Diagnostic value of surgical testicular biopsy after therapy for acute lymphocytic leukemia

Mechanisms of extramedullary relapse in acute lymphoblastic leukemia: Reconciling biological concepts and clinical issues

Long-term survival rates in childhood acute lymphoblastic leukemia (ALL) are currently above 85% due to huge improvements in treatment. However, 15-20% of children still experience relapses. Relapses can either occur in the bone marrow or at extramedullary sites, such as gonads or the central nervous system (CNS), formerly referred to as ALL-blast sanctuaries. The reason why ALL cells migrate to and stay in these sites is still unclear. In this review, we have attempted to assemble the evidence concerning the microenvironmental factors that could explain why ALL cells reside in such sites. We present criteria that make extramedullary leukemia niches and solid tumor metastatic niches comparable. Indeed, considering extramedullary leukemias as metastases could be a useful approach for proposing more effective treatments. In this context, we conclude with several examples of potential niche-based therapies which could be successfully added to current treatments of ALL.

Functional status of testicular macrophages in an immunopriviledged niche in cadmium intoxicated murine testes

PROBLEM

The present study investigates the extent of immunomodulatory effects associated with semenological alterations in the testes, after exposure to cadmium (in vivo) in male Swiss albino mice. Despite residing in an immunopriviledged site, testicular macrophages have immunogenic functions.

METHODS OF STUDY

Experimental animals were divided into two groups: (i) control (isotonic saline) and (ii) treated (0.35 mg/kg b.w of cadmium chloride) intraperitoneally for 15 days. Murine testicular macrophages were isolated and the cell function studies such as morphological alteration and tumor-necrosis factor (TNF-α) release assay were performed. Among the semenological parameters, sperm count, sperm motility, sperm morphology and the testosterone levels in the epididymal semen samples from both groups were determined.

RESULTS

The present work shows that cadmium is responsible for a significant alteration, degenerative changes and reduced cell function in testicular macrophages probably by increasing oxidative damage. Such oxidative stress also causes a parallel dysfunction of the semenological parameters.

CONCLUSION

TNF-α which is probably unable to bind with the surface receptor in testicular macrophages as because of altered structural morphology with reduction of cell function, render the animals more prone to infection and ultimately causes subfertility.

Immunology of the Testis and Male Reproductive Tract

A large body of evidence points to the existence of a close, dynamic relationship between the immune system and the male reproductive tract, which has important implications for our understanding of both systems. The testis and the male reproductive tract provide an environment that protects the otherwise highly immunogenic spermatogenic cells and sperm from immunological attack. At the same time, secretions of the testis, including androgens, influence the development and mature functions of the immune system. Activation of the immune system has negative effects on both androgen and sperm production, so that systemic or local infection and inflammation compromise male fertility. The mechanisms underlying these interactions have begun to receive the attention from reproductive biologists and immunologists that they deserve, but many crucial details remain to be uncovered. A complete picture of male reproductive tract function and its response to toxic agents is contingent upon continued exploration of these interactions and the mechanisms involved.

Early testicular biopsy in males with acute lymphoblastic leukemia: lack of impact on subsequent event-free survival

PURPOSE

Children with acute lymphoblastic leukemia (ALL) who had bulky disease (lymphomatous features) at diagnosis had the highest rate of testicular relapse (20%) of any ALL subgroup on previous Children's Cancer Group (CCG) studies in the late 1980s. To limit curative, but sterilizing, testicular irradiation to those with testicular disease, testicular biopsies were performed to detect occult testicular disease within the first 6 months of treatment. Testicular irradiation then was provided to those with occult disease to increase disease-free survival. Identification of those with occult disease was believed to be a factor that would influence ultimate survival in such patients in that era.

PATIENTS AND METHODS

One hundred ninety-nine patients had bilateral testicular wedge biopsies performed during the first maintenance therapy phase of the four different chemotherapy regimens. Patients with positive biopsy results were treated with testicular irradiation and continued on therapy.

RESULTS

Eleven of 199 biopsy results (5.5%) were judged positive. Patients with positive biopsy results given testicular radiation had a 45% subsequent adverse event rate, compared with 36% for those with a negative biopsy results (P = 0.4). The survival rates for the two groups were similar. The low rate of positive biopsy specimens resulted in discontinuation of the procedure before closure of the study.

CONCLUSION

Positive testicular biopsy results early in remission identified patients at a slightly higher risk of subsequent adverse events but did not influence survival. However, because negative biopsy results (94.5%) did not alter the prescribed treatment, the small number of positive biopsy results did not warrant undertaking the procedure in most male patients with ALL, and this procedure was abandoned.

