Fertility status of patients with clinical stage I testis tumors on a surveillance protocol

Romantic and sexual relationships, body image, and fertility in adolescent and young adult testicular cancer survivors: a review of the literature

This review presents a summary of existing knowledge regarding the effect of testicular cancer along four broad domains, including romantic and sexual relationships, body image, and fertility. A total of 37 studies were reviewed. Of note, most research consists of older adult testicular cancer survivors, with very little research attention afforded to adolescent and young adult survivorship. Relationship status (i.e., partnered versus unpartnered) appears to play an important role as it relates to adjustment outcomes in testicular cancer survivors. In addition, sexual function (and thereby fertility) and body image are also frequently compromised. Implications regarding a lack of developmentally focused research on adolescent and young adult testicular cancer survivorship are discussed, along with recommendations for new research.

Infertility and testis cancer

Testicular cancer is the most common solid organ tumor in young men and affects men during their reproductive years. Current therapeutic regimens have significantly improved survival but often adversely impact fertility. Understanding the effects of testicular cancer, the systemic effects of neoplasia, and the effects of treatment protocols, such as radiotherapy, chemotherapy, and retroperitoneal lymph node dissection, is essential to restoring and maintaining fertility in men who have germ cell neoplasms.

Births using sperm retrieved via immediate microdissection of a solitary testis with cancer

OBJECTIVE

To determine the feasibility of achieving births using sperm retrieved from a solitary testis with cancer.

DESIGN

Prospective clinical study of azoospermic men with testis cancer in a solitary testis.

SETTING

Infertility patients in an academic environment.

PATIENT(S)

Azoospermic men with previous history of orchiectomy and testis cancer in a remaining solitary testis.

INTERVENTION(S)

Viable sperm were retrieved by immediate microdissection of paratumor testicular tissue from orchiectomy specimen.

MAIN OUTCOME MEASURE(S)

Live births were achieved using sperm from immediate microdissection of orchiectomy specimen with testis cancer.

CONCLUSION(S)

Azoospermic men with cancer in a solitary testis have potential for fertility.

Management of recurrence and follow-up strategies for patients with seminoma and selected high-risk groups

Seminoma is characterized by high sensitivity to both radiation and chemotherapy. Localized recurrences in the retroperitoneum after surveillance for stage I can be treated with radiotherapy; however, multiple or large bulky retroperitoneal recurrences or systemic metastasis requires cisplatin-based chemotherapy. Salvage chemotherapy for those who recur after initial CR to induction chemotherapy is based on ifosfamide- and cisplatin-containing regimens. Incomplete response or failure after induction chemotherapy requires high-dose chemotherapy and stem cell rescue. Patients with seminoma need long-term follow-up because of the possibility of late recurrence and the risk of a second primary tumor.

Gonadal function in patients with testicular germ cell tumors

The gonadal function of 18 patients with testicular germ cell tumors was evaluated. Seminal parameters after orchiectomy were examined in 15 patients. Six of them were available for follow-up observation after 2 or 3 courses of adjuvant chemotherapy. Serum gonadal hormones before and after orchiectomy were evaluated in 7 patients (testosterone and PRL were not examined in one patient). Five of 15 (33.3%), 8 of 15 (53.3%), 13 of 15 (86.7%), 7 of 13 (53.8%), and 9 of 12 (75.0%) had abnormal values in seminal volume, sperm concentration, motility, morphology, and vitality, respectively. The sperm concentration gradually improved after chemotherapy following orchiectomy in 5 of 6 (83.3%) patients. In all the patients examined, serum levels of follicular stimulating hormone (FSH), luteinizing hormone (LH), and prolactin (PRL) increased after orchiectomy. Serum levels of testosterone increased in 4 patients, but decreased in 2 after orchiectomy. These findings suggest that several factors, including preexisting intrinsic defect and disturbance of the hypothalamus-pituitary-gonadal axis, are involved in the deterioration of gonadal function in patients with testicular germ cell tumors.

