaved as invasive embryonal carcinoma (EC) stem cells. The vascular pattern of the experimental teratocarcinomas showed a highly disorganised architecture, and some of the neoplastic capillaries were derived, at least in part, from the original transplanted ES cells.

CONCLUSION

The transplantation of pluripotent ES cells into seminiferous tubules efficiently recapitulates the early stages of development of teratocarcinomas. Consequently, this method constitutes a novel in vivo model to study the mechanisms of invasion and progression of experimental germinal tumours.

Versican but not decorin accumulation is related to metastatic potential and neovascularization in testicular germ cell tumours

AIMS

To investigate the expression of versican and decorin in patients with testicular germ cell tumours (GCTs) and to correlate this with the clinicopathological findings. Matrix proteoglycans versican and decorin are frequently overexpressed in various malignancies and are involved in the progression of cancer.

METHODS AND RESULTS

Overexpression of versican and decorin was detected in GCTs by immunoblotting. Immunohistochemical staining for proteoglycans was performed on 71 cases of paraffin-embedded tissues. In most of the cases increased decorin and versican stromal staining was demonstrated. In both seminomas and non-seminomatous germ cell tumours (NSGCTs) strong staining of decorin was not found to be related to any of the clinicopathological variables. Accumulation of versican was found to be associated with vascular and lymphatic invasion, nodal metastasis and disease stage in seminomas and NSGCTs and, in addition, with tumour size and distant metastasis only in NSGCTs. Additionally, only the deposition of versican was linearly correlated with the number of microvessels in the tumour stroma in GCTs.

CONCLUSIONS

Ectopic versican and decorin expression is a frequent feature in GCTs. Versican but not decorin accumulation in GCTs is related to metastatic potential and neovascularization and might be a useful marker for testicular malignancy.

Complications of surgery and chemotherapy for testicular cancer

Testicular cancer is a malignancy for which an interdisciplinary approach offers the highest likelihood of cure. In many patients, both chemotherapy and surgery play a prominent role in their care. Although cure can be achieved in a majority of patients, the treatment can occasionally leave the patient with late sequelae. This article discusses the long-term toxicity of curative surgical or cytotoxic therapy for germ cell tumors.

Evaluation of angiogenesis in canine seminomas by quantitative immunohistochemistry

Angiogenesis, which assists in supplying the nutritional and respiratory needs of proliferating cells, is essential for tumour growth. Angiogenic control is complex, involving a network of cytokines, in particular vascular endothelial growth factor (VEGF), a potent endothelial cell mitogen which also stimulates neoplastic cell proliferation. The purpose of this study was to evaluate VEGF expression and microvessel density (number of microvessels per mm(2)), in canine seminomas. VEGF expression and microvessel density were higher in seminomas than in normal testicular tissue; both parameters were higher in diffuse tumours than in intratubular tumours. These data demonstrate an increase in angiogenesis in the more malignant histological types of seminoma and suggest that both VEGF and microvessel density are useful criteria for evaluating the intrinsic malignancy and growth potential of canine testicular tumours.

Serum levels of basic fibroblast growth factor reflect disseminated disease in patients with testicular germ cell tumors

The potential role of angiogenesis stimulators in the pathogenesis of different tumor entities has been confirmed in several studies. We measured the serum levels of basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF) and platelet derived growth factor (PDGF) in 51 patients with testicular germ cell tumors and in 39 healthy volunteers. Serum concentrations of bFGF, VEGF and PDGF-AB were determined by enzyme-linked immunosorbent assay. The median serum bFGF level for tumor patients was 3.46 pg/ml (range 0-61.6) compared to 0.7 pg/ml (0-11) in the control group (P<0.01). In patients with metastatic disease, the median serum bFGF level was 10.3 pg/ml (0-61.6) in contrast to 2.8 pg/ml (0-50) in patients with localized disease (P<0.01). The median serum VEGF and PDGF levels were 270 pg/ml (0-1,903) and 37,837 pg/ml (9,075-108,800), respectively, for tumor patients and 200 pg/ml (44-585) and 23,000 pg/ml (4,250-70,650) in the control group ( P<0.05). Our data suggest that angiogenesis, as reflected by serum concentrations of bFGF, VEGF and PDGF, plays a functional role in the growth and progression of testicular germ cell tumors.

Angiogenesis and lymphangiogenesis in stage 1 germ cell tumours of the testis

OBJECTIVE

To determine whether angiogenesis can be used as an additional prognostic indicator in patients with stage 1 germ cell tumours of the testis.

