'Burned-out' primary testicular cancer

Burned-Out Testicular Carcinoma Presenting as Inferior Vena Cava Tumor Thrombus With Pulmonary Tumor Embolism on FDG PET/CT: A Case Report

ABSTRACT

"Burned-out" testicular tumor is a very rare clinical phenomenon, which refers to the presence of a metastatic germ cell tumor with no clinical findings in the testicle due to spontaneous regression of the primary testicular lesion. We present an unusual case of burned-out testicular embryonal germ cell carcinoma presenting as an extensive inferior vena cava tumor thrombus with malignant pulmonary embolism in which FDG PET/CT played a pivotal role in detecting the extent and significance of the disease.

Pure intertubular seminoma (PITS) of the testis: A multi-institutional cohort of a rare growth pattern of seminoma

Pure intertubular seminoma (PITS) of the testis is described as the presence of seminoma cells within the interstitium of testis without any evidence of diffuse growth pattern or mass lesion of classical seminoma. These tumors are clinically and grossly inconspicuous and are diagnosed incidentally or during investigations for testicular pain, infertility or other symptoms. Rarely metastasis is the first presentation. Microscopic identification can be difficult and poses a diagnostic challenge in the absence of a mass lesion. Seminomas with exclusive intertubular growth patterns were gathered in an international cohort. Diagnoses were confirmed by fellowship-trained or specialized urologic pathologists. Cases with the presence of a classical diffuse or nested pattern of seminoma or any other germ cell tumor component were excluded. The patient's age, tumor characteristics and additional clinicopathologic features were recorded and analyzed. 15 patients of pure intertubular seminoma (PITS) were collated. The mean age of presentation was 29 years. Patients presented with variable symptoms, including undescended testis (26%, n = 4/15), testicular heaviness/pain (20%, n = 3/15) infertility (20%, n = 3/15) and metastasis (6%, n = 1/15); presentation was unknown in 4 patients. Of note, none of the patients presented because of testicular mass. Serum markers were within normal limits in most patients (93%, n = 14/15) with available data. No tumors were identified macroscopically; however, an ill-defined, grey-white, firm area was noted in one orchiectomy specimen. Microscopically, tumor cells were seen in intertubular spaces as dispersed individual cells or small clusters. Tumor cells were round to polygonal with large nuclei and prominent nucleoli. Mild to moderate lymphocytic infiltrates were seen admixed with tumor cells in 40% (n = 6/15) of the tumors. GCNIS was present in association with most PITS (73%, n = 11/15). Tubular atrophy with thickening of the basement membrane and Leydig cell hyperplasia was observed in one tumor. Thirty-three percent (n = 5/15) of the tumors showed pagetoid involvement of rete testis, including the tumor with metastasis. All tumors showed the classical immunohistochemical profile of seminoma, with PLAP, c-KIT, OCT3/4, D2-40 and SALL4 positivity. PITS can be clinically & pathologically inconspicuous, difficult to stage and liable to be misdiagnosed especially if presented with metastasis. Despite the inconspicuousness, PITS may represent an aggressive growth pattern of seminoma with the propensity for rete testis invasion.

Long-term Outcomes of Regressed or "Burnt Out" Primary Testicular Germ Cell Tumors

OBJECTIVE

To review the presentation and long-term oncologic outcomes of patients with regressed ("burnt out") primary testicular germ cell tumors (GCT). Certain testicular GCT can present with complete regression of the primary tumor. It is not well established if this is associated with more aggressive disease or worse oncologic outcomes.

METHODS

We queried our prospectively maintained testicular cancer clinical database at a tertiary cancer center and identified patients without prior chemotherapy who had regressed primary GCT at radical orchiectomy from 1990 to 2023. All specimens were reviewed by a genitourinary pathologist at diagnosis. Long-term clinical outcomes were reported by Kaplan-Meier method.

RESULTS

Fifty-six patients met inclusion criteria; at diagnosis, 17 had no evidence of extra-testicular disease and 39 had advanced (clinical stage [CS] II+) GCT. All CSx (no viable disease or germ cell neoplasia in situ at orchiectomy, and no evidence of advanced disease) and CS0 patients were managed with surveillance and had 5-year recurrence-free survival (RFS) of 88% (95% CI: 39%, 98%). All patients with CS II+ disease underwent primary treatment with surgery (n = 5) or first-line chemotherapy (n = 34). Two- and 5-year RFS for patients with CSII+ disease was 94% (95% CI: 78%, 98%) and 90% (95% CI: 72%, 97%), respectively.

CONCLUSION

Patients with regressed primary testicular GCT often present with advanced disease, possibly due to lack of early clinical signs from the primary tumor. Our analysis shows excellent long-term oncologic outcomes similar to those reported in the literature for patients with viable primary testicular GCT.

Multiparametric Ultrasound for Diagnosing Testicular Lesions: Everything You Need to Know in Daily Clinical Practice

BACKGROUND

Ultrasonography (US) represents the gold standard imaging method for the assessment of testicular lesions (TL). The gray-scale (GSUS) and color-Doppler (CDUS) ultrasound examination allow sonographers to investigate the size, margins, echotexture, and vascular features of TLs with the aim to differentiate benign from malignant lesions. Recently, the use of contrast-enhanced US (CEUS) and sonoelastography (SE) has led to further improvements in the differential diagnosis of TL. Although GSUS and CDUS are often sufficient to suggest the benign or malignant nature of the TL, CEUS can be decisive in the differential diagnosis of unclear findings, while SE can help to strengthen the diagnosis. The contemporary combination of GSUS, CDUS, CEUS, and SE has led to a new diagnostic paradigm named multiparametric US (mp-US), which is able to provide a more detailed characterization of TLs than single techniques alone. This narrative and pictorial review aimed to describe the mp-US appearance of several TLs.

