Treatment of testicular intraepithelial neoplasia (intratubular germ cell neoplasia unspecified) with local radiotherapy or with platinum-based chemotherapy: a survey of the German Testicular Cancer Study Group

BACKGROUND

The treatment of testicular intraepithelial neoplasia (TIN), the progenitor of testicular germ cell tumours (GCTs), is based on little data.

PATIENTS AND METHODS

Two hundred and twenty-eight GCT patients with contralateral TIN were retrospectively enrolled. Ten had surveillance, 122 radiotherapy to testis with 18-20 Gy, 30 cisplatin-based chemotherapy (two cycles), 51 chemotherapy (three cycles), and 15 carboplatin. The study end point was a malignant event (ME), defined as detection of TIN upon control biopsy or occurrence of a second GCT. The Secondary end point was hypogonadism during follow-up.

RESULTS

Numbers, proportions of ME, and median event-free survival (EFS) times were: radiotherapy N = 3, 2.5%, 11.08 years; chemotherapy (two cycles) N = 15, 50%, 3.0 years; chemotherapy (three cycles) N = 12, 23.5%, 9.83 years; carboplatin N = 10, 66%, 0.9 years; surveillance N = 5, 50%, 7.08 years. EFS is significantly different among the groups. Hypogonadism rates were in radiotherapy patients 30.8%, chemotherapy (two cycles) 13%, chemotherapy (three cycles) 17.8%, carboplatin 40%, surveillance 40%.

CONCLUSIONS

Local radiotherapy is highly efficacious in curing TIN. Chemotherapy is significantly less effective and the cure rates are dose-dependent. Though hypogonadism occurs in one-third of patients, radiotherapy with 20 Gy remains the standard management of TIN.

[Concordance of the Gleason score in prostate multibiopsy and definitive histology]

BACKGROUND

Due to an insufficient mean agreement between the Gleason score (GS) revealed from multibiopsy and definitive histology after radical prostatectomy (RP) of merely about 45 %, a modification of the GS including an elimination of GS 2-4 was -accomplished in 2005. The aim of the present study was to evaluate the concordance of GS and WHO grading in biopsy and definitive histology and to -determine parameters influencing the diagnostic accuracy of the biopsy and the prognosis.

MATERIALS AND METHODS

Within a 10-year-period before modification of the GS, radical prostatectomy was performed in 856 patients (study group, SG; mean age 64.2 years). The grade of agreement between GS and WHO grading in biopsy and definitive histology was calculated by kappa statistics (kappa) (for the complete and single time -periods). Furthermore, we assessed the univariable and multivariable influence of different preoperatively available parameters on disease-free survival (DFS). The mean follow-up period was 39 months (range: 10-139 months).

RESULTS

Undergrading of GS and WHO grading decreased continuously within the three time -periods in favour of a higher agreement regarding the histological results revealed from biopsy and definitive histology. However, we found only a poor to moderate agreement in the complete time period (kappa values of 0.354 for GS and 0.404 for WHO grading) that - with regard to both parameters - was improved by an increased number of biopsy cores taken. PSA value, clinical -tumour stage, number of positive cores (dichotomised at 34 %), annual RP case load (dichotomised at 75), and GS revealed an independent significant influence on DFS. Patients with GS 2-4 in the biopsy exhibited an upgrade to GS > or = 7 in only 5.7 %, and -showed, -independent of the definitive histology, a significantly better prognosis in comparison with patients presenting with a higher GS.

CONCLUSIONS

The results of the present study again suggest the independent prognostic impact of the GS revealed from biopsy. However, the concordance with the GS in the definitive histology remains deficient and is improvable by taking a higher number of biopsy cores. Although the elimination of GS 2-4 might be comprehensible for the pathologist's purpose, it results in a considerable loss of pretherapeutic prognostic information.