PATIENTS AND METHODS

Paraffin sections were assessed immunohistochemically from 51 patients with clinical stage 1 germ cell tumours of the testis (28 seminoma, 23 teratoma) treated by orchidectomy and surveillance only. Sections were analysed for microvascular density (MVD), and expression of the angiogenic factors vascular endothelial growth factor (VEGF) and thymidine phosphorylase (TP). In addition, in the seminoma cases the presence of mRNA for the lymphangiogenic factor VEGF-C was examined by in situ hybridization, and its corresponding receptor VEGFR-3 by immunohistochemistry.

RESULTS

Teratoma specimens had a significantly higher mean (range) MVD (85, 26-163; P < 0.01) than both seminoma (37, 16-91) and four normal specimens (26, 18-30). Teratoma specimens also had significantly higher VEGF expression than both seminoma and normal specimens (P < 0.01). Despite these differences between groups, and indeed individual tumours, there was no significant correlation between MVD and VEGF, or between either MVD or VEGF and relapse-free survival. TP expression was significantly greater in tumours than in normal specimens (P < 0.02) but with very little inter-tumour variation. VEGF-C mRNA and VEGFR-3 protein were detected in a third to a half of cases, with expression mostly around endothelial vessels.

CONCLUSIONS

The marked differences between normal testis and tumours implicate angiogenesis in the biology of germ cell tumours of the testis. In addition, the detection of factors involved in lymphangiogenesis in some seminomas, tumours which initially metastasize primarily to lymph nodes, indicate that although not prognostic in this study, further studies are warranted in both these areas in the search for further prognostic indicators and therapeutic targets.

Lesion characterization using vessel permeability map to new blood pool contrast agent calculated from dynamic magnetic resonance images

Use of contrast enhancement in conjunction with magnetic resonance (MR) imaging provides a means to evaluate tissue function, as well as morphology. Moreover, physiologic properties derived from kinetic analysis of dynamic contrast-enhanced data can improve the specificity of MR examinations. In this study, quantitative analysis of microvascular characteristics based on dynamic MR imaging were performed both for malignant and benign lesions using two types of contrast agents (CAs). A new MR macromolecular contrast medium (MMCM), 24 gadolinium-tetraazacyclododecanetetraacetic acid (DOTA)-dendrimer, was found to have a greater ability to distinguish benign from malignant lesions. When a blood pool agent was used, permeability differences in the two types of lesions were the most significant findings among all parameters considered.

Five different anti-prostate-specific membrane antigen (PSMA) antibodies confirm PSMA expression in tumor-associated neovasculature

Prostate-specific membrane antigen (PSMA) is a type II integral membrane glycoprotein that was initially characterized by the monoclonal antibody (mAb) 7E11. PSMA is highly expressed in prostate secretory-acinar epithelium and prostate cancer as well as in several extraprostatic tissues. Recent evidence suggests that PSMA is also expressed in tumor-associated neovasculature. We examined the immunohistochemical characteristics of 7E11 and those of four recently developed anti-PSMA mAbs (J591, J415, and Hybritech PEQ226.5 and PM2J004.5), each of which binds a distinct epitope of PSMA. Using the streptavidin-biotin method, we evaluated these mAbs in viable prostate cancer cell lines and various fresh-frozen benign and malignant tissue specimens. In the latter, we compared the localization of the anti-PSMA mAbs to that of the anti-endothelial cell mAb CD34. With rare exceptions, all five anti-PSMA mAbs reacted strongly with the neovasculature of a wide spectrum of malignant neoplasms: conventional (clear cell) renal carcinoma (11 of 11 cases), transitional cell carcinoma of the urinary bladder (6 of 6 cases), testicular embryonal carcinoma (1 of 1 case), colonic adenocarcinoma (5 of 5 cases), neuroendocrine carcinoma (5 of 5 cases), glioblastoma multiforme (1 of 1 cases), malignant melanoma (5 of 5 cases), pancreatic duct carcinoma (4 of 4 cases), non-small cell lung carcinoma (5 of 5 cases), soft tissue sarcoma (5 of 6 cases), breast carcinoma (5 of 6 cases), and prostatic adenocarcinoma (2 of 12 cases). Localization of the anti-PSMA mAbs to tumor-associated neovasculature was confirmed by CD34 immunohistochemistry in sequential tissue sections. Normal vascular endothelium in non-cancer-bearing tissue was consistently PSMA negative. The anti-PSMA mAbs reacted with the neoplastic cells of prostatic adenocarcinoma (12 of 12 cases) but not with the neoplastic cells of any other tumor type, including those of benign and malignant vascular tumors (0 of 3 hemangiomas, 0 of 1 hemangioendothelioma, and 0 of 1 angiosarcoma). The mAbs to the extracellular PSMA domain (J591, J415, and Hybritech PEQ226.5) bound viable prostate cancer cells (LNCaP and PC3-PIP), whereas the mAbs to the intracellular domain (7E11 and Hybritech PM2J004.5) did not. All five anti-PSMA mAbs reacted with fresh-frozen benign prostate secretory-acinar epithelium (28 of 28 cases), duodenal columnar (brush border) epithelium (11 of 11 cases), proximal renal tubular epithelium (5 of 5 cases), colonic ganglion cells (1 of 12 cases), and benign breast epithelium (8 of 8 cases). A subset of skeletal muscle cells was positive with 7E11 (7 of 7 cases) and negative with the other four anti-PSMA mAbs. PSMA was consistently expressed in the neovasculature of a wide variety of malignant neoplasms and may be an effective target for mAb-based antineovasculature therapy.

