Handling and Reporting of Biopsy and Surgical Specimens of Testicular Cancer

Sonoelastography for Testicular Tumor Identification: A Systematic Review and Meta-Analysis of Diagnostic Test Accuracy

The objective of this review was to summarize the applications of sonoelastography in testicular tumor identification and inquire about their test performances. Two authors independently searched English journal articles and full conference papers from CINAHL, Embase, IEEE Xplore®, PubMed, Scopus, and Web of Science from inception and organized them into a PIRO (patient, index test, reference test, outcome) framework. Eleven studies (n = 11) were eligible for data synthesis, nine of which (n = 9) utilized strain elastography and two (n = 2) employed shear-wave elastography. Meta-analyses were performed on the distinction between neoplasm (tumor) and non-neoplasm (non-tumor) from four study arms and between malignancy and benignity from seven study arms. The pooled sensitivity of classifying malignancy and benignity was 86.0% (95%CI, 79.7% to 90.6%). There was substantial heterogeneity in the classification of neoplasm and non-neoplasm and in the specificity of classifying malignancy and benignity, which could not be addressed by the subgroup analysis of sonoelastography techniques. Heterogeneity might be associated with the high risk of bias and applicability concern, including a wide spectrum of testicular pathologies and verification bias in the reference tests. Key technical obstacles in the index test were manual compression in strain elastography, qualitative observation of non-standardized color codes, and locating the Regions of Interest (ROI), in addition to decisions in feature extractions. Future research may focus on multiparametric sonoelastography using deep learning models and ensemble learning. A decision model on the benefits-risks of surgical exploration (reference test) could also be developed to direct the test-and-treat strategy for testicular tumors.

Active surveillance in stage 1 disease: standard of care independent of risk factors?

PURPOSE OF REVIEW

Approximately 30% of clinical stage 1 (CS1) nonseminomatous germ cell tumours (NSGCT) and 15-20% of CS1 seminoma relapse without adjuvant treatment. Despite this, the 5-year survival for CS1 is 99%. The purpose of this review is to assess if active surveillance should be standard for all patients with CS1 testis cancer independent of risk factors.

RECENT FINDINGS

Recent data from Princess Margaret Cancer Centre suggest a nonrisk-adapted surveillance approach avoids treatment in ∼70% of patients. Most relapse early at a median time of 7.4 months. The majority of relapses are confined to the retroperitoneum (66%) and only one modality of treatment is required: chemotherapy only in 61% and RPLND only in 73%.

SUMMARY

Surveillance is the preferred option and a safe proven strategy for the management of CS1 disease independent of risk factors. The prognosis for CS1 disease is excellent and the decision to offer surveillance or adjuvant treatment needs to highlight the treatment-related morbidity in an otherwise fit and healthy young man.

Discrepancy in pathology reports upon second review of radical orchiectomy specimens for testicular germ cell tumors

INTRODUCTION

We sought to evaluate the discrepancies between primary pathology report and second pathology review of radical orchiectomy (RO) specimens.

METHODS

A retrospective review was performed of RO specimens from the Ontario Cancer Registry. All cases required both a primary pathology report and a second pathology review from another institution. Histopathological variables assessed included histological subtype and components of mixed germ cell tumor (GCT), pathological tumor (pT) stage, lymphovascular invasion (LVI), spermatic cord invasion, and surgical margin.

RESULTS

Between 1994 and 2015, 5048 ROs were performed with 2719 (53.9%) seminoma and 2029 (40.2%) non-seminoma. Of these, 519 (10.3%) received a second pathology review. There was concordance between primary pathology report and second pathology review in 326 (62.8%) cases. The most common discrepancies involved a change in pT stage (n=148, 28.5%), with upstaging in 83 (16%) and downstaging in 65 (12.5%) cases relative to the original pT stage. The second most common discrepancy regarded the reporting of LVI (n=121, 23.3%), with 62 (11.9%) reporting presence of LVI when the primary pathology report did not. Other discrepancies included a change in the histological subtype in 28 (5.4%) cases and spermatic cord margin status in five (9.6%) cases.

CONCLUSIONS

Only 10% of orchiectomy specimens underwent a second pathology review, with nearly 40% of reviews leading to a meaningful change in parameters. Such variation could lead to incorrect tumor staging, estimate of relapse risk, and inappropriate treatment decisions. Expert pathology review of RO specimens should be considered, as it has significant implications for decision-making.

