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PubMed1973

Fertility after unilateral orchidectomy and radiotherapy for patients with malignant tumours of the testis.

The results of treatment for patients with seminoma of the testis by orchidectomy and irradiation are so satisfactory that retroperitoneal lymph node dissection is no longer practised. However, this operation is still used routinely in some centres for patients with testicular teratomas despite the lack of evidence that it gives better results than those obtained with irradiation followed by removal of lymphographically demonstrable residual tumour and in the face of the high incidence of ejaculatory impotence which follows. On grounds of preservation of sexual function and fertility there is a great advantage to be gained from the latter form of treatment. Thirty-four of our patients between the ages of 25 and 45 years treated by irradiation to the para-aortic and iliac nodes for testicular tumours fathered 52 children to term after their treatment.

Adult↗
PubMed1978

Treatment of testicular tumors.

A total of 145 consecutive primary testicular tumors were treated with radiation therapy at the University of Michigan Hospital from 1955 through 1974. In patients with seminoma, the 5-year survival rate was 98% for Stage I and 88% for Stage II regardless of whether retroperitoneal lymph node dissection was done. The 5-year survival rate for embryonal carcinoma was 63% for Stage I and 66% for Stage II. For teratocarcinoma it was 100% for Stage I and 54% for Stage II. Adjuvant chemotherapy appeared to be beneficial for patients with Stage II teratocarcinoma but made no difference in patients with embryonal carcinoma.

Adolescent↗
PubMed1983

Irradiation of para-aortic lymph node metastases from carcinoma of the cervix or endometrium. Preliminary results.

Twenty-two patients with biopsy-proved para-aortic lymph node metastases from carcinoma of the cervix (15 patients) or endometrium (7 patients) received a median dose of 5,000 rad/25 fractions. Para-aortic nodal metastases were controlled in 77% of cases. Control was significantly lower following radical retroperitoneal lymph node dissection than less extensive sampling procedures. Obstruction of the small bowel developed in 3 patients with tumor recurrence in the para-aortic region. Eight of the 10 patients who were disease-free at 2 years received greater than 5,000 rad. Three patients were still alive without disease at 129, 63, and 60 months, respectively. The 5-year disease-free survival rate was 40% for cervical cancer and 60% for endometrial cancer: in the former group, it was significantly different depending on whether the para-aortic nodes were irradiated (40%) or not (0%). The authors suggest that 5,000-5,500 rad in 5-5.5 weeks is well tolerated and can control aortic nodal metastases in cervical and possibly endometrial cancer.

Abdominal Neoplasms↗
PubMed2006

Clonal origin of metastatic testicular teratomas.

PURPOSE: Testicular teratomas in adult patients are histologically diverse tumors that frequently coexist with other germ cell tumor (GCT) components. These mixed GCTs often metastasize to retroperitoneal lymph nodes where multiple GCT elements are frequently present in the same metastatic lesion. Neither the genetic relationships among the different components in metastatic lesions nor the relationships between primary and metastatic GCT components have been elucidated. EXPERIMENTAL DESIGN: We examined metastases from 31 patients who underwent primary retroperitoneal lymph node dissection for metastatic testicular GCT. All patients had metastatic mature teratoma with one or more other GCT components. This study included a total of 72 metastatic GCT components and 16 primary GCT components from 31 patients. Genomic DNA samples from each component were prepared from formalin-fixed, paraffin-embedded tissue sections using laser-assisted microdissection. Loss of heterozygosity (LOH) assays for seven microsatellite polymorphic markers on chromosomes 1p36 (D1S1646), 9p21 (D9S171 and IFNA), 9q21 (D9S303), 13q22-q31 (D13S317), 18q22 (D18S543), and 18q21 (D18S60) were done to assess clonality. RESULTS: Twenty-nine of 31 (94%) cases showed allelic loss in one or more components of the metastatic GCTs. Twenty-nine of 31 mature teratomas showed allelic loss in at least one of seven microsatellite polymorphic markers analyzed. The frequency of allelic loss in informative cases of metastatic mature teratoma was 27% (8 of 30) with D1S1646, 34% (10 of 29) with D9S171, 37% (10 of 27) with IFNA, 27% (8 of 30) with D9S303, 46% (13 of 28) with D13S317, 26% (7 of 27) with D18S543, and 36% (10 of 28) with D18S60. Completely concordant allelic loss patterns between the mature teratoma and all of the other metastatic GCT components were seen in 26 of 29 cases in which the mature teratoma component showed LOH. Nearly identical allelic loss patterns were seen in the three remaining cases. In six cases analyzed, LOH patterns of each metastatic component were compared with each GCT component of the primary testicular tumor. In all six cases, each primary and metastatic component showed an identical pattern of allelic loss. CONCLUSION: Our data support the common clonal origin of metastatic mature teratomas with other components of metastatic testicular GCTs and with each component of the primary tumor.

