Clinical stage II seminoma: management options

INTRODUCTION

The management of clinical stage II seminoma has evolved with a recent emphasis on minimizing long-term morbidity while achieving oncologic cure.

METHODS

In this review we discuss the available management options for clinical stage II seminoma with an emphasis on the emerging role of surgery in this patient population.

RESULTS

Historically, treatment options available to clinical stage II seminoma patients were limited to radiotherapy and chemotherapy. Survival rates with these options are excellent; however, both are associated with significant long-term morbidities including cardiovascular, pulmonary, and neurologic toxicities. Additionally, higher rates of secondary malignancies are witnessed in this young patient population, decades after successful treatment of the primary cancer. Recently, retroperitoneal lymph node dissection has been proposed as a first-line treatment option for patients with low-volume metastatic seminoma.

CONCLUSION

The SEMS and PRIMETEST trials are two studies examining the role of primary retroperitoneal lymph node dissection in clinical stage II seminoma, and early data show significant promise.

Intraabdominal mass in adult men with unilateral UDT revealed as seminoma: A case report

Undescended testis is most common congenital malformation in boys. Most common location is inguinal canal but rarely it is found in intraabdominal. 10% of them will grow become mass if left untreated. This case report describes cases of men of 40s with unilateral UDT and not noticeable until they felt heavy and feel palpable mass in abdomen revealed as seminoma. He is sterile and not be able to reproduce. Chemotherapy was done and the response was remarkable. This case report reiterates the need for a scrotal examination in men presenting with an abdominal mass, so as to rule out an intra-abdominal seminoma.

Analysis of Genetic Alterations Related to DNA Methylation in Testicular Germ Cell Tumors Based on Data Mining

Embryonal carcinoma (EC) and seminoma (SE) are both derived from germ cell neoplasia in situ but show big differences in growth patterns and clinical prognosis. Epigenetic regulation may play an important role in the development of EC and SE. This study investigated the DNA methylation-based genetic alterations between EC and SE by analyzing the datasets of mRNA expression and DNA methylation profiling. The datasets were downloaded from the Gene Expression Omnibus database. The differentially expressed genes (DEGs) were identified between EC and SE by limma package in R environment. Gene function enrichment analysis of the DEGs was performed on the DAVID tool, the results of which suggested differences in capability of pluripotency and genomic stability between EC and SE. The minfi package and wANNOVAR tool were used to identify differentially methylated genes. A total of 37 genes were discovered with both mRNA expression and the accordant DNA methylation changes. The findings were verified by the sequencing data from The Cancer Genome Atlas database, and Kaplan-Meier survival analysis was performed. Finally, 5 genes (PRDM1, LMO2, FAM53B, HCN4, and FAM124B) were found that showed both low expression and high methylation in EC, and were significantly associated with relapse-free survival. The findings of methylation-based genetic features between EC and SE might be helpful in studying the role of DNA methylation in cancer development.

Tumor markers and 18F-FDG PET/CT after orchiectomy in seminoma: Is there any correlation?

OBJECTIVE

The aim of our study was to analyze the potential relationship between tumor markers and ¹⁸F-fluorodoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) results in patients affected by seminoma.

MATERIAL AND METHODS

65 ¹⁸F-FDG PET/CT scans of 41 patients with diagnosis of seminoma were analyzed and compared to alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG). PET/CT studies were analyzed qualitatively and measuring the maximum and mean standardized uptake value body weight max (SUVbwmax, SUVbwmean), maximum SUV lean body mass (SUVlbm), maximum SUV body surface area (SUVbsa), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) of hypermetabolic lesions. All values were compared with serum markers.

RESULTS

31 PET/CT studies were true negative, 28 true positive, 6 false positive and 0 false negative with sensitivity of 100%, specificity of 84%, negative predictive value of 100%, positive predictive value of 82% and accuracy of 91%. No correlation between PET results and tumor marker levels was found and also between AFP and PET/CT semiquantitive parameters. All semiquantitative PET parameters were significantly related to hCG level.

CONCLUSIONS

¹⁸F-FDG PET/CT has good accuracy in evaluating patients with relapsed seminoma. HCG levels were significantly correlated with metabolic PET/CT parameters.