Germ Cell Neoplasia in situ (GCNIS) in Testis-Sparing Surgery (TSS) for Small Testicular Masses (STMs)

Purpose: The testis-sparing surgery (TSS) is surgical technique accepted for small testicular masses (STMs). Frozen section examination (FSE) is an essential assessment at the time of TSS. The aim of this study is to measure the maximum distance of the foci of ITGCN from STMs. Methods: In our hospital between June 2010 and October 2017 a total of 68 patients with STM underwent a TSS. All the testis specimens were totally embedded and processed via the whole-mount method and a diagnosis of germ cell tumor with GCNIS were made. The distance between STMs and GCNIS were calculated by two pathologists directly on the slides considering for the third dimension the number of the paraffin blocks in which the foci of GCNIS were found. Results: The STMs were classic seminoma in 62 out 68 cases, embryonal carcinoma in 4 cases, while in 2 case a diagnose of mixed germ cell tumor were made. The size of the STMs was between 0.5 and 2 cm and the foci of GCNIS were observed in seminiferous tubules very closed to SMTs or as skip lesions in the surrounding testicular parenchyma, dispersed in normal testis. In 48 out of 68 cases (70.5%) foci of GCNIS were at the distance from SMTS of 1.5 cm or below and in 60 out of 68 cases (88%) at the distance of 2 cm or below The distance of GCNIS from the STMs was not related to the histological subtype of the germ cell tumor, while there is a linear correlation between size of the STMs and the distance of foci of GCNIS (p = 0.0105; r = 0.9167). Conclusion: Our data showed that foci of ITGCN were not observed beyond 2.5 cm from the STM. In particular we demonstrated that exist a linear correlation between size of STMs and distance of the foci of GCNIS from STMs (p = 0.0105; r = 0.9167). In conclusion mapping the tissue around the tumor not randomly but in targeted areas could reduce the false negative biopsies of the testis with GCNIS, increasing the radicality of the TSS procedure.

Contralateral biopsies in patients with testicular germ cell tumours: What is the rationale?

INTRODUCTION

In 1979, the Copenhagen group around Dr. Skakkebaek introduced contralateral biopsy in patients with testicular germ cell tumour (GCT) as a means of early diagnosing a contralateral testicular tumour (Berthelsen et al. in Br Med J 2(6186):363-364, 1). Although the rationale of contralateral biopsies is based on much of scientific evidence, no issue regarding the management of GCTs has been more controversial than the issue of contralateral biopsies (Heidenreich in BJU Int 104(9 Pt B):1346-1350, 2; Grigor and Rorth in Eur Urol 23(1):129-135, 3). A poll conducted during the GCT Consensus Meeting in Berlin 2011 revealed that 43 % of 60 leading experts would not recommend a contralateral biopsy and only 13.7 % would do the biopsy in all cases with GCT (Beyer et al. in Ann Oncol 24(4):878-888, 4). Likewise, the European Association of Urology and the European Society of Medical Oncology offer only weak recommendations with respect to contralateral biopsies in their guidelines of testicular cancer (Albers et al. in Eur Urol 68(6):1054-1068, 5; Oldenburg et al. in Ann Oncol 24(Suppl 6):vi125-vi132, 6).

CONCLUSION

This review summarizes contemporary knowledge regarding contralateral biopsies to provide professionals caring for GCT patients with sufficient information to decide for or against the procedure in clinical practice.

Real-Time Elastography and Contrast-Enhanced Ultrasonography in the Evaluation of Testicular Masses: A Comparative Prospective Study

