Bilateral testicular tumors: A report of nine cases with long-term follow-up

BACKGROUND: The incidence and clinical features of bilateral germ cell testicular tumor (GCTT) in the Japanese population are not fully characterized. We examined the incidence, clinical features, management and outcome, sexual status, hormonal environment, implication of androgen replacement, and human leukocyte antigen (HLA) typing of bilateral GCTT. METHODS: We treated nine consecutive patients with bilateral GCTT from 1980 through to 1999, and reviewed their hospital and clinic charts. Testosterone, luteinizing hormone, follicle stimulating hormone, dehydroepiandrosterone, and dehydroepiandrosterone-sulfate were measured in bilateral orchiectomized patients. Human leukocyte antigen typing was assessed with peripheral lymphocyte. RESULTS: The incidence of bilateral GCTT against the total number of patients with GCTT was 9/274 (3.3%). The median age of the first tumor was 29 (range 21-75) years. Three cases were synchronous and the remaining six cases were metachronous. In the case of metachronous tumor, the median interval between first and contralateral tumor was 8 (range 2-25) years. Standard treatment was defined as surveillance policy in stage I, chemotherapy for higher stages of non-seminoma, and radiotherapy for stage II seminoma. Human leukocyte antigen typing was examined for seven cases. Five cases were positive for HLA-A24. The incidence of HLA-A24 in bilateral GCTT was identical to that of the Japanese population. The relapsing incidence of stage I disease with surveillance policy was almost identical to unilateral GCTT. A 74-year-old patient with stage II seminoma died of the disease at 1.3 years. The other eight patients remained well without any evidence of recurrence at a median follow-up period of 78 (range 12-204) months. Four patients with bilateral orchiectomy did not require androgen replacement without easy fatigability. Sexual status was conserved using androgen replacement. CONCLUSIONS: Long-term follow-up, as long as 25 years, is recommended for contralateral relapse. Some patients with bilateral orchiectomy do not require androgen replacement. The significance of HLA-A24 for bilateral testicular tumor is equivocal in the Japanese population.     

Bilateral germ cell cancer of the testis: a report of 11 patients with a long-term follow-up

OBJECTIVE: To describe the incidence, clinical characteristics, treatment methods and long-term follow-up of bilateral germ cell tumours of the testis (GCTT) in patients treated at one institution. PATIENTS AND METHODS: Of 552 patients with GCTT, 11 (2%, mean age 26. 9 years) developed bilateral disease; all 11 underwent radical orchidectomy. Additional treatment was planned according to the histological type and clinical stage of the tumour, and previous treatments. Intramuscular testosterone was administered periodically after total castration. The data on survival, sexual status and treatment complications were reviewed. RESULTS: Of the 11 patients, seven developed a second tumour metachronously (median interval 87 months) and four had synchronous bilateral GCTT. Cryptorchidism, infertility or atrophic testis was associated with the development of bilateral GCTT in seven of the 11 patients. All synchronous tumours and most of the sequential tumours had identical histology on both sides. Although all sequential tumours presented at an early clinical stage, three of four synchronous bilateral GCTTs presented at an advanced stage. Five patients received platinum-based chemotherapy; three patients underwent post- chemotherapy resection of the retroperitoneal residual mass. Sexual libido and potency were conserved in all patients. No significant morbidity was recorded as being caused by any of these treatments. At a median follow-up of 11. 6 years, all patients were alive with no evidence of cancer. CONCLUSIONS: All patients with unilateral GCTT have an increased risk of developing a contralateral testicular tumour, even decades after diagnosis. Management should be adapted to each patient. As all patients in this series survived in the long-term, developing a second germ cell cancer does not necessarily predict a poor prognosis.     

