Burn out bilateral testicular tumor

Differentiating a primary retroperitoneal seminoma from a metastatic testicular tumor with an occult testicular primary or a burned out testicular cancer remains difficult. We present a case of a burned out tumor. The patient had a retroperitoneal seminoma with ultrasonically and pathologically demonstrated abnormalities in both testes, but without evidence of tumor. The patient received chemotherapy and underwent surgery of the residual retroperitoneal mass and bilateral orchiectomy. All surgical specimens were negative for testis cancer. CONCLUSION: Primary extragonadal germ cell tumors in the retroperitoneum are a rare entity. The presence of a retroperitoneal tumor with ultrasonographical abnormalities in testicular evaluation should be considered as a metastases of a burned out testicular cancer, and biopsy is mandatory. Surgical evaluation and orchiectomy should be evaluated in a individual setting.     

Management of residual non-retroperitoneal disease following chemotherapy for germ cell tumor

Over the past 20 years, it is estimated that approximately 195,969 patients were diagnosed with testicular cancer in the United States and that 22,144 of those patients had non-retroperitoneal (non-RP) metastases at the time of diagnosis. Although most patients with testicular cancer can be cured with platinum-based systemic chemotherapy, 35% of patients with Stage III/IV disease will have residual non-RP masses after treatment. The management paradigms for residual, non-RP disease following chemotherapy for nonseminomatous germ cell tumor are influenced by the site of metastases as well as whether there is concordant histology between the testicle and the metastatic site. Although retroperitoneal lymph node dissection findings such as the presence of fibrosis only are helpful indicators of concordant histology, no set of criteria provides a perfect prediction such that the risk of residual teratoma or viable GCT outside the retroperitoneum is eliminated. This acknowledgement, in conjunction with the long-term survival data favoring resection, establishes that surgical resection remains an important part of the management of patients with non-RP residual masses.     

Improved Management of Abdominal Undescended Testicular Tumors with Bulky Confluent Retroperitoneal Nodal Metastases

Purpose

Germ cell tumors of the abdominal undescended testis associated with confluent bulky retroperitoneal metastases are challenging problems. We report the results of neoadjuvant cisplatin based chemotherapy after diagnosis of germ cell tumors by fine needle aspiration cytology of the abdominal testicular mass. After chemotherapy all patients underwent abdominal orchiectomy with retroperitoneal lymph node dissection for residual nonseminomatous germ cell tumors or radiotherapy for pure seminomas.

Materials and Methods

Between 1980 and 1991, 57 of 425 patients (13.4 percent) with germ cell tumors of the testicle had malignancy in an undescended testis, while 39 (68.4 percent) had tumor in an abdominal testis with confluent bulky metastasis. Metastatic evaluation included tumor marker studies, chest x-ray and computerized tomography of the abdomen. Among the tumors 29 (74.4 percent) were large volume seminomas (stages IIc, III and IV) and 10 (25.6 percent) were large volume nonseminomas. All 39 patients received 3 cycles of induction chemotherapy, and orchiectomy was deferred until its completion (14 received vinblastine, actinomycin D and bleomycin-6, and 25 received bleomycin, etoposide and cisplatin). After evaluation of response, the testis was excised. Overall followup was 2 to 12 years (median 4.6).

Results

Of 29 seminomas 14 (48.3 percent) showed a complete and 11 (37.9 percent) showed a partial response. The latter tumors were treated subsequently with radiotherapy. Four patients with progressive disease died, for an actuarial survival rate of 86 percent. Of the 10 patients with nonseminomatous germ cell tumor 2 (20 percent) had a complete response and 4 had a partial response. All patients with a partial response underwent retroperitoneal lymph node dissection. Overall, 4 patients with progression and 2 with a partial response died, for an actuarial survival rate of 39 percent. Of 39 post-chemotherapy orchiectomy specimens 24 (61.5 percent) showed viable tumor cells. Furthermore, 16 of 39 patients (41 percent) had additional ilioinguinal metastases requiring adjuvant radiotherapy or surgery.

Conclusions

Surgical removal of the primary tumor in an undescended testis with bulky metastasis is difficult. We believe that initial chemotherapy followed by 1-stage surgical removal of the primary and residual metastasis is a favorable option to improve compliance and decrease the incidence of loss to followup. Atypically altered ilioinguinal metastases may necessitate a change in radiotherapy ports and/or retroperitoneal lymph node dissection boundaries.The significantly poorer survival with nonseminomatous germ cell tumor could be due to the fact that 50 percent of the lesions were stage IV at presentation. However, multivariate analysis showed only tumor histology to be the significant parameter and not initial stage at presentation.     