[Results of the randomised phase III study of the German Testicular Cancer Study Group. Retroperitoneal lymphadenectomy versus one cycle BEP as adjuvant therapy for non-seminomatous testicular tumours in clinical stage I]

OBJECTIVE

As 30% of non-seminomas in clinical stage I will progress during active surveillance, alternative adjuvant strategies of 2 cycles of bleomycin, etoposid, cisplatin (BEP) or nerve sparing retroperitoneal lymphadenectomy (RPLND) can be offered. The risk of relapse is reduced to 2% and 10%, respectively. Without prognostic markers and with lowered toxicity it is postulated that only one cycle of BEP could significantly reduce the recurrence rate in comparison to RPLND.

MATERIALS AND METHODS

Between 1996 and 2005, 382 patients were randomly assigned to receive either RPLND (n=191) or 1 cycle of BEP (n=191). In accordance with the protocol, 174 patients were treated with 1 cycle of BEP and 173 underwent RPLND. The primary study end-point was a reduction of recurrence from 10% after RPLND to a maximum of 3% after 1 cycle of BEP.

RESULTS

After a mean follow-up of 4.7 years, there were 2 and 13 recurrences in the according-to-protocol population with chemotherapy and surgery, respectively. The difference between chemotherapy (1.15%) and surgery (7.5%) was statistically significant (p=0.0033). The tumor-specific survival was 100%.

CONCLUSION

This largest randomized trial investigating treatment strategies in clinical stage I non-seminomas (AUO AH 01/94) showed the superiority of one cycle BEP over RPLND. The data obtained represent the basis for a reduced chemotherapy.

Optimised surgery (so-called TME surgery) and high-resolution MRI in the planning of treatment of rectal carcinoma

BACKGROUND

Since November 1998, we have applied the concept of total mesorectal excision (TME) to rectal carcinoma together with a standardised pathological quality assessment. Participation in the European MERCURY study [The MERCURY Study Group Radiology (in press), 2006] required us to establish the indication for neoadjuvant radiochemotherapy on the basis of an magnetic resonance imaging (MRI) scan. The aim of the present retrospective study is to evaluate the quality of the surgery, the efficacy of the MRI and the oncological outcomes achieved.

MATERIALS AND METHODS

Between November 2001 and October 2005, 68 out of 109 patients with carcinoma of the rectum were submitted to radical surgery in curative intent and 23/68 (34%) were given neoadjuvant therapy. In an interdisciplinary study group, each patient was evaluated pre-operatively and post-operatively using standardised MRI and histopathological methods.

RESULTS

The quality of surgery was established on the basis of the pathological examination of the surgical specimen. The rates of incomplete mesorectal excision, intra-operative tumour cell dissemination and positive circumferential margins were all low at 4%, 7% and 3%, respectively. The effectiveness of MRI proved to be greatest in predicting the tumour status at the circumferential resection margin: in the admittedly limited number of patients it proved possible to correctly predict the tumour status for every patient. The assessment of the anatomic extent of the primary tumour and of the regional lymph node metastasis according to the TNM system, in contrast, was considerably less successful at 73% and 75%, and 37% and 57%, respectively.

CONCLUSION

By applying the TME concept and MRI-based therapy planning, excellent results can be achieved and, at the same time, the number of patients requiring neoadjuvant treatment is considerably reduced.

Visual estimation of the tumor volume in prostate cancer: a useful means for predicting biochemical-free survival after radical prostatectomy?

Absolute and relative (ratio absolute tumor volume to gland volume) tumor volumes were visually estimated in 528 prostatectomy specimens. Surveying a mean post-surgical follow-up of 49 months, both parameters were analyzed regarding their aptitude for prognostication. We found relative tumor volumes exceeding 25% to independently predict biochemical recurrence reflected by post-surgical prostate-specific antigen progression, which was also determined to be increased to 28% when absolute tumor volumes exceeded 10 cm(3). However, this cutoff failed to be an independent prognosticator. Because the visual estimation of both parameters can easily be performed, they are felt to be formidable candidates for deriving prognostic information during routine procedures.