Incidence and clinical pattern of contralateral synchronous and metachronous germ cell testicular cancer

BackgroundIncidence of a second testicular tumor is higher in patients diagnosed with testicular cancer than in the general population. As incidence of unilateral germ cell cancer is increasing worldwide and most of these patients are cured, a growing number of patients at risk of developing a contralateral testis cancer is expected.ObjectiveTo analyze clinical and histological characteristics, as well as the absolute and cumulative incidence of a second testicular cancer in a cohort of 3,834 patients diagnosed with germ cell testicular cancer between I/1994 and I/2018 in 18 referral hospitals of the Spanish Germ Cell Cancer Group.MethodsPatients were treated according to stage and year of diagnoses. Contralateral testis biopsy was not routinely performed, according to European Association of Urology rules. Follow-up of the contra lateral testis consists of a physical exam only and an annual optional testicular ultrasound for 10 years.ResultsMedian age of the patients included was 32 years (18–82). With a median follow-up of 61 months (0–240), 67/3,834 patients (1.74%) were diagnosed with a second testicular tumor. The second testicular tumor was synchronic (diagnosed within 6 months of the first orchiectomy) in 19 patients, and metachronous in 48. Pathology of the second tumor was reported as a seminomatous testis tumor in 47 patients and a nonseminomatous cancer in 20. Cumulative incidence of contralateral testicular cancer was 2% at 5 years, and 4% (IC 95% 3%–5%) at 14 years. Younger age was a risk factor for developing a second testicular tumor (P = 0.006), whereas chemotherapy reduced the risk for a metachronous testicular cancer (P = 0.046). Within our cohort, 6 families with testicular cancer aggregation (more than 2 tumors in the same family) were identified.ConclusionsIncidence of second testicular neoplasm in this cohort of 3,834 patients was similar to that which has been reported in other countries. Metachronous tumors and seminomas are more common. Follow-up of the contralateral testis is mandatory, as well as adequate information for patients to prevent a second neoplasm if feasible, and to detect and treat it as soon as possible.     

Experience with testis sparing surgery for testicular teratoma

PURPOSE: Testicular teratoma is a rare neoplasm affecting the pediatric population and has classically been reported to be the second most common testis tumor in children behind yolk sac tumors. Testicular teratomas are benign and partial orchiectomy may be considered. We describe our single institution experience with testicular teratoma and definitive treatment with testis preserving surgery. MATERIALS AND METHODS: We reviewed the pathology records at our institution for all testicular and paratesticular tumors diagnosed between 1976 and November 2002 in males younger than 18 years. We specifically examined the prepubertal incidence of teratoma, including epidermoid cysts, and our experience with testis preserving surgery. Preoperative and postoperative ultrasonography images were used to calculate the atrophy index following surgery. Patients were contacted for long-term followup. RESULTS: Of 77 primary testicular and paratesticular tumors 38 were diagnosed in prepubertal boys (age younger than 13 years) including 11 mature teratomas and 5 epidermoid cysts. Mean patient age at treatment was 34.4 months (range 4 months to 10 years). All boys presented with a painless scrotal mass, cystic foci within an intratesticular mass on ultrasound and a normal alpha-fetoprotein level. Of the 16 boys with benign teratomas 13 (81%) were treated with a testis sparing procedure. At a mean 7-year followup no patient has presented with recurrent tumor in the ipsilateral or contralateral testicle. Postoperative physical examination and scrotal ultrasound were obtained in 9 patients at a median followup of 10.2 months, and there was no evidence of testicular atrophy or persistent discomfort. CONCLUSIONS: Unlike previously published series based on tumor registries, benign teratoma was the most common pediatric testicular tumor treated at our institution. Our single institution experience with testis preservation and long-term followup confirms the role and safety of this technique. Testis sparing surgery remains our technique of choice for testicular teratoma.     