[Testicular biopsy at the stopping of the treatment in acute lymphoblastic leukemia: value of the immunohistochemical detection of residual blasts]

BACKGROUND

The prognostic value of clinical and histological detection of testicular leukemia after completion of therapy is still debated. Immunohistochemical study could improve the results of this detection.

PATIENTS AND METHODS

Between 1982 and 1992, 70 consecutive boys with acute lymphoblastic leukemia (ALL) and treated with the same therapeutic regimen were included in the study. Testicular biopsy (TB) was surgical and bilateral. One piece of tissue was fixed and analysed by conventional microscopy. An immunohistochemical study was performed on the other sample with a panel of anti-T and anti-B Mc Ab, including JCB 117 (anti-CD79a) which stains early pre B lymphoblasts.

RESULTS

Twenty-five children relapsed while on treatment and did not undergo TB. Among the 45 boys who underwent routine TB, one had a diffuse infiltration seen in conventional histology. Thirty-nine had normal morphological and immunohistochemical study: among them, six relapsed subsequently in bone marrow; in this group, event free survival (EFS) was 85 +/- 10% with a median follow-up of 80 months after the biopsy. In the five remaining boys, anti-CD79a was found positive on blasts in four cases and anti-CD3 in one case; four of those relapsed, including two in the testes during the year following the biopsy; EFS was 20 +/- 36% (P = 0.001).

CONCLUSIONS

New Mc Ab such as JCB 117 (anti-CD79a) might detect a minimal residual disease in the testes of children treated for ALL, particularly on routine histological material. These results, if confirmed in larger series, might influence further therapeutic strategy.

Fine-needle aspiration cytology as a tool for the early detection of testicular relapse of acute lymphoblastic leukemia in children

Fine-needle aspiration cytology (FNAC) of the testis was done in 31 children (33 aspirates) with acute lymphoblastic leukemia (ALL) either as part of an end-therapy protocol (Group I, n = 20) or because of clinical suspicion of testicular relapse (Group II, n = 13). In Group I, none of the smears showed evidence of leukemic cells. However, two of these patients developed subsequent testicular relapse within 1 yr and were considered false-negative cases. Blast cells were present in nine patients of Group II; in the remaining four patients no neoplastic cells were observed in the smears and none experienced a relapse after a mean follow-up of 18 mo. Our findings indicate that FNAC can be a valuable method to evaluate clinically suspected testicular infiltration in children with ALL, and can be considered as an alternative procedure to surgical biopsy for screening testicular recurrence of childhood ALL.

Primary testicular and paratesticular tumors of childhood

Testicular and paratesticular neoplasms are uncommon tumors of childhood. Consequently, the experience gained with regard to their optimal management is limited in any given children's cancer centre. Here we review the classification, diagnosis, and staging of testicular and paratesticular neoplasms and subsequently discuss the more frequently occurring ones: germ cell tumors, gonadal stromal tumors, gonadoblastoma, tumors of the supporting tissue, lymphomas and leukemias, tumor-like lesions, secondary tumors, and tumors of the adnexa.

An immunohistochemical study of testicular biopsies in childhood acute lymphoblastic leukemia: reactivity of normal testicular components and leukemic infiltrates

We performed an immunohistochemical analysis of frozen sections from testicular biopsies from 23 children with acute lymphoblastic leukemia. Eleven cases were infiltrated by leukemia. Tumor cells were immunostained by a panel of antibodies that identified CD10, CD43, CD19, CD3, CD7, and MHC class I and II. The immunoreactivity of normal testicular components was also studied. Normal testis showed no CD10 reactivity. Wide variation in the number of stromal macrophages identified by CD11c was found. Transferrin receptor (CD71) was expressed by some stromal macrophages, by seminiferous tubules, and by Leydig cells. B lymphocytes were absent from the testicular stroma but small numbers of T lymphocytes were consistently present. MHC class I and II were expressed by most stromal cells but not by seminiferous tubules.

The detection of minimal residual disease in acute lymphoblastic leukaemia

The detection of minimal residual disease in acute lymphoblastic leukaemia (ALL) can be achieved by assessing leukaemia-specific features at a cellular, chromosomal or molecular level. The application of the polymerase chain reaction to the amplification of leukaemia-specific chromosomal translocations and clone-specific immunoglobulin and T-cell receptor gene rearrangements allows assessment of the majority of cases of ALL. The sensitivity of detection of this technique is around one leukaemia cell in 10(5) normal marrow cells. A comparative review of the advantages and pitfalls of the different methods of detecting minimal disease is presented. The clinical relevance of such detection is discussed, with early results suggesting that this may have predictive value for future disease relapse.