[Regression of germ cell tumors after chemotherapy]

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

European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG)

Germ cell tumour is the most frequent malignant tumour type in young men with a 100% rise in the incidence every 20 years. Despite this, the high sensitivity of germ cell tumours to platinum-based chemotherapy, together with radiation and surgical measures, leads to the high cure rate of > or = 99% in early stages and 90%, 75-80% and 50% in advanced disease with 'good', 'intermediate' and 'poor' prognostic criteria (IGCCCG classification), respectively. The high cure rate in patients with limited metastatic disease allows the reduction of overall treatment load, and therefore less acute and long-term toxicity, e.g. organ sparing surgery for specific cases, reduced dose and treatment volume of irradiation or substitution of node dissection by surveillance or adjuvant chemotherapy according to the presence or absence of vascular invasion. Thus, different treatment options according to prognostic factors including histology, stage and patient factors and possibilities of the treating centre as well may be used to define the treatment strategy which is definitively chosen for an individual patient. However, this strategy of reduction of treatment load as well as the treatment itself require very high expertise of the treating physician with careful management and follow-up and thorough cooperation by the patient as well to maintain the high rate for cure. Treatment decisions must be based on the available evidence which has been the basis for this consensus guideline delivering a clear proposal for diagnostic and treatment measures in each stage of gonadal and extragonadal germ cell tumour and individual clinical situations. Since this guideline is based on the highest evidence level available today, a deviation from these proposals should be a rare and justified exception.

[Endocrine tumors of the testis]

The most characteristic endocrine tumours of the testis are germ cell tumours and sex cord/gonadal stromal tumours. They include the primary carcinoid, the relation of which to teratomas is still unclear. In general, gonadal stromal tumours are rare, however, endocrine activity occurs in at least 10%-20%. Among gonadal stromal tumours, only Leydig cell tumours and Sertoli cell tumours are of practical importance. Endocrine disorders are mostly related to Leydig cell tumours (gynaecomastia, pubertas praecox). Although less frequent than the other gonadal stromal tumours, they can, in principle, occur. The large cell calcifying Sertoli cell tumour occurs in association with other complex disorders (i.e. Peutz-Jeghers syndrome). Valuable markers are: inhibin, calretinin, cytokeratin, melan-A, CD-99, Ki-67, androgen receptor and p53. As the conventional morphology and immunohistological markers frequently overlap, unclear cases should be referred to specialised centres.

False-negative biopsies for the diagnosis of testicular intraepithelial neoplasia (TIN)--an update

PURPOSE

Testicular intraepithelial neoplasia (TIN; or carcinoma in situ of the testis) is the precursor of testicular germ-cell tumours (GCT). It is detected by conventional surgical biopsy of the testis. To date, only little information is available in regard to the accuracy of the biopsy. False-negative biopsies have been reported only sporadically.

PATIENTS AND METHODS

Twenty-one patients who developed a testicular GCT despite a testicular biopsy negative for TIN were analysed clinically and histologically. The median age of the patients is 34 years. The median interval from biopsy to the clinical appearance of GCT is 39 months. Four of the 21 patients had their biopsy done within a previously reported multicentric study (n=1859 cases with negative biopsy including five cases with false-negative biopsy hitherto known). All of the biopsy specimens were re-examined immunohistologically. In 15 cases, the orchiectomy specimens were re-examined for the presence of TIN in the tumour-surrounding tissue.

RESULTS

In five cases, TIN was found in the biopsy specimen upon re-examination. In all of the 15 orchiectomy specimens there was evidence of TIN in the tissue adjacent to the tumour. In three biopsy specimens there were microcalcifications in the seminiferous tubules. Severe impairment of the spermatogenesis was observed histologically in only 3 of the 21 patients. The relative proportion of false-negative biopsies is 0.5% (95% confidence intervals (CI): 0.22%; 0.92%). The sensitivity of the biopsy to detect TIN is 0.914 (95% CI: 0.842; 0.959) and the overall accuracy is 0.995 (95% CI: 0.991; 0.9979). A total of 44 false-negative biopsies are reported to date.

