Synchronous bilateral testicular germ cell tumors of different histologic type. Pathogenetic and practical implications of bilaterality in testicular germ cell tumors

Synchronous Bilateral Testicular Tumors With Discordant Histopathology: A Rare Case in an Infertile Male

Testicular cancer, accounting for 1-1.5% of male malignancies, rarely presents bilaterally, with only 2-3% of cases being bilateral and a mere 10% being synchronous, typically sharing histological patterns in both testes. Discordant histological presentation is exceedingly rare, with only a few reported cases. In this report, we detail a case involving a 35-year-old infertile male with bilateral synchronous testicular tumors, each exhibiting different histopathologies. This case highlights the diagnostic intricacies and the necessity for tailored management in the face of such uncommon presentations. The implications of oncological treatment and fertility preservation significantly affect the patient's overall quality of life.

Exceedingly Rare Bilateral Synchronous Germ Cell Testicular Tumors With Different Histopathological Features

Bilateral synchronous testicular tumors are a relatively uncommon occurrence, especially when they involve germ cell tumors of different histology. In this context, we present a compelling case report of a male patient who was diagnosed with bilateral synchronous germ cell testicular tumors, with one being a seminoma and the other a non-seminomatous germ cell tumor (NSGCT). The coexistence of two distinct histological types, seminoma and NSGCT, necessitates a comprehensive diagnostic approach to accurately identify and characterize each tumor. This underscores the importance of clinical history, physical examination, imaging techniques, and histopathological analysis to establish an appropriate diagnosis. Careful consideration must be given to factors such as tumor stage, histological subtype, and individual patient characteristics to determine the most suitable treatment strategy. Treatment options may encompass a combination of surgery, chemotherapy, and radiation therapy, tailored to each tumor's specific characteristics and the patient's overall health. By highlighting this unique case, we aim to underscore the significance of meticulous evaluation and accurate diagnosis when confronted with bilateral synchronous testicular tumors of different histology.

Synchronous Bilateral Primary Testicular Tumors With Discordant Histopathology

Concomitant presentation of histologically distinct bilateral testicular tumors is exceedingly rare. Here we report the case of a 20-year-old male who presented with a left testicular mass. He was found to have bilateral testicular masses on ultrasound and underwent bilateral orchiectomy. Left testicular pathology revealed a mixed germ cell tumor consisting of teratoma, seminoma, and germ cell neoplasia in situ; right testicular pathology revealed two foci of pure seminomas. He is currently on active surveillance and remains in remission at 18-month follow-up. Our case demonstrates the rare occurrence of bilateral primary synchronous testicular tumors with different histopathology in each testis. Despite the rarity of this condition, its treatment is based on standard management of unilateral testicular carcinoma, with the added element of prioritization of one tumor over the other. It is important for clinicians to tailor management for bilateral testicular germ cell tumors according to the most aggressive component.

Bilateral testicular intratubular germ-cell neoplasia, unclassified in an azoospermic patient

We report the case of a 29-year-old man, who was examined in our hospital for infertility. After complete evaluation, the patient was found to be azoospermic with normal follicle-stimulating hormone levels, whereas his testes were slightly smaller than normal. Thus, there was an indication for testicular biopsy, which showed bilateral testicular intratubular germ-cell neoplasia, unclassified. The patient was informed about his status, and when the staging was completed and the possibility of distant or lymphatic metastases was excluded, the therapeutic choices were discussed. In this case, bilateral orchiectomy was recommended and carried out, followed by hormone replacement therapy.

[Radiotherapy in stage I testicular seminoma: retrospective study and review of literature]

INTRODUCTION

Seminoma accounts for about 40% of germ cell tumours of the testicle. In this retrospective analysis, we review literature concerning management of stage I seminoma.

MATERIALS AND METHODS

Between March 1987 and April 2001, 65 patients with stage I pure testicular seminoma received adjuvant radiotherapy with a 25 MV linear accelerator.