Primary mediastinal seminoma with florid follicular lymphoid hyperplasia: a case report and review of the literature

BACKGROUND

First described in 1955 Primary mediastinal seminomas are rare. Only 1-4% of mediastinal tumours are germ cell tumors; majority of which are teratomas. They typically present in men aged between 20 and 40 years. Very few cases are reported in the literature. Florid follicular lymphoid hyperplasia can obscure the malignant cells and is a rarer finding still. We present a rare case of a 48 year old man with a primary mediastinal seminoma with florid follicular lymphoid hyperplasia; found following excision of a clinically presumed thymoma.

CASE PRESENTATION

A 48 year old man was referred for excision of a thymic mass. The presumed diagnosis was a thymoma; following preoperative investigations. The mass was incidentally found on a radiological imaging. However, the patient did report mid-sternal discomfort on lying flat and breathlessness. The patient underwent a thymectomy via a partial median sternotomy with good recovery. Histological assessment was that the mass was in fact a primary mediastinal seminoma with florid follicular lymphoid hyperplasia. A primary testicular malignancy was excluded and the patient required no further oncological treatment.

CONCLUSIONS

Only 11 cases have previously been reported of primary mediastinal seminoma with florid follicular lymphoid hyperplasia. Although rare, a primary mediastinal seminoma should be considered as a differential diagnosis for presentations with a thymic mass. Tumour markers can be helpful, however are only positive in third of cases. Ultrasound imaging of the gonads is essential to exclude a primary gonadal lesion. Pure seminomas are radiotherapy and chemotherapy sensitive however the mainstay treatment of primary mediastinal seminomas remains surgical excision. Radiotherapy is reserved postoperatively for incomplete surgical margins.

When is a seminoma not a seminoma? The incidence, risk factors and management of patients with testicular seminoma with discordant elevated serum alpha-fetoprotein

OBJECTIVE

To describe the incidence, clinical and demographic factors, and treatment patterns associated with discordant elevated AFP findings in patients with pure seminomatous histology.

METHODS

We queried the National Cancer Database to identify patients with testicular GCT diagnosed in 2011-2015. Patients were grouped based on histologic diagnosis and pre-operative serum AFP level.

RESULTS

Of 18,616 patients diagnosed with testicular GCT, 53% (N=9,849) had pure seminomatous histology, of whom 8.3% (N=821) had an elevated serum AFP pre-operatively. Non-white patients with seminoma were more likely to have a pre-op elevated AFP (OR 1.42; 95% CI: 1.10-1.83); patients treated at higher volume centers were less likely to have a pre-op elevated AFP (0.66, 95% CI: 0.53-0.83). Patients with seminoma with elevated AFP received adjuvant radiation more frequently than those with NSGCT (Stage I: 15% vs 0.2%, p < 0.01; Stage II: 21.9% vs 0.1%, p <0.01) and less frequently underwent retroperitoneal lymph node dissection (RPLND) (Stage 1: 1.9% vs 11.1% p <0.01; Stage II: 8.8% vs 17.4%, p <0.01).

CONCLUSION

The detection of elevated serum alpha-fetoprotein (AFP) in patients with pure seminomatous testicular germ cell tumors (GCT) is a discordant finding that implies the presence of occult non-seminomatous GCT (NSGCT) elements. 8% of patients with pure seminomatous GCTs had diagnostically discordant elevated pre-operative AFP levels. Despite recommendations to manage these patients as NSGCT, patients with seminoma and elevated AFP were managed in a fashion comparable to those with seminoma and normal AFP levels.