Fertility issues and their management in men with testis cancer

Although a curable malignancy, testis cancer and its treatment have unique associated morbidities that largely affect reproductive dysfunction. In this focused review, the factors that contribute to infertility in men with testis cancer are outlined. The treatment-specific risks to fertility that accompany cancer management are also discussed. Contemporary methods of overcoming infertility in testis cancer patients are addressed, and several exciting and promising experimental approaches to the preservation or restoration of fertility for men with testis cancer are presented.

Fertility after chemotherapy for testicular germ cell cancer

OBJECTIVE

To investigate the impact of cytostatic chemotherapy on long-term fertility in patients with testicular germ cell cancer.

BACKGROUND

Many patients with testicular germ cell cancer show impaired spermatogenesis before undergoing cytotoxic chemotherapy. The known infertility before treatment and the reversibility of the fertility problems observed in some of them after successful anticancer treatment so far have prevented an assessment of the true impact of chemotherapy on long-term fertility. The introduction of a wait-and-see strategy (surveillance) for patients with testicular cancer and recent prospective trials comparing patients with and without cytotoxic chemotherapy now have provided the means for estimating the extent to which chemotherapy itself affects long-term fertility.

RESULT(S)

Whether spermatogenesis is impaired irreversibly by chemotherapy is determined by the cumulative dose of cisplatin. At cumulative doses > 400 mg/m2, irreversible impairment of gonadal function should be expected.

CONCLUSION(S)

At cumulative cisplatin doses < 400 mg (equivalent to 4 courses of state-of-the-art treatment), chemotherapy is unlikely to cause irreversible damage to fertility.

Cost- and risk-benefit considerations in the management of clinical stage I nonseminomatous testicular tumors

BACKGROUND

The high curability of clinical stage I nonseminomatous germ cell tumors (NSGCTs) and the availability of equally effective management options (retroperitoneal lymph node dissection [RPLND] and surveillance) allows for treatment decisions based on secondary end points, including sort- and long-term toxicity and cost relative to benefit. The purpose of this study was to perform cost-benefit and risk-benefit analyses of management options in clinical stage I NSGCT using data from the literature and Indiana University.

METHODS

The overall costs for 100 patients undergoing a primary RPLND were compared with the total costs of 100 patients managed by surveillance for clinical stage I disease. These two options were then analyzed in terms of survival, late relapse, acute and chronic toxicity (including fertility), and perioperative morbidity.

RESULTS

The overall costs of these two approaches were essentially identical. The two options were similar in terms of survival, although RPLND demonstrated superiority in terms of fertility, toxicity, and late relapse.

CONCLUSIONS

The choice of nerve-sparing RPLND or surveillance in clinical stage I NSGCT patient cannot be made on the basis of cost as a discriminator. Instead, the decision should be made based on patient desires, physician expertise, biological predictors, and short- and long-term toxicity.

Cost and risk benefit in the management of clinical stage II nonseminomatous testicular tumors

BACKGROUND

Two similarly effective treatment options exist for managing clinical low volume Stage II nonseminomatous germ cell testis tumors (NSGCT). Primary retroperitoneal lymph node dissection (RPLND) (with immediate adjuvant chemotherapy or chemotherapy at relapse) and primary chemotherapy have resulted in similar survival rates in large series. Because the chance for cure is similar with either approach, the cost and morbidity of therapy should be considered important discriminating factors in deciding which option to pursue for an individual patient. The purpose of this study was to undertake a cost/benefit and risk/benefit analysis of these two options using data and costs from the Indiana University experience.

METHODS

The overall direct costs for 100 patients undergoing primary RPLND were compared with the total direct costs of 100 patients receiving primary chemotherapy for low volume Stage II disease, including the costs of adjuvant chemotherapy, salvage chemotherapy in relapsing patients, and routine follow-up for a 5-year period. In addition, the two treatment options were analyzed relative to survival, late relapse, acute and chronic toxicity, (including fertility), and perioperative morbidity.