METHODS

An extensive Medline search was performed to identify studies in the English language focusing on the mp-US evaluation of TLs.

RESULTS

A practical mp-US "identity card" and iconographic characterization of several benign and malignant TLs is provided herein.

CONCLUSIONS

The mp-US characterization of TL reported herein can be useful in daily clinical practice.

Rare "Burned-Out" Testicular Mixed Germ Cell Tumor on 18 F-FDG PET/CT

ABSTRACT

Spontaneous regression of testicular mixed germ cell tumor is rare and is also called burned-out testicular tumor. We herein present the case of a 20-year-old man who was initially diagnosed with metastatic embryonal carcinoma. 18 F-FDG PET/CT demonstrated apparent metastases in the lymph node regions and both lungs. A covert right testicular lesion was noted according to the features on the CT component of PET/CT, which was subsequently confirmed as burned-out testicular mixed germ cell tumor.

Ultrasound and Magnetic Resonance Imaging of Burned-Out Testicular Tumours: The Diagnostic Keys Based on 48 Cases

The spontaneous regression of testicular germ-cell tumours is a rare event whose mechanisms have yet to be elucidated. In the majority of published cases, tumour regression is concomitant with the metastatic development of the disease. Residual lesions, often referred to as burned-out testicular tumours (BOTTs), are difficult to diagnose due to the paucity of published data, especially in the field of imaging. The aim of this article is to describe the radiological signs of BOTTs on multimodal ultrasound and multiparametric MRI from a series of 48 patients whose diagnosis was confirmed histologically. The demographic, clinical and laboratory characteristics of the patients are studied, as well as the data of the imaging examinations, including conventional scrotal ultrasound, shear-wave elastography, contrast-enhanced ultrasound (CEUS) and multiparametric MRI. A total of 27 out of 48 patients were referred for investigation of primary testicular lesion following the discovery of retroperitoneal metastases, 18/48 patients were referred because of lesions suspected on an ultrasound that was performed for an infertility work-up, and 3/48 were referred because of scrotal clinical signs. Of these last 21 patients (infertility work-up/scrotal clinical sign), 6 were found to be metastatic on the extension work-up. Of the 48 orchiectomy specimens, tumour involution was complete in 41 cases, and a small active contingent remained in 7 cases, with 6 suspected upon advanced US and MRI. Typically, BOTTs appear on a conventional ultrasound as ill-delineated, hypoechoic and hypovascular nodular areas. Clustered microliths (60.4%) and macrocalcifications (35.4%) were frequent. Shear-wave elastography showed areas of focal induration (13.5 ± 8.4 vs. 2.7 ± 1.2 kPa for normal parenchyma, p < 0.01) in 92.5% of the patients for whom it was performed, and contrast ultrasonography demonstrated hypoperfusion of these lesions. Of the 42 MRIs performed, BOTTs corresponded to nodules on T2-weighted sequences (hyposignal) with significantly increased ADC values compared with healthy parenchyma (2 ± 0.3 versus 1.3 ± 0.3 × 10−3 mm2/s, p < 0.01) and an enhancement defect after injection. This enhancement defect overlapped the lesions visible on T2-weighted sequences in most cases. In the case of predominant partial regression, an enhanced portion after contrast injection was visible on MRI in all seven patients of our series, and in six of them a focal diffusion restriction zone was also present. Spontaneously involuted testicular germ-cell tumours have specific radiological signs, and all of the mentioned examinations contribute to this difficult diagnosis, even histologically, because there is no tumour cell left. These signs are similar whether the patient is initially symptomatic metastatic or whether the discovery is fortuitous on the occasion of an infertility work-up, and whatever the seminomatous or non-seminomatous nature of the germ-cell tumour, when this can be determined. The appearance of regressed germ-cell tumours is often trivialized, which can lead to the wrong diagnosis of an extra gonadal germ-cell tumour (in metastatic patients) or of scarring from an acute event such as trauma or infection, which is not recognized or forgotten. In our series, two patients had an unrecognized diagnosis in their history, with local and/or distant recurrence. An improvement in diagnosing burned-out tumours, combining advanced US and MRI, is necessary in order to optimize patient management, with special attention paid to asymptomatic patients, to prompt extension screening and orchiectomy with analysis of the whole testis. This may reveal a persistent viable tumour or lesions of germinal neoplasia in situ, which are precursors of testicular germ-cell tumours.