Gene expression microarray analysis of adult testicular germ cell tumor: a comparison between pure-type seminomas and seminoma components in mixed tumors

We previously demonstrated a genetic evidence of the progression from seminoma to embryonal carcinoma in mixed testicular germ cell tumors (TGCTs). This process, the "reprogramming" of seminoma cells, is crucial for pathological tumorigenesis and should be kept in mind while designing clinical therapeutic strategies. We hypothesized that a comparison between pure-type seminomas and seminoma components in mixed tumors (mixed-type seminomas) could reveal early changes in the reprogramming process. In the present study, we performed gene expression microarray analysis of six pure-type and six mixed-type seminomas. Hierarchical clustering analysis properly grouped each type of seminomas into a separated cluster. Supervised analysis between pure-type and mixed-type seminomas revealed 154 significantly dysregulated genes (Storey-adjusted q < 0.05). The genes with the highest overexpression in mixed-type seminomas compared with the pure-type seminomas included MT1 isoforms, PRSS8, TSC22D1, and SLC39A4; downregulated genes included DEFB123, LMTK2, and MYRF. Functional annotation analysis of the differentially expressed genes revealed that the top-ranked functional categories were related to cellular zinc metabolism and consisted of MT1 isoforms and SLC39A4, the results of which were validated using quantitative polymerase chain reaction and immunohistochemical analysis. In conclusion, this research provides further evidence that pure and mixed types of seminomas are molecularly different, which may contribute to elucidate the reprogramming mechanism in the progression of TGCTs.

[non-metastasised clincial stage I testicular germ cell tumours : Patient information, suitability and limitations of surveillance]

BACKGROUND

Surveillance is the most frequently used treatment option in testicular germ cell tumour (TGCT) patients in nonmetastasised clinical stage I (cSI).

OBJECTIVES

Presentation of indications for surveillance, the process of individual patient's advice and the limitations of surveillance.

MATERIALS AND METHODS

An overview of the current literature is given, including basic research, systemic reviews and expert recommendations. Basic principles are illustrated by case reports.

RESULTS

The risk of progression for cSI TGCT patients under surveillance is 5-30% for seminomas and 15-50% for nonseminomas. Surveillance is the preferred treatment option in seminoma and low-risk nonseminoma without lymphovascular invasion. Patients should be informed concerning the individual risk of progression, the possibilities of adjuvant therapy, side effects of adjuvant therapy, the kind of therapy in case of progression and the cure rate. A high risk of progression, psychological issues and malcompliance are important limitations of surveillance.

CONCLUSION

By thoroughly considering the limitations of surveillance, cSI TGCT patients can be safely treated with surveillance.

Primary mediastinal germ cell tumours with high prevalence of somatic malignancy: An experience from a single tertiary care oncology centre

BACKGROUND

Primary mediastinal germ tumours (PMGCT) constitute, a mere 3-4% of all germ cell tumours (GCT). Although they account for approximately 16% of mediastinal tumours in adults and 19-25% in children as per western literature, there is hardly any large series on PMGCT reported from the Indian subcontinent.

DESIGN

We have retrospectively analysed clinicopathological features of 98 cases of PMGCT diagnosed over 10 years (2010-2019) from a tertiary-care oncology centre.

RESULTS

The study group (n = 98) comprised predominantly of males (n = 92) (M:F ratio-15:1), with an age range between 3 months to 57 years (median: 25 years). The tumours were predominantly located in the anterior mediastinum (n = 96). Broadly, Non-seminomatous germ cell tumours (NSGCT) were more common (n = 73, 74%) compared to pure seminoma (n = 25, 26%). Mixed NSGCT was the most common histological subtype (n = 30) followed by pure mature teratoma (n = 18), pure Yolk sac tumour (n = 13), mixed seminoma and NSGCT (n = 5), pure immature teratoma (n = 3) and GCT; NOS (n = 4). Interestingly, all female patients had exclusive teratomas. Nine cases revealed secondary somatic malignancy (5 carcinomas and 4 sarcomas). The majority of patients received neoadjuvant chemotherapy (n = 71). Surgical excision was performed in 60 patients. Follow up was available in 68 patients. NSGCT showed a poor prognosis as compared to seminoma (p value = 0.03) and tumours with somatic malignancies had a more aggressive clinical course.

CONCLUSION

PMGCT was seen predominantly in young adult males and somatic malignancies were noted in as high as 9% of cases. Patient with somatic malignancy have aggressive clinical course, hence, extensive sampling and careful histopathological evaluation are recommended for the identification and definitive characterization.

[Active surveillance for testicular tumors: adherence and safety.]