Adolescent↗
PubMed2001

Adult testicular pure yolk sac tumor.

Here we describe the clinical, ultrasonographic and histological features of a rare pure adult yolk sac tumor detected in the right testis of a 44-year-old male. Due to the rarity of this neoplasm (less than 10 cases have been reported), there is no unanimous consensus for therapy following inguinal orchiectomy. We believe that nerve-sparing retroperitoneal lymph node dissection could be potentially curative and useful for future interpretations of this tumor's potential evolution.

Adult↗
PubMed1988

Value of computed tomography in the staging of testicular tumors.

To analyze the value of computed tomography (CT) for the exact staging of testicular tumors, 2 groups of 28 patients each were examined. All patients underwent retroperitoneal lymph node dissection in the course of their treatment. Pretherapeutic stages as determined by CT were compared to the histologically verified definite tumor stages. In 68% of the patients, the stage found by CT was correct but 3 (5%) false-positive and 13 false-negative results were obtained. Thus, almost 40% (13/33) of the patients with clinical stage I disease presumably would have had a progression if managed by a surveillance strategy. It can be concluded that this strategy should be restricted to certain centers with guaranteed long-term standardized patient observation and extremely high patient compliance.

Dysgerminoma↗
PubMed1988

Simultaneous bilateral testicular germ cell tumors with dissimilar histology. Case report and review of the literature.

A 32-year-old male presented with simultaneous bilateral germ cell tumors of the testicles. Histological examination revealed dissimilar histology in both testes showing pure seminoma in the left side and mature teratoma with malignant transformation in the right testicle. A survey of the literature revealed a total of 151 previously described cases of synchronous bilateral germ cell tumors, the majority of which presenting as bilateral seminoma. Treatment of synchronous bilateral germ cell tumors with dissimilar histology should consist of bilateral orchiectomy and bilateral retroperitoneal lymph node dissection.

Adult↗
PubMed1987

[Position of surveillance therapy in clinical stage I testicular non-seminoma].

Since the initiation of a 'surveillance' therapy the role of retroperitoneal lymph node dissection as standard treatment in the management of patients with clinical stage I nonseminomatous germ cell testicular tumor (NSGCTT) continues to be debated. Noninvasive staging techniques (CT scans, lymphography, ultrasound and serologic tumor markers) help to identify more accurately patients with distant metastases. 'Surveillance' alone as a possible treatment modality following orchidectomy in selected patients with clinical stage I NSGCTT requires cooperative and reliable patients. In our urological clinic surveillance alone is not justified any longer because of a noncompliance rate of 10% and a relapse rate of 30%, although the early detection of small-volume metastatic disease, lymphadenectomy and polychemotherapy result in a high rate of cure. Any patient should be excluded from 'wait and see' protocols if metastatic prognostic factors such as vascular infiltration of the primary tumor or local tumor stage greater than pT1 are identified.

Biomarkers, Tumor↗
PubMed1994

An unusual late relapse in pathologic stage I non-seminomatous germ cell tumor: case report and review of the literature.