Fine-needle aspiration biopsy (FNAB) diagnosis of testicular involvement in acute lymphoblastic leukemia in children

A series of 106 fine-needle aspiration biopsy specimens obtained from the testes of children with acute lymphoblastic leukemia was reviewed retrospectively. Involvement by leukemia was seen in 34, there was no evidence of disease in 52, and the cellular sample was inadequate in 20. All aspiration smears, except those with leukemic involvement, showed a variable number of Sertoli cells. Testicular leukemia was diagnosed by the presence of numerous leukemic cells and rare or no Sertoli cells. Fine-needle aspiration biopsy is a simple but effective technique for diagnosing leukemic involvement of the testis in children with acute lymphoblastic leukemia.

Improved treatment results in boys with overt testicular relapse during or shortly after initial therapy for acute lymphoblastic leukemia. A Pediatric Oncology group study

Boys with acute lymphoblastic leukemia (ALL) who have overt testicular relapse (OTR) during initial continuation chemotherapy or within 6 months thereafter have poor outcomes, with long-term survival similar to patients with marrow relapse during treatment. In April 1983, the Pediatric Oncology Group (POG) adopted for these patients an intensive treatment protocol (POG 8303) consisting of a four-drug systemic reinduction (prednisone, vincristine, daunorubicin, and asparaginase), a brief intensive consolidation phase with teniposide and cytarabine, and a 2-year program of continuation chemotherapy with weekly rotating drug pairs (vincristine/cyclophosphamide and teniposide/cytarabine) with or without (by randomization) four-drug reinforcement pulses every 16 weeks. Bilateral testicular radiation (2600 cGy) was administered during reinduction, and intrathecal chemoprophylaxis was given every 4 to 6 weeks. Among 38 eligible study patients with OTR, 5 had prior or concominant extramedullary relapse in other sites. The median duration of complete remission before OTR was 27 months (range, 10 to 42 months). All 38 patients achieved clinical remission after reinduction. Three patients withdrew while in remission, 22 had another relapse (12 marrow, 5 central nervous system (CNS), 2 testicular, 1 retroperitoneal, 1 prostate, and 1 eye), and 13 (34%) remain in complete remission from 32+ to 74+ months after OTR (median, 53+ months). Eighteen patients had their therapy electively discontinued, and five relapses occurred thereafter. These results are superior to those observed in patients with first marrow relapse treated with the same protocol. Approximately one third of patients with OTR treated with POG protocol 8303 exhibit prolonged second remissions with the potential for cure.

Immunophenotyping to detect and characterize acute lymphocytic leukemia in testicular biopsies

This study establishes the utility of immunophenotyping testicular biopsy specimens in patients with acute lymphoid leukemia. The value of immunophenotyping in detecting or excluding leukemic testicular infiltration is demonstrated in six children with acute lymphocytic leukemia. A panel of monoclonal antibodies was employed on snap-frozen testicular biopsies, allowing both detection and immunologic characterization of four neoplastic lymphocytic infiltrates. Two samples were proven both histologically and phenotypically negative for leukemic infiltration. One of the four leukemic cases was clinically silent and might have escaped detection except for phenotyping. One leukemic infiltrate was also suspected to possess a multidrug-resistant phenotype (p-glycoprotein +); the latter possibility was excluded by an absence of reactivity with anti-p-glycoprotein monoclonal antibody. Thus, three clinically useful applications are demonstrated: (1) confirmation of testicular leukemic relapse, gaining assertion in histologically uncertain cases; (2) exclusion of clinically suspected disease relevant to cessation of therapy, and (3) detection/exclusion of drug-resistant phenotypes. Unexpectedly, we found expression of plasma cell-associated antigen in testicular germ cells, which may prove to be diagnostically useful in the future evaluation of germ cell tumors.