INTRODUCTION

The active surveillance (AS) of testicular tumors (seminoma and non-seminoma) is the most frequent management option in the stage I disease. Relapses generally occurred within the first 3 years and <5% appear after this time cut-off point is fulfilled. Therefore, the adherence is one of the most important pillars in the AS protocol. The aim of this study is to evaluate the adherence to the AS protocol in a community hospital and, in turn, evaluate the safety of it emphasizing in the relapse-free rate in patients with and without risk factors.

MATERIALS AND METHODS

A retrospective study of all the patients included in the AS protocol with seminoma tumors (ST) or non-seminoma tumors (NST) stage I was performed. Postoperative controls were performed according to the NCCN (National Comprehensive Cancer Network) recommendations. Different variables were taken into account, emphasizing in the risk factors: testicular tumor >4cm and the rete testis invasion in the ST, the linfovascular invasion and the percentage>40% of embrionary carcinoma in the NST. Adherence to the AS protocol was evaluated, focusing on those patients who lost it and what time it occurred.

RESULTS

A total of 64 patients were included. The median follow-up was 36 months (IC 21-48 months). 12 patients lost the follow-up during the protocol with a median follow-up of 27.5 months (IC 16-30 months). A 21.8% of patients entered in the AS protocol with some associated risk factor. Adherence follow-up was successful in the first year (96.8%) and decreased over time (92.2% at 24 months and 86.3% at 36 months).

CONCLUSION

We presented an important adherence to the AS protocol in patients with clinical stage I testicular cancer and in our series there no recurrences after 36 months of follow-up.

Outcomes and expanding indications for robotic retroperitoneal lymph node dissection for testicular cancer

Treatment of testicular cancer has made significant progress in the past decades in terms of reduction of treatment-associated morbidity and preventing over-treatment. At the forefront of this progression is utilization of the da Vinci robot to perform retroperitoneal lymph node dissections (RPLNDs) via a minimally invasive approach. The robot offers multiple potential advantages such as smaller incisions, improved 3D visualization, more precise dissection, and faster convalescence, leading to its increased usage the past several years. In this chapter, we summarize the recent progress made in robotic surgery for testicular cancer and its potential in the future. Promising preliminary data has also renewed interest in defining the role of primary RPLND in patients with seminoma, potentially sparing patients of the harmful long-term radiation and cisplatin-based chemotherapy. SEMS and PRIMETEST trials are ongoing trials that will provide significant insight into this area and potentially expand the role of robotic RPLND.

Semen quality from patients affected by seminomatous and non-seminomatous testicular tumor

Testicular cancer is considered a rare disease affecting approximately 1% to 2% of the male population. This neoplasm has a cure rate of over 95%; as a result, a major concern is the future of fertility of carriers from this disease. There are several histological subtypes of testicular tumors; however, the Testicular Germ Cell Tumors (TGCTs), comprising both seminoma and non-seminoma tumors, are considered the main subtypes of testicular neoplasms. TGCT are characterized by being a solid tumor that mostly affects young men aged between 15 and 40 years old. While TGCT subtypes may have an invasive potential, seminoma subtype does not affect other cells rather than germ cells, while non-seminomas have more invasive properties and can achieve somatic cells; thus, having a more aggressive nature. This research intends to review the literature regarding information about sperm parameters, correlating the data found in those studies to the subfertility and infertility of patients with TCGTs. Furthermore, it will also correlate the data to the non-seminoma and seminoma histological subtypes from pre- and post-cancer therapy. PubMed databases were used. Searched keywords included: seminoma AND non-seminoma; male infertility; germ cell tumor; chemotherapy AND radiotherapy. Only articles published in English were considered. Current studies demonstrate that both TGCT subtypes promote deleterious effects on semen quality resulting in decreased sperm concentration, declined sperm total motility and an increase in the morphology alterations. However, findings suggest that the non-seminoma subtype effects are more pronounced and deleterious. More studies will be necessary to clarify the behavior of seminoma and non-seminoma tumors implicating the reproductive health of male patients.

