Management of the contralateral testis in patients with testicular germ cell cancer

Imaging of pediatric testicular tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper

Primary intratesticular tumors are uncommon in children, but incidence and risk of malignancy both sharply increase during adolescence. Ultrasound is the mainstay for imaging the primary lesion, and cross-sectional modalities are often required for evaluation of regional or distant disease. However, variations to this approach are dictated by additional clinical and imaging nuances. This paper offers consensus recommendations for imaging of pediatric patients with a known or suspected primary testicular malignancy at diagnosis and during follow-up.

Management and outcome of bilateral testicular germ cell tumors: Twenty-five year experience in Munich

We analyzed characteristics, therapy and outcome of patients with bilateral testicular germ cell tumor (TGCT) at our institutions. Among 1,180 TGCT patients diagnosed and/or treated between 1979 and 2003, 47 (4.0%) developed a second TGCT. Nine of 14 patients (64%) with synchronous TGCT are alive with no evidence of disease (NED) at a median follow-up of 37 months. Thirty-three patients had a metachronous bilateral TGCT. Median time to the 2(nd) TGCT was 71 months. At diagnosis of 2(nd) TGCT 30 patients had stage I, 1 had stage II and 2 had stage III disease. Thirty-two of 33 patients are alive with NED at a median follow up of 41 months. No patient died from second TGCT. As a review of the literature confirms our data we do not recommend a routine biopsy of the contralateral testicle for early detection of testicular intraepithelial neoplasia (TIN).

Contralateral intratubular germ cell neoplasia in a patient with testicular cancer

BACKGROUND

A 27-year-old man was referred to an oncology department following right orchiectomy for a stage I testicular seminoma at high risk for recurrence. He presented 6 weeks after the orchiectomy with an atrophic left testis, fatigue and a history of infertility.

INVESTIGATIONS

Measurement of serum levels of urea, electrolytes, liver enzymes, bilirubin, human chorionic gonadotropin, alpha-fetoprotein, lactate dehydrogenase, testosterone and luteinizing hormone, full blood count, and left testicular biopsy.

DIAGNOSIS

Tubular atrophy of the left testis with islands of intratubular germ cell neoplasia (ITGCN), and hypergonadotropic hypogonadism.

MANAGEMENT

The patient received adjuvant chemotherapy as a single dose of carboplatin for the seminoma at high risk for recurrence, and testosterone replacement for the hypergonadotropic hypogonadism. Radiotherapy to the ITGCN-bearing solitary testis or a second orchiectomy was offered to prevent the progression of ITGCN into an invasive germ cell tumor. After exploring his options with regards to fertility treatment, the patient chose to undergo second orchiectomy with a subsequent, unsuccessful, attempt at sperm retrieval. At 20 months after diagnosis of his initial seminoma the patient showed no sign of recurrence.

Bilateral testicular cancer: a preventable problem? Experience from a large cancer centre

OBJECTIVE

To report a retrospective review of patients with a testicular germ cell tumour treated in a large cancer centre who developed a second tumour, as 1.8-5% of such patients will subsequently develop a new primary tumour in the contralateral testis.

PATIENTS AND METHODS

From a database of 570 men treated for testicular cancer in the West of Scotland between 1989 and 1998, all those who developed bilateral testicular tumours were identified.

RESULTS

Nineteen men (3.3%) developed a second primary testicular malignancy; the mean age at diagnosis of the first tumour was 29.5 years, with the mean (range) interval to diagnosis of the second tumour of 76 (11-181) months (except for one man with synchronous tumours). The first tumour was teratoma in 11 and seminoma in seven; one patient had synchronous bilateral teratoma. The second primary was teratoma in 10 and seminoma in eight. Known risk factors for carcinoma in situ were present in nine patients, i.e. a small atrophic contralateral testis in five, a family history of testicular cancer in two, a history of infertility in two and unilateral undescended testis in one. Two patients had had contralateral testicular biopsies at the first diagnosis; both were negative for intratubular germ cell neoplasia (IGCN). Eight patients had chemotherapy to treat the first tumour and 14 for the second. All underwent bilateral orchidectomy. Overall, 18 of 19 men are alive and disease-free, with a median follow-up of 51 months. Pathology for 12 of the second testicular tumours was available for review; there was no IGCN in any of the slides from three patients, it was only present focally around the tumour in seven, and was diffuse in two patients.