RESULTS

In this analysis, the overall 5-year costs of RPLND were significantly less than the costs of primary chemotherapy. The two options did not differ significantly in terms of survival or quality of life. Patients receiving RPLND were found to have an advantage also in terms of fertility, toxicity, and late relapse.

CONCLUSIONS

Treatment decisions for patients with clinical low volume Stage II NSGCT may be based on cost/benefit and risk/benefit considerations, including relative toxicity, long term cure rate, and individual patient preference. Patient compliance with follow-up, the specific expertise of the physicians, and the availability of specialized therapeutic care ultimately may influence such decisions.

Quality of life in long-term survivors of nonseminomatous germ cell testicular tumors

A total of 109 survivors of curative therapy for nonseminomatous germ cell testicular tumor was interviewed an average of 9 years after treatment to assess long-term physical, emotional and sexual sequelae. An age-matched group of healthy men were interviewed similarly as controls. Of the physical sequelae loss of ejaculation was prominent (30% of the patients) and appeared directly related to retroperitoneal lymph node dissection surgery (p < 0.01). Hypofertility was apparent among patients during the posttreatment period compared to controls (p < 0.01). Other physical complications were present in 35% of the patients and 8% were severe. Laparotomy was associated with incisional hernia and radiotherapy with gastrointestinal complications (p < 0.001). Psychoemotional status was similar among patients and controls before cancer diagnosis but 60% of the patients had obvious emotional problems during the treatment period, which were more severe in those who had a history of such problems. Anxiety, often with insomnia, affected 49% of the patients, while irritability and depression were noted in 34%. At the interview 30% of the patients versus 5% of the controls had psychoemotional dysfunction (p < 0.001) but half of the affected patients had a history of problems preexisting the diagnosis of cancer. Sexual complaints were encountered in 19% of the patients before cancer diagnosis compared to only 7% of the controls (p < 0.02). During cancer therapy 57% of the patients had sexual symptoms, primarily loss of erection and decreased frequency of intercourse. Residual problems were more prevalent among patients (38%) than controls (11%, p < 0.001). Sexual impairment was associated with direct treatment effects and persisted more often when symptoms developed during the treatment period. Although direct treatment related effects should decrease with modern single modality therapy, appropriate attention should be placed on counseling to help avoid long-term psychoemotional and sexual complications of the disease process and its treatment.

Effects of chemotherapy on fertility

Over recent years radical improvements in the treatment of malignant disease have resulted in the cure of patients in or approaching reproductive age, and with that cure, the effects on gonadal function have become apparent. Gonadal failure is particularly important in Hodgkin's disease, germ cell tumours, choriocarcinoma, and leukaemia, diseases of young people which are largely curable. Premature ovarian and testicular failure are easily missed by doctors concerned primarily with the erradication or arrest of a life-threatening disease, but for the patient the hormonal, psychological and social sequelae of treatment may be devastating. In this article we review the effects of chemotherapy on gonadal function and discuss the management of gonadal failure.

Germ cell function and hormonal status in patients with testicular cancer

Sperm counts, serum gonadotropins, and androgen levels were investigated in 39 seminoma patients and 58 patients with a nonseminomatous germ cell tumor of the testis after unilateral orchiectomy. In 58% of the patients, the total sperm count was below the lower reference value (80 million). A multiregression analysis demonstrated a correlation between a decreased total sperm count and the following three explanatory variables: (1) an elevated serum alpha-fetoprotein (AFP), (2) a history of chryptorchidism, or (3) a seminomatous tumor. In 42% of the patients, the sperm concentration and the sperm motility met criteria considered sufficient for cryopreservation. Serum follicle-stimulating hormone (FSH) was elevated in 33% of the patients. Androgens (serum testosterone [T] or urine 17-oxy-steroids [17-OS]) were subnormal in 5% of the patients, whereas serum luteinizing hormone (LH) was elevated in 14% of the patients without human chorionic gonadotropin beta-subunit (beta-HCG) in serum.