Orchiectomy in advanced germ cell cancer following intensive chemotherapy: a comparison of systemic to testicular response

A total of 16 patients with advanced germ cell cancer underwent initial chemotherapy that was followed by a delayed orchiectomy for an unrecognized primary in 3 and for life-threatening distant metastatic cancer in 13. Of these patients 13 had a complete and 3 had a partial remission at the time of the delayed orchiectomy. Of the former 13 patients 3 (23 per cent) had persistent viable tumor in the testis. To date all 3 patients have remained free of disease for more than 12, 20 and 30 months, respectively, without further therapy. One early relapse (1 month) was found in the remaining 10 patients with a complete remission and without viable disease in the testis. Of the 3 patients with a partial remission 1 had residual tumor in the testis and disease progressed despite further therapy. There was no evidence of tumor in the testis in the other 2 patients. These data document the presence of a differential response of germ cell tumors in the primary and metastatic sites. Post-chemotherapy orchiectomy for a suspicious primary tumor of the testis is necessary because of the risk of persistent primary disease. The post-chemotherapy pathological findings in the resected primary tumor do not reflect the systemic response.     

A case of late recurrence of germ cell tumor

A 19-year-old male was admitted to our hospital because of retroperitoneal tumor and metastases in the lung and liver. He underwent chemotherapy followed by retroperitoneal lymph node dissection and pathologic examination revealed mostly necrotic tissue with a small amount of teratomatous tissue. Two years later, a hyper echoic lesion was found in the left testis, and left high orchiectomy was performed. The resected specimen appeared to be a burned-out testicular tumor. Ten years later, CT scan detected lymph node swelling in the retroperitoneum, and excision of the tumor was performed. Pathologic examination revealed well-differentiated adenocarcinoma. Since no primary adenocarcinoma was found, this case was considered late relapse of a germ cell tumor.     

Resection of pulmonary metastases following chemotherapy for high stage testicular tumors

BACKGROUND: Our objective was to analyze retrospectively our experience with 19 patients who had metastatic germ cell testicular tumor and had undergone resection of pulmonary metastases following chemotherapy. We wished to determine the necessity of thoracic surgery on these patients. METHODS: Of 103 patients in need of postchemotherapeutic surgery for metastatic germ cell testicular tumors, 19 patients (mean age 31) underwent surgery for thoracic masses following cis-platin based chemotherapy. Resection of pulmonary metastases was performed on patients with normal tumor markers after chemotherapy, who did not achieve complete radiological remission. Histopathological findings, correlation with the pathology of abdominal surgery and probable prognostic factors for disease-free and overall survivals were evaluated. RESULTS: Disease-free and overall survival rates were 14/19 (73%) and 16/19 (84%), respectively, within a median follow-up time of 30 months (15-212 months). Patients with and without viable tumor cells in their thoracic histopathological specimen had 40% and 85% disease-free survival rates, respectively (P < 0.05). Eight patients had both abdominal and thoracic postchemotherapy surgery. Only two (25%) of these patients had the same histopathological features at both sites. CONCLUSIONS: All patients with residual thoracic masses must be considered candidates for surgery, because there are no predictive factors to determine the thoracic pathology without surgery. With the resection of the pulmonary metastases only, surgery can be performed without significant morbidity and is essential to select patients for further chemotherapy, to remove all visible masses and to provide histopathological confirmation. Patients with viable tumor cells in the thoracic surgical specimen have a poor prognosis.     

Testis sparing surgery for the treatment of a sequential bilateral testicular germ cell tumor

Standard therapy of sequential bilateral testis cancer is generally considered to be orchiectomy. We present a case of sequential bilateral testicular germ cell tumor treated with testis sparing surgery. The patient was disease free 50 months after surgery without local recurrence or distant metastases. Testis sparing surgery provides a better quality of life and may be considered a safe, feasible alternative in the treatment of carefully selected patients with bilateral testicular germ cell tumor.     

Acute pericarditis as a result of unusual metastasis of the visceral pleura in a patient with testicular seminoma

A 30-year-old man with a left testicular swelling was referred to our hospital. We performed a left high orchiectomy based on a diagnosis of clinical stage II testicular cancer. Pathological specimens of the left testis showed seminoma. The patient underwent three courses of combined chemotherapy. The retroperitoneal lymph nodes were dissected and there were no viable cancer cells. Twelve years later a right testicular tumor was discovered. The patient underwent a right high orchiectomy. Pathological specimens of the testis showed seminoma, and the patient was treated with prophylactic irradiation. One year after discharge a metastasis was found at a left supraclavicular fossa. The patient was treated with combined chemotherapy and irradiation. Six months after the treatment he complained of dyspnea. We diagnosed the condition as pleuritis carcimatosa. Two days after irradiation to the left thorax the patient suffered a sudden and fatal cardiac arrest. Autopsy survey revealed pericarditis as a result of a direct invasion of visceral pleural metastasis.     