Burned-Out Testicular Germ Cell Tumor Presenting as Retroperitoneal Lymphadenopathy in a Patient With Cryptorchidism: A Case Report & Review of Literature

Testicular germ cell tumors are the most common malignancy in young and middle-aged men. Spontaneous primary testicular tumor regression, or testicular tumor burn-out, is a rare clinical phenomenon where extragonadal metastatic lesions are observed concurrently with the spontaneous regression of the primary testicular germ cell tumors. Here, we describe the case of a 36-year-old male who presented to our hospital with left-sided abdominal pain and testicular swelling and was found to have significant retroperitoneal lymphadenopathy on his abdominopelvic CT scan. His testicular ultrasound showed multiple echogenic calcifications through the right testicle consistent with microlithiasis. Biopsy of the retroperitoneal lesion revealed a mixed germ cell tumor of testicular origin composed of embryonal carcinoma and teratoma. The patient received four cycles of bleomycin, etoposide, and cisplatin, followed by retroperitoneal lymph node dissection (RPLND) and radical right testicular orchiectomy. Here, we report the second case of burned-out testicular tumor in a patient with ipsilateral cryptorchidism. Furthermore, we elucidate the etiology, clinical presentation, and diagnostic modalities in burned-out testicular germ cell tumors.

Burned-Out Testicular Tumor Presenting as a Retroperitoneal Mass: A Case Report

Spontaneous primary tumor regression, or burned-out tumors, refers to the presence of a metastatic tumor with the histological regression of the primary lesion. The burned-out phenomenon has been reported in various malignancies, with testicular germ cell tumors (GCTs) accounting for a significant share of these cases. However, burned-out testicular tumors are a rare clinical phenomenon and are generally difficult to diagnose, as there is no evidence of primary testicular cancer. Here, we describe the case of a 42-year-old male who presented to our hospital complaining of right abdomen and groin pain for several months. On physical exam, the patient had normal genital and rectal exams. An abdominal-pelvic computed tomography (CT) scan of his abdomen and pelvis revealed a large retroperitoneal mass with radiographic characteristics of a sarcoma. Given his groin pain, the patient had a testicular ultrasound, which revealed scar tissue in the right testicle. His testicular tumor markers showed elevated β-human chorionic gonadotropin (β-hCG) and lactate dehydrogenase (LDH) but normal α-fetoprotein (AFP). He underwent right radical inguinal orchiectomy, with pathologic examination of the testicle revealing a burned-out testicular tumor. The patient was then treated with four cycles of bleomycin, etoposide, and cisplatin (BEP). His post-treatment tumor markers were normalized; however, his abdomen-pelvic CT scan showed a persistent mass. The patient underwent retroperitoneal lymph node dissection (RPLND) with the removal of 12 lymph nodes. However, pathologic evaluation of the lymph nodes revealed no evidence of neoplastic cells. The patient has remained disease-free after five years of follow-up.

This report highlights the potential of burned-out testicular tumors in young and middle-aged men presenting with a retroperitoneal mass. Furthermore, it underscores the importance of obtaining testicular ultrasound in these patients to rule out regressed testicular tumors.

'Burned-out' syndrome of testicular teratoma: A case report

The majority of testicular tumors are germ cell tumors (GCTs) which, although rare, frequently present in young adults. In exceptional circumstances, spontaneous regression of the primary tumor occurs. The appellation ‘burned-out’ is applied to situations in which a metastatic GCT is found to be present, accompanied by histological regression of the primary testicular lesion. It is of crucial importance that a clinical examination of the testis is performed, and scrotal sonography is essential in the preliminary diagnosis of such neoplasms. In the present case report, a burned-out, non-seminomatous testicular GCT case is described. A CT scan revealed that a 29-year-old male patient who was experiencing loss of weight and appetite had retroperitoneal and mediastinal masses. A testicular examination did not reveal the presence of any palpable lesion, and an ultrasound examination of the scrotum disclosed a normal left testis and an atrophic right testicle with heterogeneous architecture, but with no evidence of a tumor. Chemotherapy was administered to the patient following surgical intervention into the retroperitoneal and mediastinal mass. It is evident that it remains problematic to accurately differentiate between a primary retroperitoneal tumor and a metastatic testicular tumor with an occult testicular primary or a ‘burned-out’ testicular cancer. The burned-out phenomenon is a rare occurrence, and further research into its pathogenesis is required. Both the rarity of this phenomenon and the difficulties encountered in diagnosis prompted the writing of the present case report, especially considering that teratomas are categorized as belonging to the histology group that shows the least likelihood of regressing.

'Burned-Out' primary testicular tumour: Is retroperitoneal lymph node biopsy mandatory prior to initiation of chemotherapy? Report of three cases and a review of the literature

The term 'burned-out' tumour of the testis describes a spontaneously and completely regressed testicular tumour that presents at the stage of metastasis. We report three cases of burned-out testicular tumour to illustrate their clinical, radiological and histopathological features and to discuss the hypothesis of the efficacy of early adjuvant chemotherapy without a previous retroperitoneal lymph node biopsy. Subsequent to radical orchiectomy, each pathohistology report revealed testicular hypotrophy or microcalcifications, with no clearly visible germ cell tumours within the specimen. Additionally, following surgery, the patients received the standard (cisplatin-etoposide-bleomycin) chemotherapy protocol, which in two out of three cases showed a complete response. Only one examinee revealed a partial response and received salvage chemotherapy, but he remained in the remission phase during the last follow-up. This study illustrates the value of the early administration of adjuvant chemotherapy in patients with burned-out testicular tumour, which offers the possibility of omitting the diagnostic retroperitoneal lymph node biopsy. Considering the low threshold for testicular malignancy, it is clearly of the utmost importance that these rare patients be treated in a timely manner and without adjunctive procedures (lymph node biopsy) leading to additional morbidity.