CONCLUSIONS

False-negative biopsies for TIN do occur but the proportion is only 0.5%. There is no clear-cut clinical nor histological feature associated with false-negative biopsies. However, young age (i.e. <18 years) and intratubular microcalcifications should increase the clinician's and pathologist's vigilance. The majority of false-negative biopsies are caused by the non-random distribution of TIN in the testis while some few cases are caused by technical problems. Two-site biopsies would probably increase the accuracy of the biopsy in high risk cases.

Radiotherapy with 16 Gy may fail to eradicate testicular intraepithelial neoplasia: preliminary communication of a dose-reduction trial of the German Testicular Cancer Study Group

Low-dose radiotherapy to the testis is effective in eradicating testicular intraepithelial neoplasia (TIN, carcinoma in situ of the testis) at the risk of androgenic deficiency. The present trial was designed to define the lowest dose effective to control TIN assuming a dose-response relation of radiation-induced endocrinological damage. Patients with TIN in a solitary testicle or with bilateral TIN were treated with 18 Gy (14 patients) and 16 Gy (26 patients) (5 x 2 Gy per week). Biopsies to ascertain clearance of TIN were performed after 6 and 24 months. The median time of follow-up is 20.5 months. There were three adverse events. In one patient, relapse of TIN along with microinvasive seminoma was observed 2 years after 16 Gy irradiation. In two other patients, persistent spermatogonia were observed with the 16 and 18 Gy regimen after 6 and 24 months, respectively. All other post-treatment biopsies showed the Sertoli cell-only pattern. These results confirm that TIN is a radiosensitive lesion efficiently controlled in most cases with doses below 20 Gy. However, sporadic failures may occur. A dose of 16 Gy is probably unsafe and should no longer be used. Future investigations should not only focus on total dosage of irradiation but also on fractionation schedules.

Testicular germ cell cancer despite previous local radiotherapy to the testis

BACKGROUND

Testicular intraepithelial neoplasia (TIN, also carcinoma in situ of the testis) is the uniform precursor of testicular germ cell cancer. Local radiotherapy to the testis with dosages of 18-20 Gy has been found to safely eradicate TIN and germ cells, too. Thus, the general assumption is that the development of invasive germ cell tumours can be prevented by this radiotherapy.

PATIENTS AND METHODS

Herein, we report two patients with one-sided testicular tumour and biopsy-proven contralateral TIN. Both of them developed germ cell neoplasms in the remaining testis although local radiotherapy with 20 Gy had been applied to the testis.

RESULTS

One patient developed pure seminoma 7 years after completion of radiotherapy, the other developed a combined tumour consisting of embryonal carcinoma and seminoma after 5 years. Treatment consisted of orchiectomy in each of the cases. Histologically, both had TIN in the testicular tissue surrounding the new growths.

CONCLUSIONS

Pathogenetically, a small fraction of radioresistent TIN cells overcoming irradiation and progressing to full-blown germ cell cancer in the later course may be the histogenetic clue to explain these unexpected events. Other explanations, though less probable, could be technical radiotherapeutic failure due to targeting problems and a pre-existing radioresistent germ cell tumour in the irradiated testicle.

Quantity and rigor of qualitative research in four pastoral counseling journals

Examines the quantity (N = 26) and rigor of qualitative research in The Journal of Pastoral Care, Pastoral Sciences, Journal of Religion and Health, and Pastoral Psychology for 1993-1997. Defines qualitative research using the work of Douglas Sprenkle and Sidney Moon. Uses the eleven criteria developed by Nicholas Mays and Catherine Pope in British Medical Journal for judging rigor. Finds low quantity and mixed quality and discusses implications.

[Pathology and pathomorphologic diagnosis of germ cell tumors of the testis]

Testicular germ cell tumors are rare and comprise about 90% of all testis tumors. Genetic factors may play a role in the pathogenesis as can be deduced by a higher family-linked incidence and the p53 gene seems to be important in the development of these tumors which derive from a malignant transformed germ cell. Testicular intraepithelial neoplasia (TIN) may differentiate in two directions, namely into seminomas which comprise nearly 50% of all testicular germ cell tumors and non-seminomas. Since the term "differentiated teratoma" may be misleading, we propose the use of the term "teratoma" only. A preoperative diagnosis by biopsy is not indicated. An exact postoperative diagnosis including all necessary classifications, particularly the WHO and the TNM classifications, requires a very careful preparation of the resected specimen. The histological diagnosis should list all the different types of the WHO classification and the percentage of the tumor should be indicated, at least for embryonal carcinomas. For T categorisation in the TNM classification, the presence of invasion of veins or lymph vessels is important. Documentation, preferably in the form of a standard checklist, is strongly recommended.