Xanthogranulomatous orchitis in an adult Nigerian

Xanthogranulomatous orchitis (XGO) is a rare benign disease of the testis which has not been previously documented in tropical Africa. We report a case of a 24-year-old Nigerian man who presented with a painless left hemiscrotal swelling. Our clinical diagnosis was left testicular cancer. Testicular tumor markers were normal. At surgical exploration, we found a left testicular tumor. Histopathological examination of the specimen showed XGO of the left testis. He had left radical orchiectomy and left inguinal node dissection. He has remained stable 8 months after the treatment. Xanthogranulomatous orchitis cannot be distinguished clinically from testicular cancer unless by histopathological examination. Orchiectomy is the treatment of choice. However, in all patients and particularly young patients and those with a single testis, histopathological confirmation is suggested to avoid unnecessary radical orchiectomy, useless irradiation and ill-timed chemotherapy.     

A case of synchronous cervical lymph node metastases from testicular and thyroid cancers showing mixed response to chemotherapy

We report a case of synchronous presentation of thyroid cancer and testicular seminoma with lymph node metastasis. A 37-year-old man presented with right scrotal swelling and multiple lymph node swelling. We performed right radical orchiectomy, and histological examination revealed a seminoma of the testis. After systemic work-up for staging, we diagnosed the patient with multiple lymph node metastasis of the seminoma, and administered three cycles of bleomycin, etoposide, and cisplatin (BEP) therapy. Although the chemotherapy was very effective for the retroperitoneal and left cervical lymph node metastases, the right cervical tumor did not change. Retroperitoneal lymphadenectomy combined with right cervical lymph node dissection and hemi-thyroidectomy were performed on September 8, 1998. Pathological examination of the thyroid revealed papillary thyroid cancer and its right cervical lymph node metastasis. There was no evidence of viable cancer cells from either of the primary cancers in the retroperitoneal lymph node. Unresponsiveness to chemotherapy for metastatic lesions from testicular cancer might be a useful clue to detect primary tumors of other origins.     

Case report of malignant sertoli cell tumor

Malignant sertoli cell tumor is a rare disease and only a few cases have been described previously. We report a terminal case of malignant sertoli cell tumor. A 38-year-old male visited a hospital with a complaint of swelling his left testis. He underwent high left orchiectomy. His pathologic diagnosis was suspected seminoma, and all tumor markers (LDH, HCG, AFP) were negative, and CT imaging confirmed clinical stage 1 (pT1N0M0S0). One year later, a CT scan showed a small retroperitoneum lymph node swelling. Four months later, these lesions increased to 55 x 45 x 70 mm in diameter. He received 3 courses of chemotherapy with BEP (bleomycine, etoposide, cisplatin), but, lymph node size did not change. After he underwent a CT guided lymph node biopsy, his pathologic diagnosis was viable embryonal carcinoma. He then came to our hospital. We selected CPT-11 and nedaplatin for his salvage chemotherapy, but lymph node lesions did not change. After he received 3 courses of chemotherapy, we performed retroperitoneal lymphadenectomy. His pathologic diagnosis was viable sertoli cell tumor, malignant type. After 30 days, he had multiple liver metastases ane died 27 months after orchiectomy. All tumor markers were negative in his all clinical courses.     

Burned-out testicular tumor: a case report

A 29-year-old man was referred to our hospital with loss of appetite and a left lower abdominal mass. A small nodule was palpable in his left testis and ultrasonographic examination demonstrated that the nodule was low echoic. Computed tomography showed a large mass in his left retroperitoneal space. We thought the mass was a metastatic lesion from a testicular tumor. Left orchiectomy was done and microscopic examination revealed no viable tumor cells. Only fibrous tissue, small calcified areas, and hyaline bodies were found. As tumor markers were normalized after 3 courses of chemotherapy with bleomycin, etoposide, and cisplatine, the retroperitoneal mass was removed with the left kidney. It consisted of embryonal carcinoma, mature teratoma, and yolk sac tumor. One course of adjuvant chemotherapy was done and the patient has since been free from recurrence. We suppose that the tumor was a so-called 'burned-out' testicular tumor.     