Expression of vascular endothelial growth factor in patients with testicular germ cell tumors as an indicator of metastatic disease

BACKGROUND

Angiogenesis is essential for tumor growth and metastasis. Vascular endothelial growth factor (VEGF) and thymidine phosphorylase (TP)/platelet-derived endothelial cell growth factor (PD-ECGF) are involved in increased angiogenic activity and disease progression in solid tumors. However, there is no information regarding the association of these angiogenic factors with clinicopathologic findings in testicular germ cell tumors (GCTs).

METHODS

The authors examined the expression of VEGF and TP as well as microvessel density in GCTs and their association with clinicopathologic findings. Expression of VEGF and TP and microvessel density were examined immunohistochemically in 80 GCTs, including 33 seminomas (25 tumors with organ-confined disease and 8 with metastasis) and 47 nonseminomatous testicular GCTs (NSGCTs) (20 tumors with organ-confined disease and 27 with metastasis). Expression of VEGF also was examined in four GCTs and one nonneoplastic testis by immunoblotting.

RESULTS

VEGF protein was expressed more highly in GCTs compared with nonneoplastic testes. VEGF expression in GCTs was correlated significantly with microvessel count (P < 0.001). Both VEGF expression and microvessel count were correlated with metastasis in seminoma (P = 0.008 and P < 0.001, respectively), but only VEGF expression was identified as statistically significant by multiple regression analysis (P = 0.006). Conversely, four variables (VEGF expression, microvessel count, the presence of venous invasion, and the presence of embryonal carcinoma elements in the primary tumor) were correlated with metastasis in NSGCT (P < 0.001, P < 0.001, P = 0.004, and P = 0.029, respectively). However, multiple regression analysis revealed that only VEGF expression and microvessel count were significant factors for metastasis (P < 0.007 and P < 0.001, respectively). In contrast, high levels of TP were observed in infiltrating cells, but not in the majority of cancer cells.

CONCLUSIONS

The findings of the current study suggest that VEGF expression is involved in tumor development, angiogenesis, and metastasis in GCT.

Sertoli cell tumors of the testis, not otherwise specified: a clinicopathologic analysis of 60 cases

Sixty Sertoli cell tumors of the testis, excluding large cell calcifying and sclerosing subtypes, are described. Patient age ranged from 15 to 80 years (mean, 45 years). The initial manifestation was usually a testicular mass; in 14 cases it had been enlarging slowly for a period of up to 14 years (mean 3.7 years). Only five patients had testicular pain. Four patients had metastatic disease at the time of presentation. All the tumors were unilateral and ranged from 0.3 cm to 15 cm (mean 3.6 cm). They were typically well circumscribed. Sectioning usually disclosed firm, tan-gray, white, or yellow tissue with areas of hemorrhage and a minor cystic component in approximately one third. Microscopic evaluation usually revealed diffuse sheets or large, nodular aggregates of tumor cells, within which solid or hollow, sometimes dilated, tubules and, less often, cords were usually at least focally identifiable. A relatively acellular, often vascular, fibrous to hyalinized stroma was frequently conspicuous. The tumor cells typically had moderate amounts of pale to lightly eosinophilic cytoplasm, but 10 tumors had cells with abundant eosinophilic cytoplasm. Large cytoplasmic vacuoles were prominent in 26 tumors. Nuclear atypicality was absent or mild in 54 cases, moderate in 4 cases, and marked in 2 cases. Mitotic rate ranged from less than 1 to 21 per 10 high power fields, with 50 tumors having no or only rare mitoses. Vascular space invasion was present in 11 cases and was prominent in 8. Follow-up of more than five years (average 8.4 years), or until evidence of metastasis was seen, was available for 16 patients. Nine were alive and well with no evidence of disease. Four were alive with disease and three died of disease. The pathologic features that best correlated with a clinically malignant course were as follows: a tumor diameter of 5.0 cm or greater, necrosis, moderate to severe nuclear atypia, vascular invasion and a mitotic rate of more than 5 mitoses per 10 high power fields. Only one of nine benign tumors for which follow-up data of 5 years or more were available had more than one of these features, whereas five of seven malignant tumors had at least three.