RESULTS

Median age was 33 years. Testicular tumour has been found on the right testis in 39 patients and on the left one in 24 patients. Patients have been treated using an anterior-posterior parallel pair and have received 20-25 Gy in 10-14 fractions. The target volume consisted of paraaortic, and paraaortic + homolateral iliac lymph nodes in 17 and 46 patients, respectively. Acute toxicity was mainly digestive, 38% of patients presenting nausea and vomiting. Median follow-up time was 37 months. All patients are alive in complete remission.

DISCUSSION

Because of good radio-sensitivity of seminoma, radiotherapy is regarded as standard adjuvant treatment (5 years relapse rate: 3-5%). Acute toxicity is dominated by moderate gastro-intestinal side effects. Secondary neoplasia represents one of the worst possible long-term complications of therapy. Waiting for ongoing randomised trials, the modern literature for seminoma reflects a trend toward lower radiation doses (20-25 Gy) and smaller treatment volumes (paraaortic field). Adjuvant chemotherapy with two courses of carboplatin, might be equivalent to radiotherapy but must be investigated in randomised trials. A surveillance policy is one of the other management options less recommended.

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.

The incidence, prognosis, clinical and histological characteristics, treatment, and outcome of patients with bilateral germ cell testicular cancer in Hungary

PURPOSE

To examine the incidence, prognosis, clinical and histological characteristics, treatment, and outcome of patients with bilateral testicular cancer in the referral center in Hungary, to determine which parameters might predict a second testicular tumor.

METHODS

. Clinical parameters-such as time of original surgery, histology of primary tumor, extent of the disease, serum marker concentrations, history of testicular abnormalities, treatment, response to treatment, follow-up period, data on second carcinoma-of bilateral testicular tumors among the 2,386 patients with testicular cancer treated between November 1988 and November 1998 were analyzed.

RESULTS

The incidence of patients with synchronous testicular tumor was 0.8% (19 of 2,386 patients). The clinical stages were 8 I/A, 5 I/B, 1 II/A, 2 II/B, 1 III/A, and 2 III/B. Median follow-up time was 93 months and the 5-year overall survival was 84%. The incidence of patients with metachronous testicular cancer (median age 28 years and 35 years at first and second tumor diagnosis) was 2.2% (53 of 2,386 patients) and the median time to second tumor was 76 months (range 18-203 months). The clinical stages at the first and second tumor diagnosis were: 14 I/A, 21 I/B, 15 II/A, 2 II/B, and 1 III/B, and 26 I/A, 16 I/B, 3 II/A, 1 II/B, 7 III/B, respectively. The median follow-up time was 42 months and the 5-year overall survival was 93%. In thirteen patients with metachronous cancers, two family histories of testicular cancer, five cases of undescended testicles, seven cases of testicular atrophy, and one case of azoospermia were detected. There was a non-significant trend to a longer cancer interval after chemotherapy and radiotherapy and a tendency to a greater incidence of asynchronous seminoma after chemotherapy. Clinical stage I tumors were more frequent in the surveyed group than among patients not followed up according to the institutional protocol ( P = 0.01), but the survival rate was good in both groups. Seminoma as a second tumor was diagnosed in an older age group (median 38 years, range 25-49 years) than nonseminoma (median 32 years, range 21-51 years, P < 0.045). The interval till the appearance of a metachronous testicular cancer depended on tumor histology: in seminoma cases it was longer than in nonseminoma cases (median time: 121 months versus 50 months, P = 0.002).

CONCLUSIONS

The overall incidence of bilateral testicular cancer in the referral center in Hungary was 3%. We could not identify clinical factors which predicted a higher risk for metachronous testicular cancer. With regular follow-up the early diagnosis of second testicular tumors is probable; therefore education, self-examination of the remaining testicle, and long-term follow-up are important in early detection.

Bilateral testicular germ-cell tumors--a single centre long-term experience

OBJECTIVES

The incidence of bilateral testicular tumors (BTT) had increased over the preceding decade. The aim of the present study is to analyse a group of patients with BTT and to high-light the need for long-term follow-up of patients treated in a single centre.

MATERIAL AND METHODS

27 (2.8%) out of 960 patients with germ-cell testicular tumors (GCTT), treated between 4/1977 and 8/2001, developed bilateral disease. All of them underwent radical orchiectomy (in one patient was done delayed orchiectomy after primary chemotherapy due to advanced disease). Additional treatment was planned according to the histologic type and clinical stage of the disease, and previous treatment as well. The survival data were reviewed.