Bilateral testicular germ-cell tumors – A single centre long-term experience

Objectives: The incidence of bilateral testiculartumors (BTT) had increased over the preceding decade. The aim of thepresent study is to analyse a group of patients with BTT and tohigh-light the need for long-term follow-up of patients treated in asingle centre. Material and methods: 27 (2.8%) out of960 patients with germ-cell testicular tumors (GCTT), treated between4/1977 and 8/2001, developed bilateral disease. All of themunderwent radical orchiectomy (in one patient was done delayedorchiectomy after primary chemotherapy due to advanced disease).Additional treatment was planned according to the histologic type andclinical stage of the disease, and previous treatment as well. Thesurvival data were reviewed. Results: 24 out of 27 patients(88.9%) developed the 2nd tumor metachronously (median interval66 months, range, 4–197 months) and three (11.1%) had synchronousBTT. Only 7 patients (25.9%) had identical histological types onboth sides (6 of them with pure seminomas, one with embryonalcarcinoma). Two of three synchronously developed BTT had differenthistologic types on both sides. GCTT of one histologic type wereobserved in respect of the first tumor: 11 seminomas, three embryonalcarcinomas, in respect of the 2nd tumor: 10 seminomas, three embryonalcarcinomas, in respect of the 2nd tumor: 10 seminomas, three embryonalcarcinomas and one mature teratoma. GCTT of more than one histologictype were observed in respect of the first and the 2nd tumors: 6 mixedGCTT with seminoma component and 7 without seminoma component. Majorityof BTT was presented in clinical stage I (in respect of the first tumorin 70.4%, in respect of the 2nd tumor in 62.9%). Themedian duration of the follow-up after the diagnosis of the first GCTTwas 149 months (range, 13–288 months) and after the diagnosis ofthe contralateral GCTT was 68 months (range, 1–167 months).Twenty-five patients (92.6%) were alive with NED at their lastfollow-up visit. Two patients died by mean of 22.5 months (range,21–24 months) after the 2nd orchiectomy. Conclusions: Allpatients with unilateral GCTT have an increased risk of developing acontralateral testicular tumor, even decades after diagnosis. Managementshould be individualised for each patient.     

Histology and clinical outcomes in patients with bilateral testicular germ cell tumors: the Memorial Sloan Kettering Cancer Center experience 1950 to 2001

PURPOSE: The optimal management of bilateral testicular tumors continues to evolve. We examined the incidence, characteristics, histology, treatment and clinical outcomes of patients with bilateral testicular cancer. MATERIALS AND METHODS: Between 1950 and 2001, 3,984 patients with testicular cancer were treated at our center. A total of 58 patients with bilateral testicular germ cell tumors were identified. The clinical records of these 58 patients were reviewed for age, histology of the 2 tumors, stage at presentation of the first and second tumor, interval between tumors, treatment and clinical outcome. Median followup was 60 months. RESULTS: Ten of the 58 patients (17%) had synchronous tumors, while the other 48 (83%) had metachronous tumors with a median interval between tumors of 50.5 months. Overall seminoma was the most common histology of the synchronous and metachronous tumors. Most patients in the synchronous and metachronous tumor groups presented with low stage disease. Of the 58 patients 52 (89%) had no evidence of disease and 6 (11%) were dead of disease at the last followup. Treatment of the second tumor appeared to be influenced by therapy for the first tumor in 16.7% of cases. CONCLUSIONS: Patients with a history of testicular germ cell tumor require careful long-term monitoring of the contralateral testicle due to the risk of bilateral disease and potentially long latent period between the first and second tumors. Overall the clinical outcome is good in these patients when they are treated appropriately for histology and stage. In patients with metachronous tumors treatment of the contralateral tumor is rarely altered by prior treatment of the initial tumor.     

Cisplatin-based chemotherapy changes the incidence of bilateral testicular cancer

Background: The introduction of cisplatin-based chemotherapy has remarkably increased the survival of testicular cancer patients. With this success, the concern for a contralateral testicular tumor has increased. The aim of this study was to investigate whether the risk for contralateral testicular tumor development was influenced by cisplatin-based chemotherapy. Methods: The incidence of a contralateral testicular tumor among 365 consecutive patients with a nonseminoma testicular tumor, diagnosed in the period 1980 and 1995, was established and related to previous therapy. Results: Eleven of 365 men (3%) developed a contralateral testicular tumor. After a total of 2403 person-years at risk, 4 of 225 chemotherapy-treated patients (1.8%) developed a contralateral testicular tumor, and 7 of 140 patients (5%) treated with orchidectomy alone developed a contralateral tumor. In comparison to this surveillance subgroup, patients previously treated with chemotherapy have a relative risk of 0.30 to develop a second testicular tumor. Conclusions: In Dutch men with a nonseminoma testicular tumor, the incidence of a contralateral testicular tumor is 3%, which is 60-fold the expected incidence rate of testicular cancer. A three times lower incidence rate of a contralateral testicular tumor was found in the chemotherapy subgroup compared with those on surveillance. This supports the hypothesis that cisplatin-based chemotherapy may eradicate carcinoma in situ or early testicular cancer.Presented at the 49th Annual Cancer Symposium of The Society of Surgical Oncology, Atlanta, Georgia, March 21–24, 1996.     