Vascular density does not predict future metastatic disease in clinical stage 1 non-seminomatous germ cell tumours of the testis

AIM

This study aimed to determine whether patients with stage 1 testicular non seminomatous germ cell tumours (NSGCT) with high vascular density have a greater risk of disease recurrence than those with a low vascular density.

METHODS AND RESULTS

Orchidectomy specimens from 42 patients with stage 1 NSGCT, treated by orchidectomy and surveillance alone, were studied. Vessel density was counted in tumour sections immunohistochemically stained for CD34. The mean of the three highest counts (x250, field size 0.67 mm2) for each tumour was used. Tumour vessel density was very similar for relapsing and non relapsing patients. Vascular invasion was the only variable significantly predictive of disease recurrence at 2 years post-orchidectomy (P = 0.025). There was wide variation of vessel counts between different blocks of a tumour, compared with interobserver variation. The tumour tissue type in the area of highest vessel density was embryonal carcinoma in 50% and teratoma (mature or immature) in 38%.

CONCLUSIONS

We confirmed the value of vascular invasion as a prognostic marker in stage 1 NSGCT. Tumour vessel density was of no prognostic value. Two factors may contribute to this. First, there was wide variation of vessel density between different blocks of a tumour. Second, the most vascular area in a tumour was frequently in low-grade tumour.

Neovascularization in human germ cell tumors correlates with a marked increase in the expression of the vascular endothelial growth factor but not the placenta-derived growth factor

Neoangiogenesis is a prerequisite for tumor growth and metastasis. In germ cell cancer patients with the disease limited to the testicle (stage A), tumor-associated neovascularization is predictive of metastatic disease (stage B). To investigate the molecular mechanisms underlying neovascularization in human germ cell tumors (GCTs), we analysed the expression of two angiogenic growth factors, vascular endothelial growth factor (VEGF) and placenta growth factor (P1GF), and of their receptors (FLT-1) and Flk-1/KDR) in a panel of testicular tumors. In this study we show a marked increase in VEGF expression in 36/44 (81.8%) primary testicular-derived GCTs, as compared to normal testis, that significantly correlates with a high density of intratumor microvessels (r = 0.72461, P < 0.001; n = 24). As determined by RT - PCR and/or Western blot, the predominant VEGF isoforms expressed in GCTs are the VEGF121 and VEGF165, which are more efficiently secreted by the cells, and thus more active in eliciting angiogenesis. Conversely, in the case of PIGF, only a weak correlation with the vascular density of tumors is observed (r = 0.26599, P < 0.05; n = 24). Northern blot analysis also revealed significant up-regulation of VEGF/ PIGF receptors in highly vascularized germ cell tumors, compared to normal testes. These findings suggest that VEGF may act in a paracrine manner to induce neovascularization, oedema extravasation and cyst formation in human germ cell tumors. The correlation between VEGF expression and the vascular density of tumors, suggest that the evaluation of VEGF expression may be of help in predicting patients at risk for metastatic diseases. Finally, we demonstrate that VEGF up-regulation may occur at the RNA level since no gene amplification is observed; conversely, in in vitro models such as the embryonal stem cell line NTERA-2 and the choricarcinoma JEG-3 cell line, VEGF (but not PIGF) mRNA expression is regulated by hypoxic stress.

Treatment of a stage I testicular yolk sac tumor with vascular invasion

There is controversy concerning the treatment of stage I yolk sac tumor of the testis, particularly of those with histological factors that indicate a high risk of relapse. Usually orchiectomy alone is sufficient and adjuvant chemotherapy is unnecessary. Retroperitoneal lymphadenectomy is indicated for patients with persistently high alpha-fetoprotein. Once recurred, treatment at that time is thought to be curative. However, postoperative chemotherapy may be necessary for patients with a tumor expressing histological factors that predict possible relapse. In this paper we report on a case of a 2 year old boy whose tumor invaded the testicular veins. The patient suffered from recurrent disease but was successfully treated by chemotherapeutic regimens including cisplatin and retroperitoneal lymphadenectomy. The importance of the histological factors in making a decision on the treatment strategy for stage I testicular yolk sac tumor is discussed.