Intra-arterial infusion chemotherapy for liver metastases of testicular tumors: report of two cases

Two cases of testicular tumors with lymph node involvement and multiple lung and liver metastases were treated successfully with intra-arterial infusion chemotherapy. Case 1: A 30-year-old man presented with right scrotal swelling and an abdominal mass. He had a large retroperitoneal mass and multiple lung and liver metastases on computed tomographic (CT) scan and chest X-ray. Right inguinal orchiectomy was performed. Histopathological diagnosis revealed embryonal cell carcinoma and choriocarcinoma. Cisplatin, vinblastine, VP-16 and pepleomycin combination chemotherapy (PVeBV) was started and repeated for 2 courses. The retroperitoneal mass and lung tumors decreased in size, but liver tumors enlarged. Systemic and intrahepatic arterial infusion combined with chemotherapy was administered, and intra-arterial chemotherapy (cisplatin, VP-16) was added. The patient also received systemic chemotherapy (carboplatin, VP-16, ifosfamide). After chemotherapy, retroperitoneal lymph node dissection was performed. Microscopic examination revealed no viable cancer cells. On CT scan, no retroperitoneal, liver, or lung tumor was detected. Case 2: A 43-year-old man presented with right scrotal swelling and an abdominal mass. CT scan revealed a large retroperitoneal mass as well as lung and multiple liver metastases. Right inguinal orchiectomy was performed. Histopathological diagnosis revealed seminoma. Cisplatin, vinblastine, VP-16 and pepleomycin combination chemotherapy (PVeBV) was administered, but the liver tumors ware enlarged on CT scan. Intrahepatic arterial infusion chemotherapy (cisplatin, VP-16) was started and repeated for 4 courses. On CT scan, the lung metastasis seemed to have disappeared, and the retroperitoneal mass and liver metastases were decreased in size.     

Simultaneous bilateral testicular tumors with different cell types: a case report

A 22-year-old man presented to our out-patient clinic with the chief complaint of a painless mass in the right scrotum and lymph node swelling around the abdominal aorta in October, 2002. The bilateral testicular tumors were palpated and visualized by ultrasound and magnetic resonance imaging (right phi5 cm, left phi2 cm in diameter). Computed tomography revealed a metastatic lymph node around the abdominal aorta (3 x 3 x 10 cm in size). He underwent bilateral radical orchiectomy after frozen storage. Enucleation of the left testicular tumor was not performed because of its irregular demarcation. Histological examination revealed typical seminoma of the right testis and embryonal carcinoma of the left testis. Retroperitoneal lymph node dissection was performed after 4 courses of systematic chemotherapy (bleomycin, etoposide, platinum). No viable tumor cells were present histologically in the excised lymph nodes. The postoperative course was good and uneventful at 16 months under androgen replacement therapy without disease recurrence.     

Testis-sparing surgery in an adult with bilateral synchronous seminomatous tumor

Bilateral synchronous testicular cancer is a rare occurrence and is usually associated with similar histological findings in each testicle. The standard therapy of bilateral testis cancer is generally considered to be orchiectomy. We present a case of synchronous bilateral testicular germ cell tumor treated with testis-sparing surgery. The patient was disease free for 30 months after surgery without local recurrence or distant metastases. Testis-sparing surgery provides a better quality of life and may be considered a safe, feasible alternative in the treatment of carefully selected patients with bilateral testicular germ cell tumor.     

Long-term followup results of 1 cycle of adjuvant bleomycin, etoposide, and cisplatin chemotherapy for high risk clinical Stage I nonseminomatous germ cell tumors of the testis Westermann DH, Schefer H, Thalmann GN, Karamitopoulou-Diamantis E, Fey MF, Studer UE, Department of Urology, University of Bern, Bern, Switzerland

PURPOSE: We evaluated the long-term outcome after 1 cycle of adjuvant modified bleomycin, etoposide, and cisplatin chemotherapy in patients who underwent orchiectomy for high risk clinical Stage I nonseminomatous germ cell tumor of the testis. MATERIALS AND METHODS: Between 1995 and 1999, a consecutive series of 44 patients underwent orchiectomy for clinical Stage I nonseminomatous germ cell tumor of the testis, followed by a single postoperative cycle of adjuvant modified bleomycin, etoposide, and cisplatin for vascular or lymphatic tumor invasion, and/or a predominance (50% or greater) of embryonal carcinoma. RESULTS: Four of the 44 patients were excluded from analysis. Of the patients, 35 had no evidence of disease at a median followup of 99 months (range 60-134). One patient with progression after 13 months showed complete remission after 3 cycles of salvage bleomycin, etoposide, and cisplatin chemotherapy but he died of pneumonia 4 weeks after the third course. Two patients underwent orchiectomy for contralateral testis cancer at 18 and 42 months, respectively, followed by an additional 3 cycles of adjuvant chemotherapy. They remained relapse-free for 4 and 92 months, respectively. The former patient was lost to follow-up after 4 months. Two other patients were disease-free at 10 and 31 months, respectively, and were lost to follow-up thereafter. Late side effects were tinnitus in 3 patients and involuntary childlessness in 3, of whom 2 had cryptorchidism of the contralateral testis. Nine patients fathered children. CONCLUSIONS: One cycle of bleomycin, etoposide, and cisplatin effectively decreases the risk of relapse in patients with high risk Stage I nonseminomatous germ cell tumor of the testis. It has minimal side effects and can be a valuable alternative to retroperitoneal lymph node dissection.     