CONCLUSIONS

Chemotherapy for the first testicular tumour does not eliminate the risk of developing a contralateral tumour. Despite careful follow-up, in most patients the second primary tumour was not diagnosed early enough to avoid chemotherapy. The focal nature of IGCN in the second testis in most patients questions the value of biopsy of the contralateral testis. Improved methods of detecting patients at risk of second testicular tumours are needed.

Endocrine function in patients treated for carcinoma in situ in the testis with irradiation

CIS is found in the contralateral testis in 5% of the patients with testicular germ cell cancer. The management of CIS in the contralateral testis is important because the majority - if not all - cases of CIS will progress to invasive disease without treatment. It is well documented that testicular irradiation with a total dose of 14-20 Gy (2 Gy x 7-10) is an effective and safe treatment for CIS in the contralateral testis in patients with unilateral testicular germ cell cancer. However few relapses of testicular cancer have been observed in testis treated with these regimens and the data on 14 Gy are sparse. One study has indicated that more radiotherapy with lower doses per fraction could be useful, but more data are needed to confirm this. Endocrine testicular function has been shown to be impaired already before treatment in patients with CIS and is further impaired after testicular irradiation with 14-20 Gy (2 Gy x 7-10) and only minor dose dependency is seen in the impairment of Leydig cell function. The optimal treatment of CIS in the contralateral testicle in patients orchidectomised for testicular cancer seems to be local radiotherapy of the testis with CIS in order to preserve at least a part of the Leydig cell function. However, the optimal dose level has to be defined.

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.

Effect of graded testicular doses of radiotherapy in patients treated for carcinoma-in-situ in the testis

PURPOSE

To determine the effect of radiotherapy in doses 14 to 20 Gy on eradication of carcinoma-in-situ (CIS) testis and on the Leydig cell function.

PATIENTS AND METHODS

Forty-eight patients presented with unilateral testicular germ cell cancer and CIS of the contralateral testis. The CIS-bearing testis was treated with daily irradiation doses of 2 Gy, 5 days a week, to a cumulative dose of 20 Gy (21 patients), 18 Gy (three patients), 16 Gy (10 patients), and 14 Gy (14 patients).

RESULTS

All patients treated at dose levels 20 Gy to 16 Gy achieved histologically verified complete remission without signs of recurrence of CIS after an observation period of more than 5 years. One of 14 patients treated at dose level 14 Gy had a relapse of CIS 20 months after irradiation. Leydig cell function was examined before and regularly after radiotherapy in 44 of 48 patients. The levels of testosterone were lower after radiotherapy than before. Testosterone showed a stable decrease for more than 5 years after treatment (3.6% per year) without dose dependency. The levels of luteinizing hormone and follicle-stimulating hormone were increased after radiotherapy. The need of androgen substitution therapy was similar at all dose levels.

CONCLUSION

Testicular irradiation is a safe treatment at dose level 20 Gy (10 x 2 Gy). Decrease of dose to 14 Gy (7 x 2 Gy) might lead to risk of relapse of CIS. Impairment of hormone production without clinically significant dose dependency is seen in the dose range 14 to 20 Gy.

Testis sparing surgery for the treatment of a sequential bilateral testicular germ cell tumor

Standard therapy of sequential bilateral testis cancer is generally considered to be orchiectomy. We present a case of sequential bilateral testicular germ cell tumor treated with testis sparing surgery. The patient was disease free 50 months after surgery without local recurrence or distant metastases. Testis sparing surgery provides a better quality of life and may be considered a safe, feasible alternative in the treatment of carefully selected patients with bilateral testicular germ cell tumor.

Carcinoma in situ in the testis

Carcinoma in situ (CIS) of the testis is a common precursor of germ-cell tumours in adults and adolescents, with the exception of spermatocytic seminoma. This article reviews existing knowledge on the pathobiology, genetic aspects and epidemiology of CIS, discusses current hypotheses concerning pathogenesis and invasive progression of germ-cell neoplasms and provides guidelines for diagnosis and clinical management of CIS.

Bilateral germ cell cancer of the testis: a report of 11 patients with a long-term follow-up

OBJECTIVE

To describe the incidence, clinical characteristics, treatment methods and long-term follow-up of bilateral germ cell tumours of the testis (GCTT) in patients treated at one institution.

PATIENTS AND METHODS

Of 552 patients with GCTT, 11 (2%, mean age 26. 9 years) developed bilateral disease; all 11 underwent radical orchidectomy. Additional treatment was planned according to the histological type and clinical stage of the tumour, and previous treatments. Intramuscular testosterone was administered periodically after total castration. The data on survival, sexual status and treatment complications were reviewed.