Prognostic significance of immunohistochemical proliferation markers (Ki-67/MIB-1 and proliferation-associated nuclear antigen), p53 protein accumulation, and neovascularization in clinical stage A nonseminomatous testicular germ cell tumors

Histopathologic features alone fail to reliably stratify patients with clinical Stage A nonseminomatous germ cell tumors of the testis into groups with high and low risk for occult metastatic disease. Previous flow cytometric studies at Indiana University demonstrated a significant correlation between high proliferative activity and metastatic disease. The current study evaluated the prognostic significance of immunohistochemical markers related to tumor proliferation and aggressiveness in a consecutive series of clinical Stage A nonseminomatous germ cell tumors patients who underwent retroperitoneal lymph node dissection. Archival material of the orchiectomy specimens of 62 patients (45 pathologic Stage A, 17 with metastatic disease) was reviewed and immunohistochemically stained for Ki-67 antigen (MIB-1), proliferation-associated nuclear antigen (PC10), p53 protein (Pab1801), and Factor-VIII-related antigen (neovascularization). Staining with MIB-1 was significantly higher in the metastatic group (mean 80.2%, standard deviation [SD] 15.5) than in pathologic Stage A cases (66.3%, SD 27.9; P = 0.0032) and was predictive of metastatic status with a sensitivity of 82% and specificity of 69%. In this study, no patient with a MIB-1 value less than 52% had metastases. Proliferation-associated nuclear antigen and p53 staining correlated with MIB-1 values (R = 0.63 and 0.55, respectively) but did not correlate with metastatic status. Tumor angiogenesis was also not predictive of metastatic status. Assessment of proliferation rates using MIB-1 antibody in clinical Stage A nonseminomatous germ-cell-tumor patients may prove helpful in predicting metastatic status.(ABSTRACT TRUNCATED AT 250 WORDS)

Vascular considerations in postchemotherapy. Retroperitoneal lymph-node dissection: Part I--Vena cava

A total of 42 patients underwent inferior vena cava resection (n = 40) or intraluminal tumor thrombectomy (n = 2) during retroperitoneal lymph-node dissection (RPLND) for bulky abdominal metastatic nonseminomatous germ-cell cancer (7% of all postchemotherapy RPLND cases). The three indications for caval resection included tumor clearance (38%), caval scar occlusion (14%), and caval tumor thrombus (48%). En bloc caval resection to achieve tumor clearance was justified by subsequent nodal pathology (cancer in 63% of specimens, teratoma in 31% specimens). Caval resection in the presence of scar occlusion was required de facto by virtue of its incorporation in the specimen. Caval resection or thrombectomy is indicated for intraluminal tumor thrombus because thrombus pathology (cancer, 35%; teratoma, 45%; fibrosis, 20%) reflected nodal pathology in 71% of cancer cases, 78% of teratoma cases, and 100% of fibrosis cases. The complications of caval resection were generally transitory. The 71% survival rate justifies this intensive surgical approach because these patients had exhausted all chemotherapeutic options.

Vascular considerations in postchemotherapy. Retroperitoneal lymph-node dissection: Part II

A total of 710 patients underwent postchemotherapy retroperitoneal lymph-node dissection (RPLND) from 1965 to 1992. Ten patients, all with bulky disease, required aortic replacement either postoperatively (n = 3) or during RPLND (n = 7). The principal risk factor for aortic rupture after RPLND was an extended subadventitial aortic dissection made necessary by tumor fixation. Also, duodenal enterotomy or extensive violation of the bowel serosa was a further risk for aortoenteric fistula. Prospective aortic grafting may be indicated in the presence of these risk factors. In our four elective cases, there was no further vascular or bowel complication. Omental interposition further protects against fistula formation. Although rarely indicated except under the most extenuating circumstances, the exposure requirements of RPLND permit aortic grafting as a relatively straightforward procedure that is feasible and well tolerated in this small subset of patients.