Immunohistochemical detection of post-therapy residual testicular lymphoblasts in childhood acute lymphoblastic leukemia (ALL)

The aim of this study was to evaluate the diagnostic value of immunohistochemistry with monoclonal antibodies (MoAbs) in detecting residual blast cells in testicular biopsies from children with acute lymphoblastic leukemia (ALL). In a prospective study of 26 patients, testicular biopsies were performed after completion of therapy, and the average follow-up after biopsies was 29 months. After immunostaining, seven patients with negative biopsies on routine histology showed scattered, strongly calla-positive cells as well as cells reacting with anti-B (CD22) MoAb. Among these seven patients with residual blast cells, four had relapsed either in testes (n = 1), bone marrow and testes (n = 1), or in the bone marrow (n = 2). In contrast, among the 15 patients without residual blast cells, all but 1 remained in complete remission. In four other cases no definite conclusion was possible after immunohistochemical study. Four testicular biopsies from patients with occult infiltration were used as positive controls. Negative controls consisted of testicular biopsies from children with testicular ectopia and postmortem testicular tissue specimens. Results suggest that the risk of relapse is significantly higher in patients with positive immunohistochemical findings indicating persistent residual blast cells. However, the predictive value of these findings requires confirmation on a larger number of cases to have therapeutic implications.

Acute lymphoblastic leukemia in childhood

This article reviews the current biologic understanding of acute lymphoblastic leukemia and describes current approaches to treatment. It discusses the areas likely to be the focus of future research for this disease, including therapy for high-risk patients, understanding the reasons for treatment failure, and identification of new antileukemic agents.

Use of fine needle aspiration cytology for the diagnosis of testicular relapse in patients with acute lymphoblastic leukemia

The testis frequently is the site of relapse in male patients with acute lymphoblastic leukemia. While many patients with testicular involvement by acute lymphoblastic leukemia have enlarged or firm testes, clinical examination alone is insufficient to establish or exclude the diagnosis completely. Open biopsy generally has been used to document the presence of acute lymphoblastic leukemia. However, this procedure requires general anesthesia and hospitalization. We studied 11 patients with a history and/or physical findings suspicious for testicular acute lymphoblastic leukemia relapse to determine the efficacy of fine needle aspiration cytology in the evaluation of the testes for leukemic infiltration. Of the 11 patients fine needle aspiration cytology correctly identified all 5 patients with histologically proved testicular acute lymphoblastic leukemia, it was negative in 5 with no histological evidence of leukemia and it demonstrated rare atypical cells that were not evident on subsequent histological examination in 1. No adverse effects were encountered in this series. Fine needle aspiration cytology appears to be a safe, reproducible alternative to open biopsy in the evaluation of patients for testicular relapse of acute lymphoblastic leukemia.

Testicular adhesion: a potential complication from wedge testicular biopsy in childhood leukemia

Elective bilateral wedge testicular biopsy is frequently performed in childhood acute lymphoblastic leukemia. Acute and delayed complications of this procedure are rarely encountered. We report on two children with testicular adhesions 16 and 20 months postsurgery. In each instance there were resultant diagnostic and management difficulties. The possible cause and potential side effects of testicular adhesions are discussed.

Fine needle aspiration cytology (FNAC) of the testes in childhood acute lymphoblastic leukemia and non-Hodgkin's lymphoma: preliminary report

Eighteen patients with childhood acute lymphoblastic (ALL) or non-Hodgkin's lymphoma (NHL) in remission and 2 patients with ALL in suspected testicular relapses were studied by testicular fine needle aspiration cytology (FNAC). Well-preserved testicular cells, both singly and in small clusters, were considered indicative of an adequate aspiration. Of 18 patients in remission, 17 had at least one adequate sample from each testis and one showed evidence of leukemic infiltrate. None of these patients experienced a relapse during a median follow up of 4 years. In 2 other patients with clinically suspected testicular relapses, the smears from fine needle aspirates contained numerous malignant lymphoid cells that could be readily distinguished from seminiferous tubular cells. The observations indicate that FNAC is a promising new approach to study testicular conditions in childhood ALL and NHL. A larger prospective study and accumulation of additional follow-up data is required before a definitive evaluation of the technique can be made.

Noninvasive testicular screening in childhood leukemia

To evaluate the potential of transscrotal ultrasound and magnetic resonance imaging as noninvasive screening methods we studied 8 boys with acute lymphocytic leukemia before testicular biopsy. Ultrasonic images of the testes were performed in 4 patients, including 2 with negative and 2 with positive biopsies, and all images were interpreted as normal. Magnetic resonance images of the testes also were interpreted as normal in 4 patients, including 2 with negative and 2 with positive biopsies, and they were technically inadequate in the remaining 4. The results suggest that neither transscrotal ultrasonography nor magnetic resonance imaging as currently applied may substitute reliably for testicular biopsy as a screen for occult testicular leukemia.