Late relapses are exceedingly uncommon in patients with pathologic stage (PS) I non-seminomatous germ cell tumors (NSGCT) of the testis treated with inguinal orchiectomy and retroperitoneal lymph node dissection (RPLND). We describe an unusual patient with PSI NSGCT who relapsed 40 months after surgery. The only evidence of recurrent disease was an elevated serum alpha-fetoprotein level, and complete remission was achieved following the prompt institution of combination chemotherapy. To our knowledge, this is the first report of a late relapse in PSI NSGCT of the testis manifested only as an elevated tumor marker.

Adult↗
PubMed1993

Semen quality after treatment for testicular cancer.

During the last 14 years repeated sperm cell analyses and serum hormone analysis were done regularly in patients with testicular cancer before and after treatment. The summarized results are hereby reported. The sperm cell count was highly impaired in 60-70% of testicular cancer patients evaluated 1-4 weeks after unilateral orchidectomy before further treatment. However, improvement of the exocrine gonadal function was regularly observed during the following 2-3 years, provided there were normal or only slightly elevated pre-treatment FSH levels. Standard irradiation and cytotoxic treatment (abdominal radiotherapy 30-40 Gy; < or = 4 cycles of cisplatin-based chemotherapy) delayed this recovery by about one year. Higher doses of chemotherapy or combined irradiation/chemotherapy reduced the chances of rapid improvement of the exocrine gonadal function. Unilateral retroperitoneal lymph node dissection resulted in a slight reduction of the post-treatment ejaculatory volume, even in patients with preserved antegrade ejaculation.

Adult↗
PubMed1993

Reproductive aspects of testicular germ cell cancer: general discussion.

Gonadal function is affected by both chemotherapy and radiotherapy in the treatment of testicular cancer. Leydig cells are more resistant than germ cells, but endocrine function is also affected. Sex life is affected by treatment for testicular cancer but major permanent sexual dysfunction is not common. Radiotherapy is more damaging to Leydig cells than chemotherapy and can also cause direct effects on Sertoli cells. Leydig cell dysfunction following chemotherapy is dose-dependent. Serum FSH levels may be elevated at the time of primary orchidectomy and this may be used to predict ultimate fertility in these patients. Fertility does not recover if FSH levels are greater than 24 IU/l which is twice the upper limit of normal. Retroperitoneal lymph node dissection does not cause erectile dysfunction, but may cause dry ejaculation unless a nerve sparing operation is performed by an experienced surgeon. LHRH analogues causes reduced testosterone secretion, impotence and loss of libido, and requires exogenous androgen therapy. CIS can be eradicated by 20 Gy fractionated radiotherapy. This dose has been shown to have some effect on Leydig cell function but this is not clinically significant in the first 5 years of follow-up. The effects of lower doses of irradiation, which may be less injurious to Leydig cells, are currently being investigated. The effects of chemotherapy on CIS is as yet unpredictable.

Follicle Stimulating Hormone↗
PubMed1995

The role of adjuvant treatment in low-stage germ cell testicular tumors.

OBJECTIVE: To find out up-to-date indications to adjuvant therapy in low-stage germ cell tumors (GCT) of the testis. METHODS: The authors reviewed the material of the National Cancer Institute in Milan and the major international papers on adjuvant therapies of GCT of the testis. RESULTS: Moderate dose irradiation of retroperitoneal nodes remains the standard therapy of stage I seminoma; mediastinal irradiation has been abandoned in stage II seminoma. Nerve-sparing retroperitoneal lymph node dissection and surveillance remain standard therapies for nonseminomatous stage I tumors; 2 adjuvant courses of cisplatin-based chemotherapy are under investigation in high-risk patients. Postoperative adjuvant chemotherapy is mandatory only in bulky pathological stage II non-seminoma, but it is advisable also in patients who cannot be carefully followed. CONCLUSION: The cure rates of GCT of the testis can approach 100% in low stages and similar results can be achieved with different treatment modalities, but the maximum results can be obtained in specialized centers only.