A scoping review on the "burned out" or "burnt out" testicular cancer: When a rare phenomenon deserves more attention

The "burned out" or "burnt out" testicular cancer (BTC) indicates the spontaneous and complete regression of a testicular germ cell tumor in the presence of distant metastases at the diagnosis. As this condition was never reviewed systematically, a scoping review was conducted to scrutinize the available literature on clinical and histological features of BTC patients. Medline was searched from inception to 19 April 2020. A virtual cohort of 68 BTC patients was generated. Our findings highlighted some inconsistencies: BTC was diagnosed in 5,9% of patients not showing distant metastases and in 2,9% of patients who did not undergo an orchiectomy. Besides, evidence of residual tumor was found in 22,7% of testis specimens, recognized as seminoma in 40% of cases. The emerged inconsistencies may derive from the lack of an unequivocal definition of BTC. Larger collaborative studies are needed to define the best diagnostic workup and treatment for BTC patients.

Burned-Out Testicular Tumors in Adolescents: Clinical Aspects and Outcome

Purpose: Testicular germ cell tumors are the fourth most common neoplasm in adolescents, accounting for 8% of all tumors in the age group 15-19 years. On rare instances, the primary testicular lesion is not clinically or radiologically evident while nodal or visceral metastases represent the clinical manifestations of the disease. This phenomenon is described as "burned-out testicular tumor." In this paper, the authors report a single-institution experience with burned-out testicular tumors in adolescents and discuss their clinical implications. Patients and Methods: All the patients diagnosed with metastatic testicular germ cell tumors at Bambino Gesù Children Hospital between January 1, 2010, and June 30, 2020, were included in the study. Patients were categorized into two groups: "primary testicular" and "burned out." All the patients were staged and treated according to the AIEOP-TCGM 2004 protocol. Results: Eleven patients were classified as "primary testicular," and five patients were classified as "burned out." "Burned-out" tumors were associated with the presence of systemic symptoms compared to "primary testicular" tumors (80 vs. 0%; p = 0.0027) and higher aFP, hCG, and LDH levels (p < 0.00001). The "burned-out" population had a statistically significant higher incidence of relevant toxicity than the "primary testicular" population (80 vs. 18%; p = 0.0357) and a worse outcome in terms of both mean overall survival (15 vs. 43 months; p = 0.0299) and mean event-free survival (12 vs. 38 months; p = 0.0164). Conclusion: "Burned-out" testicular tumors seem to be a well-distinct clinical entity with a high treatment-related toxicity and poor prognosis. Further studies are needed to clarify the "burned-out phenomenon" and to identify more effective therapeutic strategies for these patients.

Successful treatment of a high-risk nonseminomatous germ cell tumor using etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine: A case report

BACKGROUND

Choriocarcinoma is an infrequent entity and the most aggressive subtype of germ-cell tumors. Because of early metastatic spread and rapid disease progression, choriocarcinoma patients display poor prognosis. Although etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine (EMA-CO) regimen is widely used to treat gestational trophoblastic tumors in females, its role in treating male choriocarcinoma is seldom reported.

CASE SUMMARY

A 32-year-old man was diagnosed with burned-out primary germ cell tumors (GCT) with retroperitoneum, liver and lung metastases. Biopsy of the liver revealed pure choriocarcinoma. The patient received bleomycin, etoposide, and cisplatin chemotherapy. After two cycles of treatment, response evaluation revealed the mixed response. EMA-CO regimen was used in the second-line therapy. After eight cycles, the patient showed a potentially resectable state and thus, all residual masses were surgically removed. The patient was completely cured, and 10 years later, he is leading a healthy life without complications.

CONCLUSION

This paper is the first case of high-risk nonseminomatous GCT in a male patient to be successfully treated with the EMA-CO regimen. The EMA-CO regimen can be used actively in patients with high-risk nonseminomatous GCT.

Rare Presentation of Burned-Out Testicular Seminoma

A 28 year old male who complained of abdominal pain over the past several months was found on CT to have lymphadenopathy along the right aspect of the inferior vena cava. The patient was subsequently seen by an oncologist where further work up of the lymphadenopathy was performed. A MR of the abdomen demonstrated right aortocaval and para-caval lymph nodes measuring to 3.7cm. A testicular ultrasound was then performed, which demonstrated an apparent peripheral focal hypoechoic region with no associated internal vascularity within the right testes. Biopsy of the retroperitoneal lymph nodes pathologically confirmed the diagnosis of seminoma. Keywords: Seminoma, Testicular Cancer, Retroperitoneal Adenopathy, Oncology, Burned-Out Tumor.

Expression of the immune checkpoint receptor TIGIT in seminoma

A characteristic feature of testicular seminoma is the abundance of immune cells in the tumor microenvironment, raising the possibility that immune checkpoint inhibitors may serve as a therapeutic option in these types of tumors. T cell immunoreceptor with Ig and ITIM domains (TIGIT) is an inhibitory immune checkpoint receptor in analogy to PD-1, and drugs targeting TIGIT are currently being investigated in clinical trials. Little is known about the expression of these proteins in testicular seminomas. Therefore the present study performed immunohistochemical analysis to determine the relative abundance of TIGIT and PD-1 in relation to the total CD3⁺ immune cell infiltration in a tissue microarray (TMA) constructed from 78 seminoma patients. The fraction of TIGIT⁺ and PD-1⁺ lymphocytes was highly variable in individual cancers and ranged from 2.3 to 69.4% (mean: 32.2±14.7%) for TIGIT and from 0.8 to 56.5% (mean: 21.6±13.2%) for PD-1. The same high degree of variability was also identified for the ratio of PD-1 to TIGIT positive cells, which varied from a dominance of TIGIT (PD-1: TIGIT ratio=0.02) in 74% of patients, to a predominance of PD-1 (PD-1: TIGIT ratio=12.5) in 23% of patients. In summary, the immune checkpoint receptors TIGIT and PD-1 are abundantly expressed in human seminomas. Once available, anti-TIGIT antibodies, possibly in combination with anti-PD-1 drugs, may be a reasonable therapeutic strategy for this type of cancer.