RESULTS

Of the 11 patients, seven developed a second tumour metachronously (median interval 87 months) and four had synchronous bilateral GCTT. Cryptorchidism, infertility or atrophic testis was associated with the development of bilateral GCTT in seven of the 11 patients. All synchronous tumours and most of the sequential tumours had identical histology on both sides. Although all sequential tumours presented at an early clinical stage, three of four synchronous bilateral GCTTs presented at an advanced stage. Five patients received platinum-based chemotherapy; three patients underwent post- chemotherapy resection of the retroperitoneal residual mass. Sexual libido and potency were conserved in all patients. No significant morbidity was recorded as being caused by any of these treatments. At a median follow-up of 11. 6 years, all patients were alive with no evidence of cancer.

CONCLUSIONS

All patients with unilateral GCTT have an increased risk of developing a contralateral testicular tumour, even decades after diagnosis. Management should be adapted to each patient. As all patients in this series survived in the long-term, developing a second germ cell cancer does not necessarily predict a poor prognosis.

Impaired testicular function in patients with carcinoma-in-situ of the testis

PURPOSE

To elucidate the biologic association between germ cell neoplasia and testicular dysfunction, through investigation of Leydig cell function and semen quality in men with carcinoma-in-situ (CIS) of the testis.

PATIENTS AND METHODS

We examined two groups of men, unilaterally orchidectomized for testicular cancer. Biopsy of the contralateral testis had showed CIS in a group of 24 patients and no evidence of CIS in the other group of 30 patients. Semen quality and serum levels of testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) were compared in these two groups of men after orchidectomy but before further treatment for testicular cancer.

RESULTS

Significantly higher LH levels (median, 8.1 IU/L v 4.8 IU/L; P < .001) and generally lower testosterone levels (median, 12.5 nmol/L v 15.5 nmol/L; P = .13) were found in the CIS group. The proportion of patients with Leydig cell dysfunction was higher in the group of patients with CIS (11 of 24) than in the group of patients without (two of 30) (P = .01). Sperm concentration and total sperm count were significantly lower (P < .001) in patients with CIS (median, 0.03 x 10(6)/mL and 0.10 x 10(6), respectively) than in patients without (median, 9.1 x 10(6)/mL and 32 x 10(6), respectively), whereas the levels of FSH were significantly higher (P < .001) in the former group of men (median, 19.6 IU/L v 9.0 IU/L).

CONCLUSION

Not only spermatogenesis but also Leydig cell function is impaired in testes with CIS. This impairment could be due to common factors in the pathogenesis of germ cell neoplasm and testicular dysfunction. Alternatively, CIS cells may have a negative impact on Leydig cell function.

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.

[Testicular intraepithelial neoplasms (TIN). An indication for radiotherapy?]

BACKGROUND

Testicular intraepithelial neoplasia (TIN), synonymous for carcinoma in situ of the testis, is a rarely observed preinvasive neoplasia located within the germinative epithelium. According to the current knowledge of the biology of TIN, it is the common precursor of all testicular germ cell neoplasms except spermatocytic seminoma.

MATERIAL AND METHODS

This report provides a review of histopathology, epidemiology and diagnostic procedures for TIN and discusses the therapeutic options with particular respect to radiooncological aspects.

RESULTS

TIN has a 70% rate of progression to invasive cancer within 7 years. Depending on the individual therapeutic setting surgery, chemotherapy and radiotherapy are alternative treatment modalities. In case of TIN in a single testis or bilateral TIN, local radiotherapy is the standard procedure. With 20 Gy recommended as standard dose in Germany, radiotherapy yields safe eradication of TIN. However, some of the patients show significantly reduced synthesis of testicular androgens. With respect to sporadic reports in the literature, total doses well below 20 Gy might be equally efficient to treat TIN safely. Yet, up to date neither the minimum dose for efficient treatment nor the toxicity profile after consecutive chemo-radiotherapy has been established.

CONCLUSIONS

The currently recommended standard dose of 20 Gy in Germany is probably in excess of the minimum dose needed for safe eradication of TIN. Thus, new radiooncological strategies should aim at reducing the total dose of treatment in order to minimize late side effects while maintaining the high efficacy of radiotherapy. This topic is under investigation in a multicenter clinical trial.

Bilateral Testis Germ Cell Tumours: Two Case Reports

The authors present 2 cases of bilateral testicular germ cell tumours occuring metachronously and synchronously. The usefulness of testicular contralateral biopsy at the time of inguinal orchiectomy is discussed. Advantages and problems concerning the new therapeutic approach of organ-sparing surgery for testicular bilateral germ cell tumours are reported.