The m6A methyltransferase METTL3 regulates autophagy and sensitivity to cisplatin by targeting ATG5 in seminoma

Background

Our previous work shows Autophagy enhanced resistance to cisplatin in seminoma. The expression of the N6-methyladenosine (m6A) methyltransferases METTL3 was significantly increased in the cisplatin-resistant TCam-2 cell line of seminoma. We aimed to investigate the role of m6A methylation in autophagy and the chemosensitivity of seminoma cells.

Methods

Plasmid and siRNA were used to overexpress and knockdown METTL3. Autophagy was detected by western blot and immunofluorescence, respectively. The expression of downstream targets of METTL3 was detected by quantitative real-time PCR (qRT-PCR) and western blot, and the m6A level of them was detected by MeRIP-qPCR. Chemosensitivity of the TCam-2 cell line was identified through MTT assay.

Results

Upon METTL3 overexpression, autophagy of TCam-2 cell line was enhanced and its sensitivity to cisplatin was decreased. The use of autophagy inhibitors 3-methyladenine (3-MA) could reverse the protective effect of METTL3 on TCam-2 cells. We found that the up-regulation of METTL3 could increase the m6A modification level of ATG5 transcript, thus increased expression of ATG5. Moreover, knockdown of ATG5 reduced METTL3-induced autophagy, suggesting that ATG5 was a potential target for METTL3 to promote autophagy.

Conclusions

In summary, our research unveiled the unique mechanism by which m6A methylation regulates autophagy and chemosensitivity of the TCam-2 cell line and METTL3 was a potential target to overcome the cisplatin resistance of seminoma.

Testicular pure seminoma in a septuagenarian with a left-ventricular assist device

The left ventricular assist device (LVAD) is an implanted mechanical pump that supports circulatory function for patients with advanced heart failure. LVAD survival has continuously improved over the last decade with an increasing number of patients requiring non-cardiac surgeries. We discuss a 77-year-old, LVAD-dependent male with an enlarging, indurated right testicular mass. Radical inguinal orchiectomy confirmed pure seminoma. The case highlights perioperative considerations in this unique cohort of patients.

Germ Cell Tumor Cell Culture Techniques

Optimization of cell culture protocol for a given cell line is critical for the proper conduct of in vitro experiments. Because germ cell tumors can be so heterogeneous, optimal culture conditions can vary widely between cell lines. Here, we describe our experience in routine culture and cryopreservation of germ cell tumor cell culture. Additionally, methods for measuring cell viability and proliferation validated on these lines are provided.

Ruptured intra-abdominal testicular seminoma with hemorrhage shock, after inadequate surgical exploration for undescended testis: a case report

BACKGROUND

Undescended testes are associated with an increased risk of malignancy and infertility, and surgical treatment in childhood is recommended.

CASE PRESENTATION

A 35-year-old man presented to the emergency department with abdominal pain and vomiting. Despite a history of surgery for a left undescended testis in infancy, his left-sided scrotum appeared underdeveloped. Contrast-enhanced computed tomography showed a pelvic mass, involving a major axis of approximately 15 cm, with high-density ascites suggestive of hemorrhage. A ruptured gastrointestinal stromal tumor was suspected. As he was in hemorrhagic shock, an emergency laparotomy was indicated. The active bleeding mass was controlled through complete resection. A pathological evaluation of the mass revealed a seminoma arising from an undescended testis. His post-operative course was uneventful, and he was discharged on post-operative day 6. Recurrence on the retroperitoneal lymph nodes was detected 1 year postoperatively, and a retroperitoneal lymph node dissection was performed after chemotherapy. He remains well without any apparent signs of recurrence.

CONCLUSIONS

Paying close attention to an empty scrotum is advisable, even postoperatively, for undescended testis because of possible subsequent potential malignancy presenting with hemorrhage, as our patient demonstrated.

The prognostic significance of lactate dehydrogenase levels in seminoma patients with advanced disease: an analysis by the Global Germ Cell Tumor Collaborative Group (G3)

Purpose

The prognostic significance of lactate dehydrogenase (LDH) in patients with metastatic seminoma is not defined. We investigated the prognostic impact of LDH levels prior to first-line systemic treatment and other clinical characteristics in this subset of patients.