Chemotherapy, Adjuvant↗
PubMed1994

Orchiectomy alone for clinical stage I nonseminomatous germ cell tumors of the testis (NSGCTT): a minimum follow-up period of 5 years.

AIMS AND BACKGROUND: Surveillance after orchiectomy alone has gained great popularity in the management of stage I NSGCTT. Preliminary results were enthusiastic, but critical voices have been raised against general use of this option as routine management. In an effort to identify patients at high risk of relapse, there has been a search for adverse prognostic factors of stage I nonseminomatous germ cell testicular tumors (NSGCTT). The aim of the study was to identify those patients in whom a surveillance policy is less likely to be successful. METHODS: Eighty patients with stage I NSGCTT were followed for at least 5 years. They were assigned to their respective clinical stage on the basis of physical examination, chest X-ray, CT of the retroperitoneum and post-orchiectomy tumor markers. The criteria for inclusion in clinical stage I were normal results of these examinations. The policy of surveillance consisted of regular follow-up with tumor markers, chest X-ray and CT of the retroperitoneum. Patients who relapsed were treated with cisplatin-containing chemotherapy. In all patients, diagnostic delay, pre-orchiectomy tumor markers, T staging category, size, histopathology and vascular invasion in the primary tumor, and semen analysis were recorded. RESULTS: Follow-up revealed that 51 of the 80 patients (63.7%) were free of disease 61-110 months (mean, 83.1) after orchiectomy. Relapse was detected in 29 patients (36.3%) 3-58 months (mean, 13) after orchiectomy. The overall survival rate was 95%. The main risk factors of relapse were: vascular invasion, a major embryonal carcinoma and a minor teratoma component in the primary tumor, and low sperm count before orchiectomy. CONCLUSIONS: The authors recommend the following risk-adapted treatment procedures: retroperitoneal lymph node dissection in patients with vascular invasion and a major teratoma component, adjuvant chemotherapy in patients with vascular invasion and a major embryonal carcinoma component, and surveillance policy in patients without vascular invasion.

Adolescent↗
PubMed2004

Surgical management of testicular cancer.

Surgery is an integral component in the management of testicular cancer. Prior to the advent of cisplatin chemotherapy, a retroperitoneal lymph node dissection (RPLND) was the only chance for cure of testicular cancer. Over the years, the surgical techniques have been improved greatly to decrease the occurrence of complications (e.g., incidence of retrograde ejaculation). Currently, RPLND can be done as the initial therapy or after chemotherapy. In either situation, the postoperative management of patients with testicular cancer can be complicated and requires thorough, ongoing assessment. This article presents the surgical indications for RPLND and the nursing management.

Chemotherapy, Adjuvant↗
PubMed1985

Curative testis cancer therapy: psychosocial sequelae.

We examined the long-term impact of advanced testis cancer and its curative therapies on emotional states and outlook on life, employment, intimate relationships, and sexual function. The sample consisted of 74 nonseminomatous and seminomatous tumor patients who had completed treatment two to ten years ago. The majority of men felt that surviving the debilitating treatment(s) was both an accomplishment and worthwhile trade-off. Neither the rate of unemployment (7%) nor divorce (10%) was remarkable. The most critical outcome was in the area of sexual functioning. One fourth to one half of the men reported some type of sexual impairment. Multiple regression results indicate that ejaculatory dysfunction, a side effect of the retroperitoneal lymph node dissection, is significantly associated with distress about both infertility and sexual impairment. Men with sexual impairment report more psychological symptoms, strained intimate relationships, and negative changes in other areas of life functioning. These data, while not definitive, suggest that there are delayed effects and that the subgroup of men, who are least likely to disclose these problems to physicians, are at greater risk for the deleterious outcomes.