Spontaneous testicular tumor regression: case report and historical review

Spontaneous regression of a primary testicular germ-cell tumour (GCT), over time known as 'Burned out', 'Shrinking Seminoma', 'pT0', 'Burnout' or 'Spontaneous Regression', is an uncommon, generally metastatic phenomenon, which may present elevated tumour markers and a suspicious testicular ultrasound image. The histological study of the testicle demonstrated morphological changes of complete or partial tumour regression and found fibrous scarring and other characteristic changes of this phenomenon, which in some cases include vestiges of GCT. There are few publications on testicular GCT tumour regression and those that exist present limited data on the biology of the disease and its etiopathogenesis. This entity was recently recognised in the latest edition of the World Health Organization's (WHO) Classification of Tumours. We present our clinical, imaging, laboratory, cytohistological and management experience, as well as a historical review of the literature.

Is Testicular Macrocalcification a Risk for Malignancy?: Tumor Development on Ultrasonographic Follow-up of Preexisting Intratesticular Macrocalcification

Testicular macrocalcification is an uncommon finding when imaging the scrotum with ultrasonography (US). It is not normally a recognized risk factor for development of testicular malignancy, and patients are not usually offered follow-up US examinations or counseled for self-examination. This aspect is in distinction to patients with testicular microlithiasis (usually with an additional risk factor), who are offered follow-up on the assumption that microlithiasis is associated with malignancy. We report a series of 6 patients with predetermined testicular macrocalcification, with development of a malignancy on follow-up US. We encourage US follow-up examinations for patients with macrocalcification, potentially in a similar manner as for those with testicular microlithiasis.

Evanescence of Endometrial Carcinomas in Hysterectomy Specimens: Observations on the "Vanishing Cancer" Phenomenon

BACKGROUND

The phenomenon of vanishing carcinomas, first described in context of prostatic carcinomas, has been documented in endometrial carcinomas as well.

METHODS

The archives of the department were searched for case files of endometrial carcinoma diagnosed on endometrial curetting/biopsy but which did not reveal any cancer on the subsequent hysterectomy specimen. Clinical and pathological correlation was established.

RESULTS

A total of 5 cases were retrieved with biopsy-diagnosed endometrial carcinomas, 4 endometrioid and 1 serous type, which on subsequent hysterectomies did not reveal any tumor. These 5 cases represented 1.56% of total hysterectomies in our series. All were Stage Ia tumors, which on follow-up (mean = 18.2 months) did not show any local reoccurrence. Adjuvant therapy was instituted in 1 case in the form of pelvic irradiation in view of the serous histology. In all cases, the primary diagnosis was reconfirmed and any remote possibility of incorrect patient identification, laboratory errors, and institution of hormonal therapy were adequately ruled out along with an extensive endometrial sampling in hysterectomy.

CONCLUSION

The recognition of "vanishing endometrial carcinoma" as a distinct entity is of utmost importance to avoid mislabeling them as medical errors.

Burned-Out Testicular Cancer: Really a Different History?

Two or more histological types characterize more than 60% of testicular germ cell tumors (GCTs). Burned-out testicular tumor refers to partial or complete histological regression of the primary testicular lesions. The most frequent GCT type involved in this kind of histological regression is choriocarcinoma, followed by embryonal carcinoma. To our knowledge, there are no cases of the burned-out phenomenon in teratoma. We report a case of a 19-year-old man presenting to our institute with a right testicular lesion, evidence of mediastinal and abdominal lymph node metastasis, and high levels of GCT serum biomarkers. After orchiectomy, the histopathological examination showed a mixed GCT: mature teratoma, immature teratoma, and histological features of testicular cancer regression (burned-out phenomenon). The patient underwent first-line chemotherapy (BEP regimen) which resulted in a complete instrumental and biochemical response after 4 cycles. Teratoma is considered a less aggressive type of GCT. In this particular case, metastatic disease seems to result from non-germ cell components which underwent early spontaneous regression.

Brain Metastases as Presenting Feature in 'Burned Out' Testicular Germ Cell Tumor