Methods

Files from two registry studies and one single-institution database were analyzed retrospectively. Uni- and multivariate analyses were conducted to identify patient characteristics associated with recurrence free survival (RFS), overall survival (OS), and complete response rate (CRR).

Results

The dataset included 351 metastatic seminoma patients with a median follow-up of 5.36 years. Five-year RFS, OS and CRR were 82%, 89% and 52%, respectively. Explorative analysis revealed a cut-off LDH level of < 2.5 upper limit of normal (ULN) (n = 228) vs. ≥ 2.5 ULN (n = 123) to be associated with a significant difference concerning OS associated with 5-years OS rates of 93% vs. 83% (p = 0.001) which was confirmed in multivariate analysis (HR 2.87; p = 0.004). Furthermore, the cut-off LDH < 2.5 ULN vs. ≥ 2.5 ULN correlated with RFS and CRR associated with a 5-years RFS rate and CRR of 76% vs. 86% (p = 0.012) and 32% vs. 59% (p  ≤  0.001), respectively.

Conclusions

LDH levels correlate with treatment response and survival in metastatic seminoma patients and should be considered for their prognostic stratification.

Tumor markers and18F-FDG PET/CT after orchiectomy in seminoma:Is there any correlation?

OBJECTIVE

The aim of our study was to analyze the potential relationship between tumor markers and ¹⁸F-fluorodoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) results in patients affected by seminoma.

MATERIAL AND METHODS

65 ¹⁸F-FDG PET/CT scans of 41 patients with diagnosis of seminoma were analyzed and compared to alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG). PET/CT studies were analyzed qualitatively and measuring the maximum and mean standardized uptake value body weight max (SUV_bwmax, SUV_bwmean), maximum SUV lean body mass (SUV_lbm), maximum SUV body surface area (SUV_bsa), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) of hypermetabolic lesions. All values were compared with serum markers.

RESULTS

31 PET/CT studies were true negative, 28 true positive, 6 false positive and 0 false negative with sensitivity of 100%, specificity of 84%, negative predictive value of 100%, positive predictive value of 82% and accuracy of 91%. No correlation between PET results and tumor marker levels was found and also between AFP and PET/CT semiquantitive parameters. All semiquantitative PET parameters were significantly related to hCG level.

CONCLUSIONS

¹⁸F-FDG PET/CT has good accuracy in evaluating patients with relapsed seminoma. hCG levels were significantly correlated with metabolic PET/CT parameters.

Mismatch repair deficiency occurs very rarely in seminomas

Background

Dense tumor-associated lymphocyte infiltration is linked to mismatch repair (MMR) deficiency in colorectal and endometrial cancer. MMR deficiency is of high clinical importance as MMR deficient cancers tend to react favorably to treatment with immune checkpoint inhibitors. Strong lymphocytic infiltration is a morphological hallmark of seminomas. We thus asked whether seminomas may exhibit MMR deficiency at relevant frequency.

Methods

To screen for tumors with MMR deficiency, protein expression of MLH1, PMS2, MSH2, and MSH6 was analyzed by immunohistochemistry (IHC) on a tissue microarray (TMA) containing 574 seminomas.

Results

In total, 536 cases were evaluable resulting in 481 seminomas with unequivocally intact MMR protein expression. In 55 cancers, one or several IHC stains were equivocal and lacked detectable MMR protein in both tumor and stromal cells. Large section IHC analysis of all 55 equivocal cases demonstrated substantial staining issues due to improper fixation in 54 cases and identified one tumor with clear-cut MLH1 and PMS2 protein loss. This seminoma showed homogeneous loss of MLH1 and PMS2 in the entire tumor mass whereas minor adjacent foci of associated germ cell neoplasia in situ (GCNIS) were MMR intact. Polymerase chain reaction (PCR) analysis using the 5 microsatellite loci of the “Bethesda Panel” revealed instability in 1 of 4 interpretable loci (“MSI-low”) and additional instability of the complex tetra-penta repeat locus MYCL1 in this tumor.

Conclusions

In summary, one single seminoma with MMR deficiency, characterized by protein loss of MLH1 and PMS2, was identified among 536 interpretable seminomas (0.19%). MMR deficiency is not a relevant determinant of lymphocyte influx in seminoma.