Recurrent lupus nephritis in renal transplant recipients revisited: it is not rare

BACKGROUND: Although recurrent lupus nephritis (RLN) after kidney transplantation is reported to be rare (1%-4%), recent studies suggest a higher incidence. The purpose of this study was to determine the incidence of RLN in a large cohort of renal transplant recipients with systemic lupus erythematosus (SLE). METHODS: The records of 54 renal transplant recipients with SLE were reviewed. Thirty-one patients underwent biopsy because of worsening renal function and proteinuria. All biopsy specimens were evaluated by light microscopy, immunofluorescence (IF), and electron microscopy (EM). RESULTS: Among the 50 patients with at least 3 months of follow-up, RLN was present in 15 (52% of patients who underwent biopsy, 30% of total patients): mesangial lupus nephritis (LN) (class II) in eight, focal proliferative LN (class III) in four, and membranous LN (class Vb) in three patients. One patient had graft loss because of RLN (class II) at 10.5 years. The duration of dialysis before transplantation was not different between patients with RLN compared to patients without RLN (P=0.40). Overall patient survival (n=50) was 96% at 1 year and 82% at 5 years, and graft survival was 87% at 1 year and 60% at 5 years. Graft survival was worse in patients who underwent biopsy compared with patients who never underwent biopsy (P<0.01). CONCLUSIONS: RLN is more common than previously reported, but in our series, graft loss because of RLN was rare. Aggressive use of allograft biopsies and morphologic evaluation with IF and EM are important factors in the diagnosis of RLN. The impact of new immunosuppressive agents on the incidence of RLN remains to be seen.     

Spermatogenesis in the contralateral testis of patients with testicular germ cell cancer: histological evaluation of testicular biopsies and a comparison with healthy males

OBJECTIVE: To assess histologically signs of testicular dysgenesis (TD) in the contralateral testes of patients with testicular germ cell tumours (GCTs) and to compare these findings with the spermatogenetic quality in healthy men, as the contralateral testis is considered to be involved with dysgenetic features such as poor sperm production, and accordingly, GCTs are hypothesized to be part of the 'TD syndrome' (TDS). One testicular biopsy is thought to represent spermatogenesis in the entire testis. We evaluated this view by using testicular two-site biopsies. PATIENTS AND METHODS: 2318 patients with testicular GCT had a contralateral testicular two-site biopsy. Testicular biopsies taken on forensic autopsy from 1388 presumably healthy men served as controls. Spermatogenesis was rated histologically according to a modified Johnsen score. Clinical factors were recorded to explore associations with reduced spermatogenesis. Differences in spermatogenesis scoring results among two-site biopsies were noted. Statistical analysis involved Wilcoxon-Mann-Whitney and Jonckheere-Terpstra tests for comparing patients and controls, and for studying associations with clinical factors. Classification and regression-tree analysis was used to explore multivariate associations. RESULTS: Histologically, patients had significantly poorer spermatogenesis than healthy men. Clinically, hypospermatogenesis was significantly associated with testicular atrophy, undescended testes, male infertility, and advanced clinical stage; 5.4% of cases (95% confidence interval 4.43-6.27) had discordant findings of >2 points on double biopsy and 9.8% had differences of 1 point. Discordance was significantly associated with poor spermatogenesis and testicular atrophy. CONCLUSIONS: We confirmed histologically that there is markedly reduced spermatogenesis in the contralateral testes of patients with GCT. This result lends credence to the view that GCT is part of the so-called TDS. But as hypospermatogenesis is associated with advanced clinical stage, impairment of sperm production might at least partly be acquired secondary to the endocrine activity of GCT. There were clinically relevant discordant results on double biopsy in 5.4%, predominantly in infertile patients and in atrophic testes. Thus the histological evaluation of male infertility is best done by multiple biopsies.     