Testicular germ cell tumors (TGCTs) are the most common malignancy in males aged 20 to 39, and the incidence is increasing. TGCTs have a tendency to grow rapidly with a high risk of metastatic spread. TGCTs generally present with a palpable testicular mass, yet may present less commonly with symptoms arising from metastatic disease.  A 24-year-old otherwise healthy male presented with progressive headaches. Initial imaging reported a single mass in the right frontal lobe. Complete surgical resection revealed suspicion for metastatic poorly differentiated carcinoma with an inconclusive immunohistochemical profile. Further staging scans revealed pulmonary and pelvic tumor deposits. Tumor markers with alpha-fetoprotein, beta-human chorionic gonadotropin, and lactate dehydrogenase were not elevated. Follow-up cranial magnetic resonance imaging revealed intracranial disease progression and he underwent whole brain radiation therapy. Additional outside pathology consultation for chromosomal analysis revealed features consistent with a TGCT. A scrotal ultrasound revealed a minimally atrophic right testicle. With evidence supporting the potential for response to chemotherapeutic treatment in TGCT, the patient was started on cisplatin and etoposide. Bleomycin was planned for the second cycle of chemotherapy if his pulmonary function improved.  A salient feature of all invasive TGCTs is a gain in material in the short arm of chromosome 12, and is diagnostic if present. Although the initial pathology revealed a non-diagnostic metastatic tumor, further testing revealed amplification of chromosome 12p. The examination of poorly differentiated carcinomas of an unknown primary site using light microscopy and immunohistochemical profiling alone may be inadequate, and should undergo molecular chromosomal analysis. This case is presented for its unconventional presentation and rarity of occurrence. It brings forward the discussion of both the commonality of TGCT in young male adults, as well as the anomaly of a 'burned out' phenomenon. With unreliable tumor markers, nonspecific symptoms, and pathological findings, 'burned out' TGCTs may account for a challenging diagnosis in a variety of cases, especially with the presenting symptom arising from a less common metastatic site. This case adds to the increasing literature on a rare entity of the 'burned out' TGCT, and upon literature review, presents itself as the first reported case presenting with brain metastasis.

Living outliers: experiences, insights and narratives of exceptional survivors of incurable cancer

AIM

Unexplained prolonged survival given a diagnosis of incurable advanced cancer is a puzzling phenomenon that recently has attracted more scientific research. The purpose of this study was to add to the understanding of how exceptional patients perceive and explain their unusual experience.

METHODS

We recruited patients for interviews from a population registry, patients with advanced lung or pancreatic malignancy who experienced exceptional survival.

RESULTS & CONCLUSION

In total, 15 participants were interviewed. The main recurrent themes in most of the interviews were patient-doctor communication, family support and the patient's proactive attitude. In this study, patients attribute their longevity to relationships with their doctor and their family - not the type of treatment they received. Further research on this phenomenon is needed.

[Cancer of unknown primary. Epidemiology and pathogenesis]

DEFINITION

The term cancer of unknown primary (CUP) describes by definition epithelial malignancies for which no primary tumor can be found after primary diagnostics have been performed.

EPIDEMIOLOGY

The CUP syndrome constitutes 2-3% of all fatal cases of malignancies in both men and women. The proportion of women has increased in parallel to the increase of tobacco consumption in women.

PATHOGENESIS

The most frequent origin appears to lie in the lungs or upper abdominal organs, while notable differences can be found between older autopsy findings and recent gene expression data with respect to identified primary tumors or tissue assignation. The fact that a primary tumor cannot be identified is probably based on various reasons: a complete regression of a primary tumor in isolated cases seems to be just as plausible as the misclassification of a primary tumor as a metastasis.

CONCLUSION

In combination with the fact that a primary tumor cannot be identified by autopsy in more than 20 % of cases, the important conclusion can be drawn that curative approaches seem appropriate for localized CUP cases.

Two Cases of Retroperitoneal Metastasis from a Completely Regressed Burned-Out Testicular Cancer

Introduction

Primary extragonadal germ cell tumors (EGCT) are rare and it is still a matter of debate if they have to be considered as primary extragonadal issues or metastases from a primary testicular neoplasm. We describe two cases of the so-called burned-out seminoma, a primary testicular germ-cell tumor that spontaneously regressed after demonstration of retroperitoneal metastases.

Cases Presentation

Two patients (35 and 50 years old, respectively) presented with CT findings of retroperitoneal masses. In both cases physical examination of the testis was not suspicious, and only scrotal ultrasound (SUS) showed parenchymal alterations such as scarring, calcifications and nodular lesions. Left orchiectomy and chemotherapy were then performed in both cases. Currently, they are both free of disease.

Conclusions

Although primary germ cell tumors may be of retroperitoneal origin, the likelihood of metastasis from a testicular primary origin should always be carefully considered in order to avoid misdiagnosis and to apply the best treatment schedule for the patients. Therefore, a testicular ultrasonography is mandatory in patients presenting CT findings of retroperitoneal adenopathy, even if patients are completely asymptomatic and their physical examination appears normal.

Spontaneous metastasis in mouse models of testicular germ-cell tumours

Testicular germ-cell tumours (TGCTs) are the most common cancer in young men; the incidence is increasing worldwide and they have an unusually high rate of metastasis. Despite significant work on TGCTs and their metastases in humans, absence of a mouse model of spontaneous metastasis has greatly limited our understanding of the mechanisms by which metastatic potential is acquired and on their modes of dissemination. We report a new model of spontaneous TGCT metastasis in the 129 family of mice and provide evidence that these are true metastases derived directly from primary testicular cancers rather than independently from ectopic stem cells. These putative metastases (pMETs) occur at similar frequencies among TGCT-affected males in six genetically distinct TGCT-susceptible strains and were largely found in anatomical sites that are consistent with patterns of TGCT metastasis in humans. Various lines of evidence support their pluripotency and germ-cell origin, including presence of multiple endodermal, mesodermal and ectodermal derivatives as well as cells showing OCT4 and SSEA-1 pluripotency markers. In addition, pMETs were never found in males that did not have a TGCT, suggesting that metastases are derived from primary tumours. Finally, pMETS and primary TGCTs shared several DNA copy number variants suggesting a common cellular and developmental origin. Together, these results provide the first evidence for spontaneous TGCT metastasis in mice and show that these metastases originate from primary TGCTs rather than independently from ectopic stem cells.