RESULTS

24 out of 27 patients (88.9%) developed the 2nd tumor metachronously (median interval 66 months, range, 4-197 months) and three (11.1%) had synchronous BTT. Only 7 patients (25.9%) had identical histological types on both sides (6 of them with pure seminomas, one with embryonal carcinoma). Two of three synchronously developed BTT had different histologic types on both sides. GCTT of one histologic type were observed in respect of the first tumor: 11 seminomas, three embryonal carcinomas, in respect of the 2nd tumor: 10 seminomas, three embryonal carcinomas, in respect of the 2nd tumor: 10 seminomas, three embryonal carcinomas and one mature teratoma. GCTT of more than one histologic type were observed in respect of the first and the 2nd tumors: 6 mixed GCTT with seminoma component and 7 without seminoma component. Majority of BTT was presented in clinical stage I (in respect of the first tumor in 70.4%, in respect of the 2nd tumor in 62.9%). The median duration of the follow-up after the diagnosis of the first GCTT was 149 months (range, 13-288 months) and after the diagnosis of the contralateral GCTT was 68 months (range, 1-167 months). Twenty-five patients (92.6%) were alive with NED at their last follow-up visit. Two patients died by mean of 22.5 months (range, 21-24 months) after the 2nd orchiectomy.

CONCLUSIONS

All patients with unilateral GCTT have an increased risk of developing a contralateral testicular tumor, even decades after diagnosis. Management should be individualised for each patient.

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.

Familial/bilateral and sporadic testicular germ cell tumors show frequent genetic changes at loci with suggestive linkage evidence

Testicular germ cell tumor (TGCT) is the most common tumor type among adolescent and young adult males. Familial clustering and bilateral disease are suggestive of a genetic predisposition among a subgroup of these patients, but susceptibility genes for testicular cancer have not yet been identified. However, suggestive linkage between disease and genetic markers has been reported at loci on chromosome arms 3q, 5q, 12q, 18q, and Xq. We have analyzed primary familial/bilateral (n=20) and sporadic (n=27) TGCTs, including 28 seminomas and 19 nonseminomas, for allelic imbalance (AI) within the autosomal regions. DNA from all tumors were analyzed by fluorescent polymerase chain reaction of 22 polymorphic loci at 3q27-ter, 5q13-35.1, 12q21-ter, and 18q12--ter. All tumor genotypes were evaluated against their corresponding constitutional genotypes. The percentages of TGCTs with genetic changes at 3q, 5q, 12q, and 18q, were 79%, 36%, 53% and 43%, respectively. The frequencies at 3q and 12q in nonseminomas were significantly higher than in seminomas (P=.003 and P=.004). In order to evaluate changes at hemizygous Xq loci, five loci were analyzed by co-amplification with an autosomal reference marker known to reveal retained heterozygosity in the tumor DNA. Gain of Xq sequences was seen in more than 50% of the tumors. The degree of amplification varied among the loci in each of five tumors, and based on these breakpoints, a common region of overlapping gains was found at Xq28. No significant differences were found between the frequencies of genetic changes in familial/bilateral versus sporadic tumors, an observation speaking in disfavor of the existence of a single susceptibility gene for TGCT in any of the analyzed regions. Our data suggest that gain of genetic material at distal Xq and losses at 5q and 18q contribute to establishment of seminomas, whereas imbalances at 3q as well as gain at distal part of 12q are associated with further progression into nonseminomas.

Bilateral testicular tumors: management and outcome in 21 patients

BACKGROUND

The authors examined the clinical course of patients with bilateral testicular tumors to determine whether the outcome after treatment was different from patients with unilateral tumors.

METHODS

Using a computerized data base of 2088 patients with testicular carcinoma at Indiana University, 21 patients (1%) were identified with bilateral testicular carcinoma. A retrospective review of hospital and clinic charts was performed. Sixteen patients with metachronous and 5 patients with synchronous testicular tumors were identified.