This study investigates the usefulness of contrast-enhanced ultrasound (CEUS) and real-time elastography (RTE) for the characterization of testicular masses by comparing pre-operative ultrasound findings with post-operative histology. Sixty-seven patients with 68 sonographically detected testicular masses underwent B-mode, color-coded Doppler sonography (CCDS), CEUS and RTE according to defined criteria. For RTE, elasticity score (ES), difference of elasticity score (D-ES), strain ratio (SR) and size quotient (Qsize) were evaluated. Histopathologically, 54/68 testicular lesions were neoplastic (47 malignant, 7 benign). Descriptive statistics revealed the following results (neoplastic vs. non-neoplastic) for sensitivity, specificity, positive predictive value, negative predictive value and accuracy, respectively: B-mode, 100%, 43%, 87%, 100%, 88%; CCDS 81%, 86%, 96%, 55%, 82%; CEUS 93%, 85%, 96%, 73%, 91%; ES 98%, 25%, 85%, 75%, 85%; D-ES 98%, 50%, 90%, 83%, 89%; SR 90%, 45%, 86%, 56%, 81%; and Qsize 57%, 83%, 94%, 28%, 61%. B-mode with CCDS remains the standard for assessing testicular masses. In characterization of testicular lesions, CEUS clearly outperformed all other modalities. Our study does not support the routine use of RTE in testicular ultrasonography because of its low specificity.

Etiology and early pathogenesis of malignant testicular germ cell tumors: towards possibilities for preinvasive diagnosis

Malignant testicular germ cell tumors (TGCT) are the most frequent cancers in Caucasian males (20-40 years) with an 70% increasing incidence the last 20 years, probably due to combined action of (epi)genetic and (micro)environmental factors. It is expected that TGCT have carcinoma in situ(CIS) as their common precursor, originating from an embryonic germ cell blocked in its maturation process. The overall cure rate of TGCT is more than 90%, however, men surviving TGCT can present long-term side effects of systemic cancer treatment. In contrast, men diagnosed and treated for CIS only continue to live without these long-term side effects. Therefore, early detection of CIS has great health benefits, which will require an informative screening method. This review described the etiology and early pathogenesis of TGCT, as well as the possibilities of early detection and future potential of screening men at risk for TGCT. For screening, a well-defined risk profile based on both genetic and environmental risk factors is needed. Since 2009, several genome wide association studies (GWAS) have been published, reporting on single-nucleotide polymorphisms (SNPs) with significant associations in or near the genes KITLG, SPRY4, BAK1, DMRT1, TERT, ATF7IP, HPGDS, MAD1L1, RFWD3, TEX14, and PPM1E, likely to be related to TGCT development. Prenatal, perinatal, and postnatal environmental factors also influence the onset of CIS. A noninvasive early detection method for CIS would be highly beneficial in a clinical setting, for which specific miRNA detection in semen seems to be very promising. Further research is needed to develop a well-defined TGCT risk profile, based on gene-environment interactions, combined with noninvasive detection method for CIS.

Organ-sparing surgery for testicular tumours

PURPOSE OF REVIEW

Testicular cancer represents the majority of testicular masses, and radical orchiectomy is still considered the standard-of-care. Testis-sparing surgery (TSS) can be an alternative to radical surgery in patients with small testicular tumours, bilateral or solitary testis masses. The aim of this manuscript is to review the current indications, oncological and functional outcomes of TSS.

RECENT FINDINGS

Our review confirmed that literature lacks studies with a high level of evidence on comparing TSS with radical surgery. Indications for TSS are controversial, specifically for patients with normal contralateral testis. For nonpalpable testicular masses less than 2 cm, bilateral tumours and solitary testis mass, TSS seems to be a viable treatment option. Frozen-section examination is a critical tool for assessment at the time of TSS that allows for diagnosis of benign from malignant tumours and evaluation of margin. TSS has been shown to be associated with less fertility alterations, hormonal deficit and potential lower impact on sexual and psychosocial aspects. Intermediate to long-term follow-up results have not revealed any significant risk of local and/or distant recurrences after TSS.

SUMMARY

TSS is well tolerated and feasible for selected patients with testicular mass without compromising oncological and functional outcomes. Further studies with a higher level of evidence are needed to confirm these findings.

Disparities in Interpretation of Primary Testicular Germ Cell Tumor Pathology

OBJECTIVES

Accurate pathologic interpretation of testicular germ cell tumors (GCTs) can be problematic due to low incidence and variation in histologic patterns. By analyzing changes in the diagnosis of testicular specimens after secondary review, we hoped to determine how these can affect prognosis and treatment.

METHODS

From 1999 to 2013, a total of 235 patients underwent radical orchiectomy at a referring facility and had pathology specimens reanalyzed by our center's pathologists with expertise in genitourinary malignancies. We identified discrepancies in pathologic reporting.