The value of the biopsy of the contralateral testis in patients with testicular germ cell cancer: the recent German experience

PURPOSE

Testicular intraepithelial neoplasia (TIN; so-called carcinoma in situ of the testis), the precursor of testicular germ cell neoplasms can be detected by testicular biopsy many years before the clinical manifestation of the tumour. This study looked at the prevalence of contralateral TIN in patients with testicular germ cell cancer. The purpose was to evaluate this new approach of early detection of testicular cancer and to evaluate the current management strategies.

PATIENTS, METHODS

1954 consecutive patients with unilateral testicular germ cell tumour underwent contralateral biopsy. All specimens were examined immunohistologically with staining for placental alkaline phosphatase. Patients with TIN were usually submitted to low-dose radiotherapy of the testis. A rebiopsy was performed after 3 months. Endocrinological evaluations were done before, during and after treatment.

RESULTS

TIN was observed in 4.9% (95% confidence intervals 3.95%-5.91%). Testicular atrophy constitutes a 4.3 fold increased risk of having contralateral TIN. 64% of the cases with TIN were found in clinically normal testes. Patients with TIN were significantly younger than those without (p < 0.017). No case with TIN was found in patients older than 50 years. Three patients developed a second testicular tumour during follow-up despite a negative biopsy. After radiotherapy, all of 23 patients had complete disappearance of TIN in the rebiopsy. After chemotherapy, 3 of 10 patients had persistent TIN histologically. After radiotherapy, 12 of 41 patients required testosterone replacement.

CONCLUSION

The prevalence of contralateral TIN accords well with the known prevalence of bilateral testicular tumours. Testicular atrophy is a strong indicator for the presence of TIN but about 60% of TIN-cases occur without atrophy. Local radiotherapy to the testis with 18-20 Gy is efficaceous in eradicating TIN, but it causes significant damage to almost one quarter of these patients. Chemotherapy is an unsafe treatment for TIN. This study shows the feasibility of early detection of testicular cancer in a high-risk population by means of searching for TIN. Although the management of the condition still needs refinement, the TIN-concept offers an avenue for the early detection of testicular cancer and early conservative management.

Risk of a second germ cell cancer after treatment of a primary germ cell cancer in 2201 Norwegian male patients

The aim of this study was to evaluate the risk of developing a second germ cell cancer (SGCC) among male patients with a primary germ cell cancer (PGCC). SGCCs, all metachronous, developed in 60 out of 2201 males treated for a PGCC at the Norwegian Radium Hospital in Oslo from 1953 to 1990. Further, 8 patients had synchronous germ cell cancers. The relative risk (RR) of developing an SGCC was 27.6 (95% confidence interval (CI) 21.1-35.6), and the cumulative risk at 15 years of follow-up 3.9% (95% CI 2.8-5.0%). In patients with primary non-seminoma, the cumulative risk of an SGCC at 15 years of follow-up was 5.0% and in patients with primary seminoma 3.4%. Patients less than 30 years of age had a higher cumulative risk of 7.8% compared to 2.1% in older patients at 15 years of follow-up. The RR of an SGCC, however, was equal in patients with primary seminoma and in patients with primary non-seminoma. If the interval between PGCC and SGCC was < 5 years, the PGCC was most often followed by an SGCC of same histological type. Treatment applied for the PGCC did not seem to be of significant importance for the development of SGCC. In conclusion, patients with PGCC have high RR of developing an SGCC and age group < 30 years display an especially high cumulative risk.

Prognosis of testicular teratoma differentiated

OBJECTIVE

To determine whether the clinical course of patients with testicular teratoma differentiated (TD) and those with testicular teratoma undifferentiated justify a different follow-up protocol.

PATIENTS AND METHODS

Between 1979 and 1989, 16 adult patients with testicular TD were treated at the Royal Marsden Hospital. These represented 2.7% of the 592 testicular teratoma patients seen during this period. With the exception of a propensity to involve the right testis (76%), there were no differences in clinical presentation between TD and non-TD histological subtypes.

RESULTS

The mean follow-up was 55 months (range 7-137). Seven of the 16 patients had Stage I disease and were entered into surveillance programmes; one relapsed at 7 months. Ten men were treated with cisplatin or carboplatin-based chemotherapy for metastases, of whom three had had prior chemotherapy at other hospitals and were referred after relapse. In the seven previously-untreated chemotherapy group two patients failed. In the concurrent era, 375 patients with other subtypes of metastatic testicular non-seminoma were treated with chemotherapy and 47 (12.5%) failed (Progress Free Survival chi square (chi 2) = 2.73, P = 0.01). Although no difference in progression-free survival was demonstrated between TD and non-TD patients, the former had a worse overall survival probability (chi 2 = 9.02, P = 0.003); this may be an artefact due to the small number of events.