Scrotal sonography revisited

Sonography is the imaging modality of choice for the scrotum because it is simple, relatively inexpensive, and quick. Recent technological advances and transducer improvements have led to exquisite high-resolution detail in gray-scale as well as Doppler imaging. The purposes of this pictorial essay are to review the anatomy and embryology of the scrotal contents and to review the various scrotal and extrascrotal pathologic conditions, including acute scrotum, pediatric and adult testicular and extratesticular scrotal neoplasms, traumatic lesions, and miscellaneous other scrotal lesions.

Clinicopathological study of regressed testicular tumors (apparent extragonadal germ cell neoplasms)

PURPOSE

Testicular germ cell tumors sometimes regress spontaneously and manifest exclusively by metastasis. We report our experience with extragonadal germ cell tumors of probable testicular origin to study the frequency of this entity, and clinical, ultrasound and histopathological correlations in a series of patients.

MATERIALS AND METHODS

A retrospective 16-year review of 1.2 million inhabitants in Spain revealed 17 with regressed testicular tumors treated at a total of 4 institutions. We analyzed clinical information, ultrasound features and histopathological characteristics of testicular lesions and metastasis, and highlight the main findings.

RESULTS

A primary testicular origin was confirmed in all cases. This entity is more common than initially suspected since it accounts for 4% of consecutive germ cell tumors. Clinical manifestations varied according to metastatic site with an abdominal palpable mass (47% of cases), loin pain (35%) and transient testicular pain (29%) the most common complaints. No evidence of testicular neoplasms was found on physical examination in any case. Metastasis histology was nonseminomatous in 53% of cases, pure seminoma in 29% and mixed in 18%. The most common ultrasound features were calcifications in 65% of cases, hyperechogenic linear images in 59% and hypoechogenic nodular areas in 41%. Histological findings consisted of fibrotic areas in 100% of cases, hemosiderin deposits in 65%, seminiferous tubule atrophy in 59% and psammoma bodies in 29%. In testicular parenchyma or spermatic chord intratubular neoplasms and viable tumor foci were also noted (47% and 41% of cases, respectively).

CONCLUSIONS

Spontaneous regression of a germ cell testicular tumor should be considered in each patient with extragonadal germ cell neoplasms. Ultrasound diagnosis of and surgical treatment for these primary testicular tumors appear critical to prevent relapse because residual disease develops in a significant proportion of cases.

Burned-out testis tumour that metastasized to retroperitoneal lymph nodes: a case report

Introduction

Burned-out testicular tumour is a very rare clinical entity. There is no clinical finding in the testicle, because it regresses spontaneously with no treatment, and generally presents with metastases. Abdominal masses in young male patients may sometimes be caused by a metastatic burned-out testicular tumour. We report a patient with a burned-out testicular tumour that metastasized to retroperitoneal lymph nodes.

Case presentation

A 28-year-old man complained of an abdominal mass and continuously increasing pain over the previous 2 months. A midabdominal mass, atrophy and minimal induration in the right testis were revealed on physical examination. Ultrasound findings revealed focally increased echogenicity, which is typical of burned-out tumours. Inguinal orchiectomy was performed, and the histological examination of the biopsy specimen revealed a large area of hyalinization, tubular hyalinization, interstitial fibrosis and focal Leydig cell hyperplasia, with no abnormal pathological findings in the epididymis and spermatic cord. The final pathological diagnosis was concluded as "burned-out" testicular tumour. Surgical treatment was followed by appropriate chemotherapy and in the follow-up, the abdominal mass was observed to regress. The patient is currently free of disease 5 years after diagnosis.

Conclusion

For the detection of intratesticular lesions, especially in patients with extragonadal metastatic involvement and normal palpation findings for the testis, scrotal sonography is very important. A burned-out testicular tumour should be considered and testis biopsies should be performed if there is any risk factor of malignancy.

[CUP syndrome: molecular pathogenesis and biology]

Carcinoma of unknown primary (CUP) is an intriguing clinical finding defined as biopsy-proven metastasis from a malignancy in the absence of an identifiable primary site after a complete clinical workup. CUP is a relatively common clinical entity, accounting for approximately 3-5% of all cancer diagnoses, and consists of a heterogeneous group of tumors that have acquired the capacity to metastasize before the development of a clinically evident primary lesion. The mechanisms responsible for early metastasis and lack of a detectable primary tumor are largely unknown. Although remarkable tools have been developed for immunohistological classification of CUP on the basis of the likely tissue of origin, data on molecular pathogenesis and biology of this disorder are rare. A wide variety of chromosomal aberrations are seen in CUP, with aberrations of chromosomes 1, 6, 7, and 11 having been most frequently described. 66-75% of CUP express epidermal growth factor receptor while overexpression of Her2/neu seems to be rare. In contrast to most other tumor entities p53 mutations have been found only in a minority of CUP tumors. Recently, several independent studies have demonstrated proof of principle for the use of gene expression microarrays in identifying a primary site for CUP. Therefore, gene expression and also genomic profiling tools represent promising analytical approaches to assist with the management of CUP patients.