Neovascularization in clinical stage A testicular germ cell tumor: prediction of metastatic disease

Increased numbers of blood vessels (angiogenesis or neovascularization) in certain primary tumors correlates with an increased risk for metastatic disease. We therefore conducted a blinded review of the resected testicular germ cell tumors of 65 clinical stage A patients to evaluate the usefulness of angiogenesis in identifying those patients with clinically occult nodal metastases (pathological stage B). Angiogenesis was assessed in the primary tumors using an immunohistochemical stain for factor VIII-related antigen assay for quantitation of microvessel counts. Of 65 clinical stage A patients, 43 had pathological stage B disease at retroperitoneal lymph node dissection. Eleven patients had microvessel counts > 30 microvessels/x 400 high powered field, and all of these patients had pathological stage B disease (P = 0.02 in univariate analysis). Multiple regression analysis using microvessel count and other histological findings found to be prognostic (venous invasion, lymphatic invasion, presence of embryonal carcinoma, and absence of yolk sac tumor) showed that only the absence of a yolk sac tumor component was significantly predictive of occult metastases. This study shows that angiogenesis, as measured by quantitation of microvessel counts in the primary tumor of germ cell neoplasms, is significantly predictive of occult nodal metastatic disease by univariate analysis in clinical stage A patients. The prospective use of angiogenesis quantitation needs to be defined.

Pediatric testicular tumors: evaluation with gray-scale and color Doppler US

PURPOSE

To evaluate the appearance of testicular neoplasms in pediatric patients at examination with gray-scale and color Doppler ultrasonography (US).

MATERIALS AND METHODS

Gray-scale and color Doppler US were performed in seven patients aged 8 1/2 months to 17 years 6 months (mean age, 7.8 years) with testicular neoplasms proved at histologic examination. Gray-scale images were evaluated for echogenicity and presence of testicular masses; color Doppler US was used to assess the presence and distribution of color flow.

RESULTS

Gray-scale US showed enlargement of the affected testis in all patients. Testicular echogenicity was normal in four prepubertal patients; discrete masses were seen in all three postpubertal patients. The gray-scale findings correlated with patient age. Color Doppler US demonstrated increased blood flow in six of seven testicular neoplasms. Three of the four patients with normal gray-scale echogenicity had diffuse hypervascularity and one had a focal hypervascular mass on color Doppler scans.

CONCLUSION

Color Doppler US is more helpful than gray-scale US in identification of testicular tumor.

Treatment decision for stage I non-seminomatous germ cell tumours based on the risk factor "vascular invasion"

Surveillance has become an alternative treatment modality for stage I non-seminomatous germ cell tumours with reported relapse rates of up to 30% in retrospective studies. Results obtained in our retrospective study showed vascular invasion in primary tumours to be the risk factor with the highest negative predictive value. Since January 1985 patients with stage I non-seminomatous germ cell tumours have been stratified by the presence or absence of vascular invasion in the primary tumour: those without vascular invasion (n = 26; group A) were subjected to a rigorous surveillance programme, while those with vascular invasion (n = 22; group B) were given 2 chemotherapy courses of bleomycin, etoposide and platinum in the hope of preventing progression. Relapse rates were 3.8% and 9% in groups A and B, respectively. The pooled relapse rate for both groups A and B (n = 48) was 6.2% (3/48). After a mean follow-up time of 36 months 95.8% (46/48) of the patients were without evidence of disease.

Tumor angiogenesis formation of vessels de novo at germ cell tumors

Systemic studies of 346 biopsy specimens and 56 necropsy specimens with testicular germ cell tumors established two types of vessel formation: (1) classic (mature) type, representing a proliferation of the vessel system that already exists; and (2) embryonal type, with a real new formation of vessels from giant multinuclear cells. Vessels and vessel convolutes with wide lumina and thin walls are characteristic of the embryonal type. Essential properties of both types of vessel formation are presented, as well as the gradual transformation of giant multinuclear cells. The way that giant cell formations are created is described, along with their role in the tumor angiogenesis.

Histiocytoid (epithelioid) hemangioma of the testis. The so-called vascular variant of "adenomatoid tumor"

Adenomatoid tumors are well-recognized neoplasms generally considered to be of mesothelial derivation. We describe an unusual vascular neoplasm that arose in the testis of a 29-year-old and resembled an adenomatoid tumor by light microscopy. An orchiectomy was performed, and the patient is alive and disease-free 3 years later. The 2-cm tumor was composed of small tubules lined by mesothelial-like cells with uniform, vesicular nuclei. However, some lumina contained erythrocytes, and immunohistochemically, the luminal cells reacted with antibodies to vimentin, Factor VIII-related antigen, and Ulex europaeus I lectin but not cytokeratin or epithelial membrane antigen. A cuff of muscle-specific actin-positive cells surrounded the luminal cell layer. This adenomatoid-like vascular neoplasm is more properly interpreted as a histiocytoid (epithelioid) hemangioma. Although some authors have considered microscopically similar lesions to represent a vascular variant of adenomatoid tumor, we prefer to reserve the term "adenomatoid tumor" for microscopically appropriate proliferations that have mesothelial features.