Unilateral or bilateral testicular biopsy in the era of intracytoplasmic sperm injection

PURPOSE: Intracytoplasmic sperm injection has significantly improved the treatment of male infertility. Since only single vital spermatozoa are required for successful fertilization, the value of unilateral or bilateral diagnostic testicular biopsies in patients with azoospermia is controversial. We evaluated differences in bilateral testicular biopsies in azoospermic patients with regard to testicular histology and focal spermatogenesis. MATERIALS AND METHODS: Histopathological results of 100 testicular biopsies from 50 patients (mean age 33.3 years) were reviewed. In all cases azoospermia was the indication for diagnostic testicular biopsy. Intra-individual differences of bilateral testicular biopsies were retrospectively reviewed by determining the latest stage of spermatogenesis. RESULTS: After bilateral biopsy a difference in testicular histology was found in 28% and identical histopathology was noted in 70% of patients. An unsuspected burned out seminoma with maturation arrest in the contralateral testis was seen in 2% of cases. Testicular symmetry determined by a Prader orchidometer was noted in 54.8% of patients whereas 45.2% had asymmetrical testis. The frequency of divergent histopathologies in relation to testicular symmetry was 21.7 and 26.3%, respectively. Spermatozoa were found in 42% of right and 44% of left testes (p >0.05), and spermatids as the latest stage of differentiation were detected in 14 and 16%, respectively (p >0.05). Differentiation of testicular histologies according to the side of biopsy revealed spermatozoa and/or spermatids in 56% of right and 58% of left testes (p >0.05). Bilateral biopsies increased the detection of focal spermatogenesis to 68%. If only unilateral diagnostic testicular biopsies had been performed, in 20% of patients focal spermatogenesis in the contralateral testis would have been missed. CONCLUSIONS: Bilateral testicular biopsies are superior to unilateral biopsies in the evaluation of patients with azoospermia. A 28% intra-individual difference in testicular pathology was seen after bilateral biopsies, and in 20% of patients focal spermatogenesis would have been missed after unilateral biopsy only. Due to the prognostic relevance of testicular biopsies for successful sperm retrieval before assisted reproduction, bilateral diagnostic testicular biopsies are recommended in the evaluation of patients with azoospermia.     

Diagnosis of contralateral testicular intraepithelial neoplasia (TIN) in patients with testicular germ cell cancer: systematic two-site biopsies are more sensitive than a single random biopsy

OBJECTIVES: Searching for testicular intraepithelial neoplasia (TIN; carcinoma in situ) in the contralateral testis of patients with germ cell tumour (GCT) may early disclose contralateral GCT. A single biopsy of the testis is thought to accurately detect TIN. Reports on false-negative biopsies have challenged this view. We investigated whether systematic two-site biopsies are more sensitive than single biopsies. We also studied the prevalence of contralateral TIN in a large patient sample. METHODS: A total of 2318 patients with testicular GCT underwent contralateral double biopsy. All of the biopsy pairs were examined histologically for spermatogenesis and for presence of TIN. Statistical analysis involved first, overall prevalence of contralateral TIN; second, associations of clinical factors with TIN; third, frequency of discordant findings regarding TIN among biopsy pairs; and finally, associations of discordance with clinical factors. RESULTS: A total of 119 patients (5.13%; 95% confidence interval [CI], 4.27-6.11) had contralateral TIN. TIN is associated with poor spermatogenesis (relative risk [RR] 15.74; 95%CI, 10.38-23.86) and with testicular atrophy (RR 3.78). According to TIN, 31.1% of biopsy pairs were discordant. Discordance was significantly less frequent in atrophic testes and in patients with poor spermatogenesis. CONCLUSIONS: We confirmed the prevalence of contralateral TIN to be about 5%. TIN is significantly associated with poor spermatogenesis and with testicular atrophy. The diagnostic extra yield imparted by double biopsies is 18%. Discordant results regarding TIN are predominantly encountered in normal-sized testicles. The new standard in diagnosing TIN is two-site biopsy.     