RESULTS

Fifty (21.3%) patients had variations in interpretation of their orchiectomy specimens. A clinically significant alteration was identified in 16 (6.8%) patients, most commonly due to recognition (or misrecognition) of lymphovascular invasion (LVI) associated with nonseminomatous germ cell tumors (NSGCTs). Changes in LVI status resulted in upstaging or downstaging from clinical stage 1A to stage 1B or vice versa in six patients with NSGCTs, with a subsequent change in therapeutic strategy. In addition, one patient with stage 1 pure seminoma had been misclassified with nonseminoma.

CONCLUSIONS

Inaccurate interpretation of orchiectomy specimens is not uncommon and may lead to incorrect tumor staging, imprecise assignment of progression risk, and inappropriate management recommendations. Secondary opinions of primary GCT orchiectomy specimens potentially facilitate appropriate counseling and therapeutic strategies.

Efficacy of ultrasound-guided testicle-sparing surgery for small testicular masses

PURPOSE

The aim of the present study was to evaluate evolution of conservative echo-guided surgery for testicular tumours ≤1.5 cm and to assess the safety of this surgical procedure.

METHODS

49 consecutive patients diagnosed with ultrasonography testicular lesions (mono or bilateral) ≤1.5 cm and treated with conservative echo-guided testicular surgery were examined. The parameters considered in this retrospective analysis included case history, physical examination, scrotal and abdominal ultrasonography, computed tomography scan, size of the nodule (maximum diameter), tumour markers, chest radiography, frozen section examination, histologic size of the tumour, overall survival (OS) and findings on follow-up.

RESULTS

Mean age of patients was 33 years (range 18-62). Patients who presented with a palpable testicular nodule were 32.7 %, gynecomastia 10.2 %, precocious pseudopuberty 4 %, and scrotal pain 12.2 %. Permanent section examination confirmed the FSE data in all cases of certainty malignant lesion and definitive histological types were: 22 seminoma, 13 non-seminomatous or mixed germ cell tumours, 4 Leydig tumours, 2 hamartoma, 1 epidermoid cyst, 2 sertoli cell tumours, and 5 fibrous pseudotumour. No complications intra- and postoperative were observed. Overall survival was 100 % and scrotal US showed evidence of local tumour recurrence in 6 patients (12.2 %) after a mean follow-up of 34.7 months.

CONCLUSION

The OS, the low rate of local recurrence, and absence of complications, tend to demonstrate the safety of the procedure. The benefits to testicular-sparing surgery include improving the patient's overall quality of life, fertility, endocrine function and negative cosmetic effects of radical orchiectomy.

Role of testis sparing surgery in the conservative management of small testicular masses: oncological and functional perspectives

INTRODUCTION

Radical orchiectomy (RO) is still considered the standard of care for malignant germ cell tumours, which represent the vast majority of the palpable testicular masses. In those patients diagnosed with small testicular masses (STMs), testis-sparing surgery (TSS) could be an alternative treatment to RO. The aim of this updated review is to evaluate the current indications for TSS, and discuss the oncological and functional results of patients who had undergone organ-sparing surgery for STMs.

EVIDENCE ACQUISITION

A non-systematic review of the Literature using the Medline database has been performed, including a free-text protocol using the terms "testis-sparing surgery", "testicular sparing surgery", "partial orchiectomy", "testis tumour", "sex cord tumour", and "testis function". Other significant studies cited in the reference lists of the selected papers were also evaluated.

EVIDENCE SYNTHESIS

No randomized controlled trials comparing TSS with radical orchiectomy have been reported yet. In those patients with normal contra-lateral testis, the use of TSS is still controversial. In selected cases of gonadal masses < 2 cm, TSS seems to be a safe and feasible treatment option. Frozen section examination allows us to discriminate between benign and malignant neoplasms during TSS. Intermediate and long-term follow-up results showed no significant risk of local and distant recurrences in the main series reported in the literature.

CONCLUSIONS

TSS is an effective treatment for STMs in selected patients, limiting the unnecessary surgical over-treatments, without compromising the oncological and functional outcomes. Further studies are needed in order to confirm the oncological safety.