"Burned out" testicular seminoma presenting as a primary gastric malignancy

In contrast to primary gastric adenocarcinomas, germ cell tumors are potentially curable even when metastatic. It is therefore essential for clinicians and pathologists to be aware of the spectrum of unusual manifestations of germ cell malignancies. Here we report on a 55-year-old man who presented with clinical and endoscopic features indicative of a primary gastric carcinoma. Surprisingly, the ulcerative mucosal lesion was found to be due to a metastasis from an occult, "burned-out" testicular seminoma. This case describes the radiological and pathological features that helped differentiate this rare situation from the much more common gastric adenocarcinoma, and extends the diagnostic possibilities that must be considered in patients presenting with gastric ulcers.

Gastrointestinal hemorrhage as the first manifestation of metastatic extragonadal choriocarcinoma

Although germ cell tumors are the most common malignancy in young men, extragonadal germ cell tumors are rare. Gastric metastasis presenting initially as upper gastrointestinal hemorrhage is also exceedingly rare. A 27-year-old man presented at our hospital with tarry stool. Gastric fiberscopy images revealed a bleeding gastric polypoid lesion in the anterior wall of the gastric body, from which a biopsy specimen was obtained. Histopathological analysis of the biopsy showed syncytiotrophoblast-like cells with multiple, large nuclei, consistent with choriocarcinoma. Based on these results, our diagnosis was extragonadal retroperitoneal germ cell tumor with gastric metastasis.

Case of seminoma with possible spontaneous regression without extragonadal metastatic lesion

We present an extraordinarily rare finding of a testicular seminoma apparently in the process of spontaneous regression without accompanying metastatic lesion. A 35-year-old man visited our institute for persistent scrotal induration after the administration of antibiotics for several weeks. Ultrasonography and magnetic resonance imaging showed a capsulized tumor in his left atrophic testicle, without other visceral tumor or lymphadenopathy. We performed left radical orchiectomy. Histological examination revealed a fibrotic tumor with a small area of pure seminoma apparently undergoing spontaneous regression, and an intratubular germ cell neoplasia, unclassified, occurring diffusely. The patient is free of disease at 1 year after surgery.

Vanishing Endometrial Carcinoma

Three cases of histologically proven endometrial carcinoma (EmCa) demonstrated no residual carcinoma or biopsy site on the subsequent hysterectomy specimen. The shared identity of both endometrial biopsy and hysterectomy specimen was proven, and specimen misidentification was excluded in all 3 cases through successful DNA profiling. Just as vanishing cancer in prostatic carcinoma has recently been defined and accepted, it is suggested that vanishing EmCa can also be defined using specific pathological and clinical criteria. DNA profiling may serve to confirm the diagnosis. Vanishing EmCa is only a small subset within hysterectomy specimens that show no EmCa after a histological diagnosis of EmCa. The concept of vanishing EmCa may be useful in both clinical and medicolegal practice.

Upper gastrointestinal hemorrhage as a rare extragonadal presentation of seminoma of testis

A rare case of a gastric presentation of a seminoma with burned out primary testicular tumor is described. The patient initially presented with upper gastrointestinal hemorrhage. Endoscopic biopsies were suggestive of seminoma, and testicular ultrasound revealed a focal lesion and testicular microcalcification. Treatment consisted of bilateral orchidectomy, followed by four cycles of etoposide and bleomycin, where a complete response was achieved. Testicular histology was consistent with the "burned out" phenomenon and no tumor cells were found. There are only two previously reported cases of extragonadal seminoma in the stomach.

Testicular seminoma occurring 8 years after treatment of a metastatic extragonadal germ cell tumor

A 30-year-old man was admitted with a chief complaint of left-sided scrotal enlargement, and was diagnosed as having testicular seminoma after orchiectomy. Eight years earlier, he had been treated with chemotherapy for an extragonadal germ cell tumor, without orchiectomy, leading to complete remission. His histological diagnosis at that time was a germ cell tumor, composed of choriocarcinoma and embryonal carcinoma. He was followed up without testicular biopsy. Routine pretreatment testicular biopsy in patients with extragonadal germ cell tumor is controversial, but regular long-term follow up and information on the risk of developing a metachronous testicular tumor are needed after treatment of extragonadal germ cell tumors, even when there seems to be a partial or complete clinical response.

Mixed Nonseminomatous Germ Cell Tumor Presenting as a Subcutaneous Tissue Mass

Extragonadal germ cell tumors most commonly arise in the midline of the retroperitoneum or the mediastinum. Primary tumors involving the skin are very rare. Only one case of malignant primary germ cell tumor located in the skin has been reported. We present the case of a 44-year-old white man with a primary subcutaneous mixed nonseminomatous germ cell tumor. This man had a long-lasting subcutaneous lump of the breast, which became painful. Surgery revealed 3 juxtaposed nodules. Microscopic examination showed a mixed germ cell tumor with a 90% immature teratoma component and a 10% embryonal carcinoma component. Testicular ultrasound and computed tomography of the chest, abdomen, pelvis, and brain were normal. Serum human chorionic gonadotrophin, beta-human chorionic gonadotrophin, alpha-fetoprotein, and lactate dehydrogenase were within normal ranges. A further surgical excision was performed. The patient is presently alive with no evidence of disease after a follow-up of 7 years. Review of the literature indicates that primary cutaneous extragonadal germ cell tumors usually occur as cutaneous or subcutaneous solitary nodules or as ulcerated lesions. They mainly consist of mature teratomas in children. Only 2 cases have been reported in adults.