Sequential bilateral germ cell tumours of the testis

Bilateral germ cell tumours of the testis are rare but a rise in their incidence is expected since with the new therapeutic possibilities a significant improvement in prognosis has been achieved even in patients with advanced metastatic spread. Of the 210 patients treated for malignent germ cell tumours at our Department, six (2.9%) developed a contralateral testicular tumour. All patients had metachronous tumours and the second tumours occurred after an interval ranging between 1 and 22 years. The epidemiology, histology, diagnosis, therapy and prognosis are discussed, and the significance of regular self-examination of the remaining testis in patients with testicular tumour is emphasized.     

Incidence of bilateral testicular germ cell cancer in Denmark, 1960–84: preliminary findings

The incidence of a second primary testicular germ cell cancer in the contralateral testicle among 2338 men with a first primary testicular germ cell cancer diagnosed in the years 1960-79 in Denmark was established in this preliminary report. The material represents 83% of the total cohort followed until 31 December 1984. The relative risk for a patient with testicular cancer to get yet another testicular cancer was studied, taking into account the histology of the first primary testicular germ cell cancer. Based on fifty-eight nonsimultaneous contralateral testicular cancer cases and 19,995 'person-years at risk', the overall relative risk of invasive germ cell cancer in the contralateral testicle following a first germ cell testicular cancer was found to be 23.3 (95% confidence interval: 18-30). Among men with nonseminoma the risk was higher (relative risk = 27.5) than among men with seminomas (relative risk = 20.1). Overall, sixty-two (2.7%) patients developed a second cancer. In four of these patients bilateral tumours occurred simultaneously.     

Re-exploration of the acute scrotum

OBJECTIVE: To investigate children and adolescents who had scrotal exploration more than once. PATIENTS AND METHODS: Between 1994 and 2004, 64 of 840 (7.6%) boys had more than one scrotal exploration at our institution. The age, laterality of the explorations, the interval between and findings at operation, whether the testes were managed by orchidopexy and how, and the complications, were reviewed from the medical records and the operating reports of the patients. All the boys were followed at the outpatient clinic 2-4 weeks after surgery. RESULTS: The median (range) age of the patients was 11.5 (2-15) years; 61 had two scrotal explorations and three were explored three times. Of the patients, 32 presented with right testicular pain, 31 had left pain, and one had bilateral testicular pain. In the second exploration, 56 of 64 had the contralateral testis explored, five had an ipsilateral exploration and three had bilateral exploration. Forty-eight of the 64 boys (70%) had torsion of the contralateral appendix testis at the second exploration, and 5.3% (45/840) of the total number of children operated for acute scrotum had metachronous torsion of the appendix testis. The median interval between the first and second exploration was 8 months (1 day to 10.5 years). Two boys had three scrotal explorations, and three of 64 (4.7%) boys developed complications that required re-exploration. CONCLUSIONS: Most indications for recurrent scrotal exploration in this study are because of a twisted contralateral appendix testis, but the risk of developing this pathology is similar to the complication rate of repeat scrotal exploration. These data support our policy that the contralateral testis should not be routinely explored nor its appendix removed unless there is ipsilateral testicular torsion.     

Laparoscopic exploration for the clinically undetected hernia in infancy and childhood

BACKGROUND: Routine contralateral groin exploration in infants and children with a clinically detected inguinal hernia is the subject of much debate. The detection of a patent processus vaginalis by transinguinal laparoscopy has proven advantageous. However, controversy remains regarding the true incidence of a contralateral patent processus vaginalis as well as which of these will actually develop into a clinically apparent hernia. METHODS: From January 1997 through December 1999, 358 infants and children (aged 1 to 157 months, mean 32) were treated in the three University of Oklahoma teaching hospitals in Tulsa, Oklahoma, for inguinal hernia. The findings at laparoscopic exploration of the contralateral side were recorded to determine the incidence of contralateral patency as it relates to a child's age, gender, and side of the initial clinical diagnosis. RESULTS: The overall incidence of a patent processus vaginalis on contralateral examination was 33% (117 of 358). All patent processus vaginalis were repaired. Bilateral inguinal hernia was significantly more common in younger patients (present in 50% if less than 1 year, 45% if less than 2 years, 37% if less than 5 years, and 15% if greater than 5 years of age; P <0.05). In boys, the incidence was 49%, 45%, and 32% in those under 1 year of age, under 2 years of age, and in total, respectively. In girls, the incidence was 59%, 50%, and 37% in those under 1 year of age, under 2 years of age, and in total, respectively. The side of the clinically detected hernia did not influence the laparoscopic findings of a contralateral hernia with 30% (50 of 169) positive findings on left inguinal exploration versus 31% (28 of 90) positive findings on right inguinal exploration. CONCLUSIONS: The high incidence of a contralateral patent processus vaginalis warrants routine laparoscopic exploration in infants and children undergoing unilateral inguinal hernia repair, especially those less than 5 years of age. The use of transinguinal laparoscopic explorations avoids unnecessary open exploration in 66% of infants and children undergoing inguinal hernia repair.     