Unenhanced MRI of the abdomen and pelvis for surveillance of patients with stage 1 testicular cancer post-radical orchiectomy

OBJECTIVE

To evaluate the ability of unenhanced magnetic resonance imaging (MRI) to detect metastatic lymphadenopathy in men with stage 1 testicular cancer on surveillance.

MATERIALS AND METHODS

With IRB approval, we identified 23 consecutive men with stage 1 testicular cancer (diagnosed after orchiectomy) undergoing surveillance with unenhanced MRI of the abdomen and pelvis. Three blinded radiologists (2 inexperienced R1/R2 and 1 experienced R3) independently assessed MRI for: presence, location and size of abnormal lymph nodes and degree of confidence (5-point Likert scale) in diagnosis. Diagnostic accuracy was tabulated and compared between groups using ROC. Inter-observer agreement was assessed using Cohen's kappa statistic.

RESULTS

17.4% (4/23) men developed 6 metastatic lymph nodes (reference standard: interval development from baseline, size > 1.0 cm short axis). R1 and R2 detected 75% (3/4) patients with abnormal lymph nodes, compared to R3 who detected all four cases. False positive interpretations occurred in: 5.2% (1/19) R1, 10.5% (2/19) R2 and no patients for R3. Sensitivity, specificity and area under the ROC curve (AUC) were: R1: 75% (95% CI 19.4-99.4%), 94.7% (74.0-99.9%) and 0.85 (0.59-1.00), R2: 75% (19.4-99.4%), 89.5% (66.9-98.7%) and 0.82 (0.57-1.00) and, R3: 100% (95% 39.8-100.0%), 100% (82.4-100%) and 1.00 (1.00-1.00) with no difference in AUC between readers (p = 0.383). Comparison in accuracy between readers is limited due to the small sample size. Inter-observer agreement was substantial (K = 0.62). Median (range) degree of confidence scores were rated: R1 5 (5-5), R2 4 (3-5) and, R3 5 (5-5).

CONCLUSION

In this study, unenhanced MRI was adequate for surveillance of stage 1 testicular cancer; however, radiologist inexperience may lead to errors.

Contemporary trends in management of stage 1 seminoma

PURPOSE

Surveillance is now the preferred treatment strategy for patients with stage 1A/1B seminoma as reflected by the National Comprehensive Cancer Network guidelines. In this study, we aimed to describe trends in adjuvant management strategy for stage 1A/B seminoma from 2004 to 2016 using the National Cancer Database.

MATERIALS AND METHODS

The database was queried for patients diagnosed with stage 1A/1B seminoma between 2004 and 2016. Staging was determined using the American Joint Committee on Cancer guidelines. Surveillance was defined as no treatment with chemotherapy or radiation within 60 days of diagnosis. Proportions of cancer patients utilizing surveillance, radiation, and single-agent chemotherapy were summarized annually. Kaplan-Meier survival analysis was used to compare overall survival between groups.

RESULTS

8,686 patients with stage 1A/1B seminoma met inclusion criteria over the course of the study period. Overall, 3,004 (34.6%) patients began adjuvant chemotherapy or radiation within 60 days. Utilization of surveillance increased from 39.8% in 2004 to 86.8% in 2016 while utilization of radiation decreased from 59.7% to 4.6%. High-volume centers adopted surveillance earlier than low-volume centers.

CONCLUSION

This study describes trends in utilization of surveillance, chemotherapy, and radiotherapy for stage 1A/1B seminoma over 12 years. A major shift from utilization of adjuvant treatment to surveillance in patients with stage 1A/B seminoma is observed in this large national cancer database; a minority of patients now receive adjuvant treatment and risk-related toxicities. Survival analysis reveals similar survival at a median 5-year follow-up. The results provide insight into the time needed for clinical practice to adopt the preferred approach of surveillance over the time period studied.

Late testicular relapse two decades after primary extragonadal germ cell tumor with uncommon metastases: a case report

BACKGROUND

Extragonadal germ cell tumor (EGCT) is a relatively rare condition, reportedly representing 3-7% of all germ cell tumors. We report a patient who had metachronous testicular tumor with uncommon metastases 20 years after primary retroperitoneal EGCT treatment, along with a corresponding literature review.