Testicular metastasis from squamous cell carcinoma of the lung

We present a case of squamous cell carcinoma of the testis that metastasized from lung cancer. The patient, who had received left pneumonectomy 2 years earlier for squamous cell carcinoma (SCC) of the lung, developed pulmonary metastasis, which was treated with chemotherapy. Although the recurrence regressed after treatment, the testicular tumor progressed gradually. Left radical orchiectomy was performed. Pathological examination revealed metastatic SCC. Testicular metastasis from lung cancer is a very rare disease.     

CLINICAL EXPERIENCE WITH YOLK SAC TUMORS AND TERATOMA IN CHILDREN

Between 1971 and 1993, 12 children with testicular germ cell tumors were treated at the Department of Urology, Faculty of Medicine, Kyoto University. Seven patients had yolk sac tumors and 5 had mature teratoma. Of the 7 patients with yolk sac tumors, 6 had stage I and 1 had stage III tumors. Initial management of the stage I tumors consisted of high orchiectomy in 5 patients and high orchiectomy plus retroperitoneal lymph node dissection in 1 patient. Of these 6 patients, 4 were cured by surgery alone but lung metastases developed in the other 2 patients. One of them was salvaged with thoracotomy and chemotherapy but the other died of tumor. The patient with stage III tumor had bulky tumor spread to lung and retroperitoneum, but seems to have been cured by chemotherapy followed by resection of the residual mass although follow-up is still inadequate (14 months). Six of the 7 patients (85.7%) are alive 13 months to 21 years after diagnosis. Five patients with mature teratoma were treated by high orchiectomy or, more recently, enucleation and all are alive 4 months to 22 years after surgery.     

Management of ultrasonically detected nonpalpable testis masses

As testicular ultrasound has evolved, nonpalpable masses have been detected for which an evaluation and treatment protocol has not been established. Our experience with nonpalpable testis masses detected only by ultrasound in 5 patients is presented, with all patients found to have nonmalignant lesions. We recommend that such cases with negative serum tumor markers and normal chest radiographs be followed with serial ultrasounds. Benign masses will resolve completely, while stable or enlarging masses can be locally excised and inguinal orchiectomy completed only if cancer is found by frozen section. A modified staging system to follow these patients is proposed to determine these patients' prognoses: Stage Ia for inguinally removed nonpalpable cancers, Stage Ib for excised nonpalpable cancers without orchiectomy (false-negative frozen section), and Stage Ic for inguinally removed palpable cancers.     

Role for retroperitoneal lymphadenectomy for testis cancer

There continue to be several controversies surrounding the role for retroperitoneal lymphadenectomy (RPL) in the management of patients with germ cell cancer of the testis. The initial treatment options for those with clinical stage I disease are surveillance (orchiectomy only), RPL or chemotherapy. Survival rates are similar with RPL and surveillance. Surgical morbidity has been reduced as techniques for RPL continue to improve. The likelihood of early or late (> 2 years) recurrence in the retroperitoneum is almost eliminated by RPL. Fewer follow-up computerized tomography scans of the abdomen are required and there are opportunities to reduce the duration and methods of follow-up, compared with surveillance. For patients with stage II disease, chemotherapy and RPL are equally effective initial treatment options but many patients require a combined approach. Initial RPL should be reserved for patients with smaller volume disease and possibly with lower preoperative marker levels. With RPL, patients are accurately staged and cured most of the time without double treatment. Approximately 30% of those with larger masses will have residual disease after initial chemotherapy and will require RPL as a second treatment. The third indication for RPL is to excise residual retroperitoneal masses following primary chemotherapy. Models to predict the presence of residual viable tumor, rather than necrosis only, at the time of surgery have been developed. If the orchiectomy specimen contained no teratoma, the tumor markers normalize after three or four courses of chemotherapy, and if the residual mass on computerized tomography scan is less than 2 cm in diameter, the rate of viable tumor may be low enough to omit RPL. In this way, the greater morbidity often associated with post-chemotherapy RPL may be avoided.