Unilateral torsion of spermatic cord in men: effect on Leydig cell

In our previous studies, we reported that short-term unilateral spermatic cord torsion had no adverse effect on the germ cells and the Sertoli cell in the contralateral testis of men. As an extension of our earlier investigations on the testicular pathophysiology in humans after unilateral spermatic cord torsion, the present study was undertaken to assess the Leydig cell function employing both fine structural and morphometric analysis in patients with short-term spermatic cord torsion. Bilateral testicular biopsy samples obtained from 4 men (15-19 years) with short-term unilateral torsion of the spermatic cord and from a control group of 6 men (15-40 years) were used in the present investigation. No appreciable difference in the Leydig morphology was noted between the biopsy samples from control and the contralateral testes. This was substantiated by morphometric analysis. The present study clearly indicates that patients with unilateral torsion of the spermatic cord may not essentially have bilateral testicular abnormalities, as suggested by the previous investigators. This report, thus lends further support to our earlier contention that alteration in microcirculation is quite likely the earliest and possibly the most significant contributor to the contralateral testicular damage in man after ipsilateral spermatic cord torsion.     

Bilateral testicular cancer: a preventable problem? Experience from a large cancer centre

OBJECTIVE: To report a retrospective review of patients with a testicular germ cell tumour treated in a large cancer centre who developed a second tumour, as 1.8-5% of such patients will subsequently develop a new primary tumour in the contralateral testis. PATIENTS AND METHODS: From a database of 570 men treated for testicular cancer in the West of Scotland between 1989 and 1998, all those who developed bilateral testicular tumours were identified. RESULTS: Nineteen men (3.3%) developed a second primary testicular malignancy; the mean age at diagnosis of the first tumour was 29.5 years, with the mean (range) interval to diagnosis of the second tumour of 76 (11-181) months (except for one man with synchronous tumours). The first tumour was teratoma in 11 and seminoma in seven; one patient had synchronous bilateral teratoma. The second primary was teratoma in 10 and seminoma in eight. Known risk factors for carcinoma in situ were present in nine patients, i.e. a small atrophic contralateral testis in five, a family history of testicular cancer in two, a history of infertility in two and unilateral undescended testis in one. Two patients had had contralateral testicular biopsies at the first diagnosis; both were negative for intratubular germ cell neoplasia (IGCN). Eight patients had chemotherapy to treat the first tumour and 14 for the second. All underwent bilateral orchidectomy. Overall, 18 of 19 men are alive and disease-free, with a median follow-up of 51 months. Pathology for 12 of the second testicular tumours was available for review; there was no IGCN in any of the slides from three patients, it was only present focally around the tumour in seven, and was diffuse in two patients. CONCLUSIONS: Chemotherapy for the first testicular tumour does not eliminate the risk of developing a contralateral tumour. Despite careful follow-up, in most patients the second primary tumour was not diagnosed early enough to avoid chemotherapy. The focal nature of IGCN in the second testis in most patients questions the value of biopsy of the contralateral testis. Improved methods of detecting patients at risk of second testicular tumours are needed.     