Prognostic indicators for failure of surveillance management of stage I non-seminomatous germ cell tumours

Fifty-three patients presenting with non-seminomatous germ cell tumours (NSGCT) of the testis were examined. Particular interest was directed towards the association of several morphological features of the primary tumour with metastatic disease, either at presentation or later in the course of the tumour. It is apparent from this study that the presence of vascular invasion in the primary tumour, high T stage (advanced local disease) and the presence of choriocarcinoma are poor prognostic signs in NSGCT. In such tumours presenting as clinical stage I, surveillance management may not be appropriate because of the high rate of relapse.

Autonomy extends to the arterial supply of rapidly growing tumors. Studies on the feeder vessel to carcinoma in rat testis

There has been longstanding interest in the characteristics of "feeder vessels" to tumors. To develop a convenient model for assessing the determinants of the responsiveness of the arterial blood supply to tumors, we assessed by arteriography the response of the spermatic artery to norepinephrine, vasopressin, and ergonovine after implantation of Walker carcinoma in the testis of the rat. Loss of response to norepinephrine of the spermatic artery supply to the tumor occurred by the fourth day of tumor growth in this model, along the entire length of the spermatic artery. As expected, there was sustained vasoconstriction of the contralateral spermatic artery to the normal testis in response to norepinephrine. Vasopressin and ergonovine exerted no effect, so that the specificity of the loss of response to norepinephrine remains unclear. The spermatic artery provides an accessible and convenient model for studying the blood supply to tumors.

Vascularization of malignant testicular tumors

Recent studies of malignant testicular tumors report a correlation between vascularization, biologic behavior, radiosensitivity, and chemotherapeutic response of the tumor. Postoperative angiographies of malignant testicular tumor specimens (seminoma n = 4, nonseminoma n = 12) showed the following results: Contrary to the symmetric vascularity pattern of normal testes, seminomas were hypovascular, well-defined from normal testicular tissue and not neovascular. Nonseminomas showed isovascularity (n = 5) or hypovascularity (n = 7) but with focal hypervascular areas in the tumor (n = 10), and pathologic neovascularization. Present angiographic studies reveal marked differences in the vasculature pattern of malignant testicular tumors. In nonseminomas, focal hypervascular or neovascular areas as centers of a high-growth rate correlate well with comparable cell kinetic studies. Assuming a similar growth behavior in metastases, the vascularization type of these growth centers theoretically favors the efficient use of chemotherapeutic agents.

Analysis of proliferative compartments in human tumors. II. Seminoma

Growth pattern and cell kinetics of 12 human seminomas were determined by means of vascular organ perfusion after orchiectomy. The arteria testicularis of the tumor-bearing testis was perfused up to 5 hours with dextran-diluted blood under normothermic and normotonic, simulated physiologic conditions. At defined periods, the specimen was exposed to tritiated and/or carbon 14-labeled thymidine. Autoradiograms prepared of whole tumor sections revealed a dependence of growth pattern on the stage of development. A homogeneous distribution of DNA synthesizing seminoma cells was found in small tumor foci. With increasing size, the zone of proliferation shifted to the periphery of the nodule giving rise to nodular subpopulations of high proliferative activity. In nodules of a diameter of more than about 2 cm the growth compartment consists of a highly proliferating invading cell layer at the edge of the tumor and intratumoral patches of proliferating cells near the vascular stroma. The largest part of the tumor remains at this stage in a quiescent state (G0). The mean labeling index of the seminoma cells was 11.6 +/- 1.4%, with the highest values found immediately adjacent to tumor vessels. High mitotic activity in an anaplastic seminoma was coupled with maximum labeling indices up to 41.9%. DNA synthesis time ts was 15.9 +/- 2.0 hours. The potential population doubling time for the proliferating fraction was in the range of 5 days. Lymphocytic infiltration reduced the proliferative activity in some parts, but was without effect in other areas of the seminoma. The seminoma is an example of a malignant human tumor with a rather regular growth pattern: The distribution of the proliferating compartment appears less dependent on cytologic or histologic structure, but more on tumor geometry and size.