CASE PRESENTATION

A 49-year-old Japanese man visited our department in November 2017 with chief complaints of indolent right scrotum enlargement and a right inguinal mass. History showed that the patient visited our department of gastroenterology with chief complaints of blackish feces and ill complexion in February 1997. Computed tomography (CT) showed a right retroperitoneal tumor, which was removed in the same month. Histopathological examination showed a teratoma and yolk sac tumor. He was diagnosed with primary retroperitoneal EGCT and received three courses of chemotherapy (bleomycin/etoposide/cisplatin; BEP). Periodic imaging and the determination of tumor markers (alpha-fetoprotein [AFP], human chorionic gonadotropin [HCG], and lactate dehydrogenase [LDH]) showed no recurrence or metastasis during the 5 years postoperatively. Subsequently, he did not visit the outpatient ward. In August 1999, he underwent surgery of right hydrocele. Contrast-enhanced CT showed a 35-mm contrast effect with uneven content in the right testicle and enlarged nodes that raised suspicion for metastases in the right inguinal and right external iliac lymph nodes. All tumor markers were within normal ranges. He underwent right high orchiectomy and resection of the right inguinal lymph nodes in the same month. Histopathological findings revealed seminoma (pT1, pN2, M0, S0, and TNM stage IIB). He received postoperative chemotherapy, one course of BEP therapy, and three courses of etoposide and cisplatin therapy. Post-chemotherapy CT confirmed a complete clinical response at the right external iliac lymph nodes, and this response continued 12 months later. No recurrence or metastasis has been found so far.

CONCLUSIONS

We report a patient in whom a testicular tumor with uncommon metastases occurred 20 years after primary retroperitoneal EGCT treatment. After EGCT treatment, testicular relapses tend to occur after relatively long-term follow-up. After EGCT treatment, such patients must be closely monitored for testicular recurrences and onset of testicular tumor.

What radiologists should know about microRNA (miRNA) serum biomarkers for germ cell tumors

MicroRNAs expressed by germ cell tumors represent a novel approach to detection of metastatic disease during staging, surveillance, and recurrence post-therapy. It has particular promise in settings of equivocal imaging, such as clinical stage I GCT, tumor marker negative stage IIA, or after chemotherapy. These miRNAs have the potential to change typical serum marker evaluation and imaging surveillance schedules.

Management of Germ Cell Tumours of the Testes in Adult Patients: German Clinical Practice Guideline, PART II - Recommendations for the Treatment of Advanced, Recurrent, and Refractory Disease and Extragonadal and Sex Cord/Stromal Tumours and for the Management of Follow-Up, Toxicity, Quality of Life, Palliative Care, and Supportive Therapy

OBJECTIVES

We developed the first German evidence- and consensus-based clinical guideline on diagnosis, treatment, and follow-up of germ cell tumours (GCT) of the testes in adult patients. We present the guideline content in 2 separate publications. The present second part summarizes therecommendations for the treatment of advanced disease stages and for the management of follow-up and late effects.

MATERIALS AND METHODS

An interdisciplinary panel of 42 experts including 1 patient representative developed the guideline content. Clinical recommendations and statements were based on scientific evidence and expert consensus. For this purpose, evidence tables for several review questions, which were based on systematic literature searches (last search in March 2018), were provided. Thirty-one experts, who were entitled to vote, rated the final clinical recommendations and statements.

RESULTS

Here we present the treatment recommendations separately for patients with metastatic seminoma and non-seminomatous GCT (stages IIA/B and IIC/III), for restaging and treatment of residual masses, and for relapsed and refractory disease stages. The recommendations also cover extragonadal and sex cord/stromal tumours, the management of follow-up and toxicity, quality-of-life aspects, palliative care, and supportive therapy.

CONCLUSION

Physicians and other medical service providers who are involved in the diagnostics, treatment, and follow-up of GCT (all stages, outpatient and inpatient care as well as rehabilitation) are the users of the present guideline. The guideline also comprises quality indicators for measuring the implementation of the guideline recommendations in routine clinical care; these data will be presented in a future publication.