Adolescent↗
PubMed1988

Clinical stage I carcinoma of the testis: a review.

Significant advances in the management of disseminated carcinoma of the testis have had a tremendous influence on the management of all stages of disease, including both stage I and stage II. Because the disease is so uniformly curable in advanced forms, strategies have evolved for lower stages of disease to maximize curative potential with minimization of therapeutic intervention and potential long-term side effects. This review addresses issues of diagnosis and initial clinical staging of patients with stage I carcinoma of the testis. The usefulness of biological tumor markers and the accuracy, sensitivity, and specificity of radiographic imaging modalities are emphasized. The traditional treatment of stage I seminomas and nonseminomas includes the role of both radiation therapy and retroperitoneal lymph node dissection (RPLND). Treatment results and complications of each modality are also reviewed. The importance of orchiectomy followed by meticulous surveillance, as well as a critical analysis of prognostic features of subsequent locoregional or systemic relapse in patients with stage I testis cancer, focuses attention on changing concepts of this disease. The rationale underlying improved ability to stage patients meticulously and offer therapeutic intervention when necessary following orchiectomy, constitutes the focus of present and future clinical research. Such strategies are discussed in detail.

Biomarkers, Tumor↗
PubMed1990

Long-term fertility and Leydig cell function in patients treated for germ cell cancer with cisplatin, vinblastine, and bleomycin versus surveillance.

Fertility and Leydig cell function were investigated in 31 patients previously treated for nonseminomatous testicular cancer. Twenty-two patients with metastatic cancer had received cisplatin-based chemotherapy, and the median follow-up was 64 months (range, 42 to 100 months). Nine patients without metastases were treated with orchiectomy alone, and follow-up in this group was a median of 61 months (range, 40 to 77 months). None of the patients have relapsed and retroperitoneal lymph node dissection was not performed in any patient. Both the concentration of spermatozoa and the volume of the remaining testis are significantly reduced in patients who had previously received chemotherapy when compared with patients treated with orchiectomy alone (P less than .05). There were no significant differences between groups when comparing morphology, motility, and penetration of the spermatozoa. Subclinical Leydig cell dysfunction with normal testosterone and elevated luteinizing hormone (LH) was observed in one patient (11%) treated with orchiectomy alone, while 59% of the patients who had received chemotherapy had elevated LH (P less than .05). We conclude that cisplatin-based chemotherapy leads to a persistent impairment of fertility and Leydig cell function in the majority of patients with testicular cancer.

Adult↗
PubMed1990

Adaptive behavioral responses to potential infertility among survivors of testis cancer.

In a retrospective study of 153 testis cancer survivors, we examined the sociodemographic and clinical determinants of attitudes and behaviors toward illness-induced infertility. Five fertility adjustment responses were identified: sperm-banking awareness (SBA); adoption awareness (AA); fertility testing (FT); trying to father children (TFC); and fertility distress (FD). Although responses to infertility are multidetermined, these data demonstrate there is a distinct sociodemographic and clinical profile for the subgroups of men who engage in different fertility-related behaviors. Multivariate analysis results show that men most likely to be concerned with banking sperm are those who at diagnosis are younger (less than 35 years), childless, college educated, and whose relationships have become strained. Men who sought fertility tests were childless, college graduates, and able to ejaculate. The only factor predicting adoption was childlessness. Those married men attempting to father children were also less than 35 years of age at diagnosis and without ejaculatory dysfunction. The men at greatest risk for continued distress about infertility were those who remained childless and had posttreatment ejaculatory dysfunction. Residual infertility distress also was significantly associated with treatments that included extensive retroperitoneal lymph node dissection (RPLND) surgery, indicating that the latter is a "risk factor" in survivors' long-term distress. These data, while not definitive, show that the prerogative to have children is very important to men and that losing it sets into motion a range of both adverse emotions and adaptive responses. Adjustment to infertility is a complex process that begins at diagnosis and extends long after treatment is completed.

Adolescent↗