RESULTS

Treatment was based on clinical stage and was similar to therapy given for unilateral disease. The mean age at presentation of the first testicular tumor was 28.4 years (range, 16-47 years). Approximately 50% of the second primary tumors presented > 5 years after the contralateral tumor. At a mean follow-up of 49.9 months (range, 1-276 months), 18 patients were without evidence of disease, 2 were alive with disease, and 1 patient had died of disease.

CONCLUSIONS

The treatment of patients with bilateral germ cell tumors is based on the pathology and clinical stage and should not be different from the traditional management of unilateral testicular carcinoma. Patients with unilateral testicular carcinoma should be informed of the necessity of long term follow-up because contralateral testicular carcinoma may occur as long as 25 years later.

Metachronous neurohypophyseal germinoma occurring 8 years after total resection of pineal mature teratoma

BACKGROUND

Metachronous germ cell tumor in the central nervous system is extremely rare. To our knowledge, only one patient presenting conceivable metachronous intracranial germ cell tumor has been reported.

CASE REPORT

A neurohypophyseal germinoma occurring 8 years after total resection of a pineal mature teratoma is presented. The patient underwent total resection of a large pineal mass in 1987. Histologic investigation revealed a mature teratoma without any immature or germinomatous components. In 1995, he developed diabetes insipidus. Magnetic resonance imaging depicted an intrasellar mass extending to the floor of the third ventricle. A transsphenoidal biopsy revealed histologically pure germinoma.

CONCLUSION

The second neurohypophyseal germinoma was considered to be a de novo metachronous neoplasm rather than a recurrence of the original mature teratoma.

Molecular mechanisms of testicular carcinogenesis

Molecular investigations into the neoplastic transformation of a normal spermatogenic precursor cell into a germ-cell malignancy have implicated a wide array of DNA and RNA alterations. Previous epidemiologic and familial patterns of cancer presentation had suggested that testicular cancer developed from one or more genetic alterations. In particular, mutations in cellular oncogenes such as c-kit and tumor-suppressor genes such as the retinoblastoma gene product have been identified as putative etiologic agents in the development and progression of testicular germ-cell tumors. Additionally, alterations in the transcription of RNA that are regulated through a process of genomic imprinting have been identified in human testis cancers. This report provides a framework for integrating this growing literature on the molecular biology of testicular germ-cell tumors into a potential etiologic hypothesis.

Synchronous bilateral testis tumor: mixed germ cell and theca cell tumors

Synchronous bilateral testis tumors of different histologic types are rare. All previous cases have demonstrated germ cell tumors on both sides. The simultaneous appearance of a germ cell tumor and a contralateral non-germ cell tumor has not been reported. We herein report a thirty-four-year-old man who presented with a mixed non-seminomatous germ cell tumor of the left testis and theca cell tumor of the right testis.

Treatment of stage I testis seminoma by radiotherapy: long-term results--a 30-year experience

PURPOSE

From 1956 to 1986, we have retrospectively studied 184 patients with a Stage I testis seminoma treated by orchidectomy and radiotherapy at the Institut Gustave Roussy.

METHODS AND MATERIALS

The 184 patients received adjuvant radiotherapy to the para-aortic and ipsilateral iliac nodes. Of the 184 patients, 133 received additional mediastinal and supraclavicular irradiation, 47 received supraclavicular without mediastinum irradiation, 98 patients received additional radiotherapy given to inguino-scrotal area. The mean dose of irradiation is 21 Gy which is the lowest dose published. The actuarial survival rate is, respectively, 96%, 93%, 83% and 77% at 5, 10, 15, and 20 years.

RESULTS

Four patients relapsed, and four died of progressive disease. Four patients presented cardiovascular disease, all of them had mediastinal irradiation, two were heavy smokers. Seventeen second malignancies were observed, six tumors in the contralateral testis. The actuarial risk of developing a second malignancy is 10% at 10 years, 21% at 20 years. The cure rate and relapse rate in our patients is the same as that obtained by higher dosage of irradiation.

CONCLUSION

We conclude that low dose of prophylactic irradiation in lumbo aortic and ipsilateral iliac lymph nodes is active and safe in the treatment of Stage I testis seminoma.