CONCLUSION

Despite the apparently more benign histology, it is recommended that the management of adult TD should not deviate from the general principles established for other histological subtypes of testicular teratoma.

Low-dose radiation therapy for testicular intraepithelial neoplasia

Four patients with unilateral testicular germ-cell tumor and biopsy-proven contralateral testicular intraepithelial neoplasia (TIN; so-called carcinoma in situ) received localized low-dose radiation therapy (18-20 Gy) of the testis with TIN. Repeated biopsies disclosed the disappearance of TIN and germ cells. No recurrence of TIN or germ cells was observed after a follow-up of 18-42 months. All patients reported a normal sex life without need of androgen supplementation. Serum follicle-stimulating hormone increased significantly immediately after radiation treatment and started to decline after 24 months. Serum luteinizing hormone increased slightly but not significantly. A decline after 24 months was observed in only one of three patients. Serum testosterone decreased significantly in all patients after 1 year but never became subnormal. Low-dose radiation treatment is efficacious in eradicating testicular intraepithelial neoplasia without destroying Leydig cells or stromal cells of the testis. Thus, a patient otherwise destined to develop a second testicular tumor can be spared orchiectomy and life-long hormonal replacement.

Paternity in a patient with testicular seminoma and contralateral testicular intraepithelial neoplasia

A 32-year-old patient with unilateral beta hCG-positive seminoma and contralateral testicular intraepithelial neoplasia (TIN; so-called carcinoma-in-situ) with no metastases (clinical stage I) received one course of adjuvant carboplatin therapy. He refused further treatment of TIN in his remaining testis. His wife became pregnant by him 4 months later and delivered a healthy child at term. This case shows that patients with TIN in their remaining solitary testis are not necessarily infertile, and testes afflicted with TIN must also contain tubules that retain normal spermatogenic potential. Surveillance may be an treatment option for patients with TIN in their remaining testis in cases where there is a strong desire for paternity.

Prevalence of bilateral testicular germ cell tumours and early detection based on contralateral testicular intra-epithelial neoplasia

The prevalence of bilateral tumours was found to be 4% in a retrospective analysis of 531 consecutive patients with testicular germ cell tumours. Patients with bilateral tumours were younger when their first tumour was diagnosed than those who had only 1 testicular tumour. Bilateral undescended testis was more frequent in 21 patients with bilateral tumours than in the total population of patients examined (2 of 21 versus 10 of 452, i.e. 9.5% versus 2.2%). Histology and unilateral undescended testis were not helpful in identifying patients at risk of developing a second tumour. In a separate study, 76 consecutive patients with unilateral testicular cancer underwent contralateral testicular biopsy at the time of orchiectomy. Five patients had testicular intra-epithelial neoplasia (TIN, so-called carcinoma in situ) in the contralateral testis; 1 of these patients had a history of bilateral undescended testis and 4 had an increased level of serum follicle stimulating hormone post-operatively. None of the other 71 patients had developed a second tumour after a median observation time of 30 months. Testicular biopsy and a search for TIN appear to be a safe method for the early identification of the patients at risk of developing a contralateral testicular tumour.

Bilateral testicular tumours: prevalence and clinical implications

In a series of 773 patients with the diagnosis of a testicular germ cell tumour, treated at Hannover University Medical School between 1972 and 1985 and with a median follow-up of 9 years (60-210 months), bilateral testicular tumours occurred in 27 (3.5%) patients. None of 157 patients receiving chemotherapy for metastatic disease of the first tumour developed a metachronous bilateral tumour. Of 24 patients with metachronous tumours 23 had stage I and 1 patient had stage II at the time of initial diagnosis. The second testicular tumour was stage I in 18 patients, stage II in 5 and stage IV in 1 patient. 3 patients (13%) relapsed after treatment for their second germ cell tumour (surveillance 13 patients, radiotherapy 7 patients, lymph node dissection 2 patients and chemotherapy 2 patients), 1 of which died after refusing further treatment. The cure rate was 96% in patients with bilateral disease. Routine biopsy of the contralateral testis to identify existing carcinoma in situ (CIS) is recommended. Patients with CIS must be informed about their increased risk of a second testicular tumour. Irradiation of CIS or close clinical follow-up might both constitute appropriate strategies for the management of these patients.