Testing testes: problems and recent advances in the diagnosis of testicular tumours and implications for treatment

The low incidence of testicular tumours and the fact that they show an extremely high diversity means that they may be poorly understood. Knowledge of the range of tumours and the differences in treatment available is essential for appropriate management. The advent of cisplatin chemotherapy and the exquisite sensitivity of seminoma to radiotherapy have resulted in excellent cure rates. Nevertheless, research has continued unabated, particularly to understand the molecular basis of germ cell tumours and why certain tumours are recalcitrant to treatment. This overview is an attempt to demystify areas of confusion and highlight areas of current interest in testicular pathology and oncology.

[Frozen section in urological oncology]

The indications of Frozen section diagnosis (FS) in surgery due to urologic neoplasia are quite specific, and this explains the fact that they amount to a mere 7.3% of the FSs performed in general hospitals. This also makes the knowledge of their usefulness necessary, and thus we are submitting the present review. Generally speaking, FS is not warranted to identify the nature of a tumoral mass, with the following exceptions: (1) Renal masses of a doubtf ul parenchymal origin, or in the urinary tract: (2) Intesticular neoplasias,when the possibility of a conservative treatment arises; (3) Determination of the presence of a prostate adenocarcinoma in an organ donor with high serum PSA; but even in these circumstances its need is widely controversial. Intraoperative determination of surgical margins is particularly useful in: (1) Partial nephrectomies (it may be limited to inspection after dyeing the margin with Indian ink--bed freezing is very seldom needed); (2) Urethral margins in women with total cystectomies and orthotopic substitution; (3) In partial penectomies (always studying the urethral margin and the cavernosal and spongIosal corpora margins). The study of the nodes is a widely debated issue, and except for those cases in which unexpectedly increased node size is found, systematic FS is indicated neither of the bladder nor of the prostate. The situation regarding penis carcinoma is different, as in the groups with intermediate and high risk of node metastasis, even though there is around 16%-18% of false negatives FS is recommended, particularly of radioisotope-marked sentinel nodes.

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.

How Harmful is Contralateral Testicular Biopsy?—An Analysis of Serial Imaging Studies and a Prospective Evaluation of Surgical Complications

OBJECTIVE

Testicular biopsy has recently gained a role in early detection of testicular cancer. However, its use is still limited mainly because of the fear of untoward consequences. There is a paucity of data regarding unfavourable effects of testicular biopsy. Therefore, we systematically looked to the consequences of the procedure by using clinical observational methods and by modern imaging techniques, respectively.

PATIENTS, METHODS

1874 patients with testicular cancer enrolled in a nation-wide contralateral biopsy study were prospectively analyzed in regard to surgical complications. Serial scrotal imaging was performed by scrotal sonography (7.5 Mhz) in 55 patients and by magnetic resonance tomography (1.5 Tesla machine, surface coil, contrast media) in 60 patients, respectively. Imaging examinations were done preoperatively and again at 1 week, 6 months, 12 months, and 18 months respectively. Imaging results were tabulated according to an abnormality score and analyzed by descriptive statistics.

RESULTS

52 patients (2.78%; 95% confidence intervals 2.05-3.60) experienced surgical complications. Forty minor complications were managed conservatively. Twelve patients (0.64%) required repeat surgery; 1 testicle was ultimately lost following a sequence of unfortunate events. No pre-existing clinical parameter was associated with complications. One week after surgery, abnormalities were detected in 33% by sonography and in 45% by MRI, respectively. Importantly, the abnormalities resolved in 96% of the cases, as found in both of the imaging modalities in the serial scans.

CONCLUSIONS

Testicular biopsy is associated with a low burden of clinically significant complications. However, scrotal imaging discloses intratesticular abnormalities in a high proportion of cases one week after the biopsy. These changes represent focal haematoma, oedema or circumscript injury to vascular supply. Most of these lesions resolve with time and are thus not significant, clinically. Evidently, testicular biopsy is a safe procedure provided the vascular anatomy of the testis is respected upon surgery.