Centripetal spread of endothelial cell mitotic activity in the artery leading to a rapidly growing tumor

Vascular proliferation and growth have been attributed either to biophysical forces in the vessel lumen or to chemical mediators. In this study growth and endothelial cell tritiated thymidine uptake in the spermatic artery of the rat during early growth of the Walker 256 carcinoma in the testicle were examined. Testicular blood flow was measured with radioactive microspheres; radioautography following administration of tritiated thymidine was employed to define the endothelial cell labeling index; angiography was employed to assess the diameter of the spermatic artery lumen; and the mass of the artery was determined directly. Endothelial proliferation in the spermatic artery was increased on the second day, simultaneous with rather than subsequent to a significant increase in blood flow to the testicle. Moreover, endothelial cell thymidine uptake began to decline well before the blood flow through the artery reached a maximum. A gradient in endothelial cell proliferation and in lumen diameter of the spermatic artery became apparent during tumor growth; the increase in both lumen diameter and endothelial cell thymidine uptake in the spermatic artery occurred first in the portions nearest the testicle and spread centripetally throughout the length of the artery over several days. Because the spermatic artery is an end artery, without branches and without a normal change in internal diameter, and because the increase in blood flow must have occurred throughout the length of the artery at the same time, we conclude that factors other than those related to an increase in blood flow were primarily responsible for the increase in endothelial cell turnover. These observations make a chemical messenger, perhaps moving retrogradely through cell-to-cell contact, the most likely candidate as the responsible mediator.

Identification of vessels by lectin-immunoperoxidase staining of endothelium: possible applications in urogenital malignancies

Ulex europaeus agglutinin I binds specifically to vascular endothelium of various human tissues irrespective of the blood group type or secretive status of the tissue. Using this property, we have developed an immunoperoxidase technique to identify vessel structures in urogenital tissues. Most vessels in malignant and nonmalignant tissues of bladder, prostate and testis of different blood types (A, B, AB and O) can be readily identified by this method. This technique has potential application in detecting tumor cell invasion of vessels and in studying distribution of vessels in relation to various normal and pathological events.

Gynecomastia in association with a complex tumor of the testis secreting chorionic gonadotropin: studies on the testicular venous effluent

The levels of progesterone, 17 alpha-hydroxyprogesterone, androstenedione, testosterone and estradiol were measured in the testicular venous effluent from a testis containing a complex malignant tumor associated with gynecomastia and increased serum levels of beta-human chorionic gonadotropin. An abnormally low testosterone/estradiol ratio was encountered (83 in the peripheral serum and 101 in the spermatic venous effluent). On the basis of the available data no delineation could be made as to the relative contributions to estradiol production of tumor tissue and Leydig cells.

[Angiographic and morphological findings in testis tumors (author's transl)]

The arterial supply of testicular tumors is compared to that of normal testes. Data were collected from comparative angiographic and morphologic studies of 21 surgical and autopsy specimens. The arterial vascularization of seminomas is rather poorly developed, newly formed vessels show only minor differences of caliber. Non-seminomatous testicular tumors show a strongly irregular pattern of arterial branching with bends, variations of caliber, irregular contours, completely avascular areas, and extravasation of contrast medium. Depending on the size of tumors, the original testicular arteries are displaced and compressed more or less strongly. Angiographic findings are correlated with morphologic finding. The relevance of different patterns of vascularization for therapeutic considerations is discussed.

Malignant lymphoma with primary manifestation in the gonad: a clinicopathologic study of 38 patients

This study is based on 38 patients, each of whom had a malignant lymphoma in which the gonad was the site of the main tumor mass at the time of diagnosis. Histiocytic lymphoma was the predominant type in the 27 male patients; in the 11 female patients, poorly differentiated lymphocytic lymphoma was the most frequent type (36%). All of the neoplasms in the males were diffuse, whereas two of the females had neoplasms that were nodular and diffuse. A striking feature was the high frequency of vascular invasion (41%) in the testicular lymphomas, which was reflected in a high incidence (86%) of noncontiguous lung involvement at autopsy, suggesting hematogenous spread. Clinically occult disease is probably responsible for the short interval between the discovery of a gonadal mass and the appearance of generalized disease. A poor prognosis may be expected if there is evidence of generalized disease within one year after diagnosis. Only 2 patients had disseminated disease after a year, whereas all those who died of disseminated disease manifested it within six months after diagnosis. Disease-freee survival times in excess of 60 months in 3 patients who were treated only by orchiectomy or oophorectomy indicate that the gonads may be the primary site of a malignant lymphoma.