Clinical and pathological features associated with the testicular tumor of the adrenogenital syndrome

PURPOSE: Testicular tumor of the adrenogenital syndrome is a rare clinical entity found in young men with endocrine disorders. Histologically it resembles Leydig cell tumor. We 1) reviewed the clinical features of testicular tumor of the adrenogenital syndrome and 2) determined if special histopathological features of the tumor and synaptophysin reactivity could distinguish testicular tumor of the adrenogenital syndrome from Leydig cell tumor. MATERIALS AND METHODS: We reviewed the medical and pathological records for all patients with testicular tumor of the adrenogenital syndrome seen at our institution from 1978 to 2004. These tumors were examined by histological and immunophenotypic methods for comparison to Leydig cell tumor. RESULTS: A total of 14 males with an endocrine disorder had pathological evidence of testicular tumor of the adrenogenital syndrome. These tumors were often bilateral (93% or 13 of 14 cases), associated with pain (92% or 12 of 13) and refractory to medical management with high dose exogenous steroids (93% or 13 of 14). Testicular tumor of the adrenogenital syndrome was managed by tumor enucleation in 7 patients (54%) and by radical orchiectomy in 6 (46%). All patients had resolution of pain at 3-month followup. Upon histological review features found to be more common to testicular tumor of the adrenogenital syndrome compared with Leydig cell tumor were nuclear pleiomorphism, low mitotic activity, extensive fibrosis, lymphoid aggregates, adipose metaplasia and prominent lipochrome pigment. Synaptophysin (ICN, Costa Mesa, California) reactivity was strong in testicular tumor of the adrenogenital syndrome but rarely observed in Leydig cell tumor. CONCLUSIONS: In our series medical treatment failed in patients with testicular tumor of the adrenogenital syndrome and conservative surgical therapy was possible in select individuals. We identified special histopathological and immunophenotypic features, including synaptophysin staining, which distinguish testicular tumor of the adrenogenital syndrome from Leydig cell tumor.     

Management of nonpalpable incidental testicular masses

PURPOSE: We report on 4 patients who presented with nonpalpable testicular masses discovered on scrotal ultrasound, and offer treatment recommendations based on our experience and a review of the literature. MATERIALS AND METHODS: Four patients underwent intraoperative ultrasound guided localization and excisional biopsy of nonpalpable testicular parenchymal masses. Radical orchiectomy was performed in 2 patients because of testicular cancer. Patient age, clinical presentation, ultrasound results, frozen section and permanent pathology results are reported. RESULTS: During a 3-year period 1,040 scrotal ultrasounds were performed for indications other than retroperitoneal mass at a single institution, and nonpalpable testicular parenchymal masses were discovered in 4 patients with an age range of 22 to 31 years. Testis mass size ranged from 5 to 6 mm in maximum diameter and serum tumor markers were negative in all patients. Frozen section pathology indicated benign lesions in all patients and permanent pathology revealed seminoma in 2 of the patients who underwent delayed radical orchiectomy. Permanent pathology of orchiectomy specimens did not reveal residual invasive tumor. CONCLUSIONS: Intraoperative ultrasound guided localization and excisional biopsy is a reasonable treatment option for patients with nonpalpable incidental testicular masses. Excisional biopsy with margins that show normal testicular tissue is essential in testis sparing surgery and patients must be cautioned that final pathology may indicate the need for delayed radical orchiectomy.     

Sonography in the early detection of non-palpable second testicular tumors: a prospective study

As part of the tumor aftercare service afforded by our policlinic, 91 patients were examined one to six times in 18 months following radical orchiectomy for testicular germ cell tumors. The period of observation averaged 35 months (3-147) after the contralateral removal of the testicle. In addition to the usual routine checks, sonography of the residual testicle also formed part of the established followup protocol. Among these patients sonography identified in residual testicles 3 testicular tumors (3.3%) which had escaped detection on palpation. The existence of these second tumors was demonstrated 3, 25 and 38 months following contralateral orchiectomy. In all instances the second lesion differed from the first tumor in histology. In another patient a plum-sized malignancy was revealed within a large concurrent hydrocele by scrotal sonography carried out 18 months following preceding contralateral orchiectomy. Thus, our group of patients gave an incidence of 4.4% for second primary testicular tumors, a poor known incidence rate. Such malignancies can be spotted early by ultrasound, they are genetically obscure just as the increasing morbidity of the unilateral disease. These results urgently suggest that after semicastration for testicular germ cell tumor the residual testicles should be regularly scanned by ultrasonography at four-month intervals. Retrograde sonography has been shown to detect even those small occult testicular tumors which pass unnoticed until metastasizing.