Microinvasive germ cell tumor of the testis

Microinvasive germ cell tumor (MGCT) consists of a limited number of malignant germ cells in the intertubular tissue of the testis. The cells have large nuclei, prominent nucleoli, abundant clear cytoplasm, and distinct cellular borders in hematoxylin and eosin staining. MGCT can be the first stage of malignancy in the development of testicular germ cell tumor (TGCT). Biopsies from men with maldescended testes have been reported to contain intratubular germ cell neoplasia, unclassified (IGCN) and MGCT in 1.8% of the examined cases (95% CI 0.5-4.6%). MGCT has also been found in testes of subfertile men and in the contralateral testis of patients with TGCT. MGCT is a frequent finding (19%) in the testicular tissue adjacent to an overt TGCT. Men with a high risk of TGCT may gain from screening for precursor lesions of TGCT with ultrasonography of the testes followed by a testicular biopsy if suspicious abnormalities are found: Treatment is high-voltage radiotherapy for intratubular germ cell neoplasia (IGCN), and orchidectomy for MGCT and germ cell tumor in situ, either intratubular seminoma or intratubular embryonal carcinoma. After local treatment, patients with precursor lesions can be followed with a surveillance program. The mRNA levels of invasion-related genes were evaluated based on a DNA microarray data set, and we found two gene abnormalities most relevant for the invasion of malignant germ cells: matrix metalloproteinase 9 (MMP9) and plasminogen activator, urokinase (PLAU) genes were up-regulated in a study comparing tissue samples of TGCT and IGCN.

PREVALENCE OF TESTICULAR INTRAEPITHELIAL NEOPLASIA IN HEALTHY MALES

PURPOSE

Testicular intraepithelial neoplasia (TIN), also called intratubular germ cell neoplasia, is thought to be the precursor of testicular germ cell tumors (GCTs). Evidence for this theory stems from clinicopathological studies because to our knowledge experimental models are lacking. While GCT clinical risk groups have been studied extensively for TIN, only 1 small study to date has assessed the presence of TIN in the general population. In the current study we analyzed the prevalence of TIN in a large group of healthy men.

MATERIALS AND METHODS

Bilateral testicular specimens were obtained from 1,388 presumably healthy men who died unexpectedly and underwent autopsy at forensic institutes in Germany. Median age in this patient sample was 33 years. Specimens were fixed in Stieve's solution and all specimens were examined immunohistologically with placental alkaline phosphatase staining.

RESULTS

TIN was found in 6 cases (0.43%, 95% CI 0.16 to 0.94). Two cases also showed microinvasive seminoma. TIN was bilateral in 1 case. The right testicle was afflicted in 4 cases and the left was affected in 1. Median age of the individuals with TIN was 33 years.

CONCLUSIONS

As found in the current study, the prevalence of TIN is consistent with the lifetime risk of GCT in Germany. Data in the current study are in accordance with those in a previous study from Denmark. In all these data represent fundamental support of the role of TIN as the precursor of GCT.

Intraoperative Frozen Section Diagnosis in Urological Oncology

The intraoperative frozen sections are indicated if the pathological findings change the surgical procedure. In urological oncology is not recommended, as a general attitude, in the tumor diagnosis/staging during the surgery. The assessment of the surgical margins is recommended in partial surgical resections but the literature discourages its systematic use in the radical surgical resections. The assessment of the lymph nodes is specially indicated in the penile cancer with intermediate or high risk and non-palpable nodes, and is debated its utility in non-palpable lymph nodes of cystectomies and prostatectomies.

[Regression of germ cell tumors after chemotherapy]

Today the treatment of gonadal germ cell tumors is standardized. The cisplatin containing chemotherapy and the multi-modal therapy strategies have increased the rate of successful treatment enormously. Germ cell tumors are almost always treated surgically. Following the rare, primary chemotherapy, the residual tumor must be classified according to the WHO as accurately as possible. A binding system for the documentation of tumor regression does not exist. The diagnostic retroperitoneal lymphadenectomy is also rare. Here as well, the classification is performed according to the WHO and the TNM classification. The examination of the tissue samples from a retroperitoneal lymphadenectomy after chemotherapy is problematic. The morphology is often bizarre, preparatory and terminological standards do not exist. Is there still vital tumor present then it can most often be diagnosed as a teratoma. In that case a classification takes place as to whether it is "mature" or "immature". If a tissue sample contains other differentiations, the classification is performed in detail according to the WHO classification of germ cell tumors. Sarcomas or carcinomas must be reliably distinguished and classified, as they lead to different therapeutic consequences. The terminology must be defined in a binding manner between both the pathology and the clinic, due to the lack of global definitions.