[Management of testicular intraepithelial neoplasia (TIN)--a review based on the principles of evidence-based medicine]

Testicular intraepithelial neoplasia (TIN; also called carcinoma in situ of the testis) is the uniform precursor of testicular germ cell tumors. There is general agreement on the biological significance of TIN, however, the treatment is still a matter of dispute. The present review summarizes the treatment options currently available. In general, the management of TIN has to be adapted to the particular clinical situation of the patient. Eradication of TIN usually implies the loss of fertility. Therefore, fertility aspects should be considered before any kind of treatment is employed. Usually, patients with TIN have only small residual potential of fertility. Nonetheless, individual patients may qualify for sperm banking or cryopreservation of testicular tissue for future sperm extraction (TESE) and assisted fertilization. The most common clinical situation is the case of contralateral TIN in the presence of unilateral testicular cancer. Low dose radiotherapy to the testis with 18 Gy is the standard management option in these patients. The same procedure may be applied to solitary testicles after partial orchiectomy for germ cell tumors. During follow-up, testosterone levels should be evaluated every six months. If chemotherapy is required due to metastatic disease of the primary tumor management of TIN should be deferred. After chemotherapy 30% of TIN cases will persist and approximately 42% will recur in the later course. Repeat biopsy should be done six months after completion of chemotherapy or later. Only in cases with persistent TIN additional radiotherapy should be administered. If one testicle is afflicted with TIN while the other testis is in healthy condition (conceivable in infertility cases or patients with primary extragonadal germ cell tumors), then the TIN-bearing testis should be excised. Radiotherapy is not feasible in these cases because of shielding problems with the healthy testis.

Risk factors for relapse in stage I non-seminomatous germ-cell tumors: preliminary results of the German Multicenter Trial. German Testicular Cancer Study Group

Risk factor analysis to identify low-risk patients for occult metastatic disease (vascular invasion, percentage embryonal carcinoma, MIB-I proliferation rate) yields reliable results if performed by experts. A correct prediction is possible at the 90% level. Similar accuracy, however, may be achieved if the computed tomography (CT) staging is optimized and the evaluation performed by an experienced investigator. The combination of both methods (biological risk factor analysis and CT staging) may virtually exclude the risk of relapse in a limited number of patients. However, so far, no risk factor that is able to reliably predict occult metastatic disease or relapse in clinical state I patients has been identified in prospective trials. The preliminary results of the current German Multicenter Trial suggest an inferior value of prediction for low-risk patients if risk factor analysis and/or CT staging is performed in non-specialized centers.

False-negative biopsies for testicular intraepithelial neoplasia

PURPOSE

Testicular intraepithelial neoplasia, also called carcinoma in situ of the testis, is diagnosed by conventional surgical biopsy based on the assumption that testicular intraepithelial neoplasia is randomly distributed throughout the testis. We evaluate the frequency of and possible reasons for false-negative biopsies.

MATERIALS AND METHODS

Contralateral testicular biopsy was performed in 1,954 consecutive patients with testicular germ cell tumor. Of the patients 1,859 with a negative biopsy for testicular intraepithelial neoplasia were followed for a median of 6 years. Patients with a second testicular tumor despite previous negative biopsy were evaluated clinically and biopsy specimens were reexamined immunohistologically.

RESULTS

Despite negative biopsy 5 patients had a second testis tumor. Testicular intraepithelial neoplasia was detected on reexamination in 2 of the specimens, and mechanical damage to the specimen and technical problems with immunohistochemical staining accounted for the diagnostic failures. The proportion of false-negative biopsies was 0.3% (95% confidence intervals [CI] 0.087 to 0.627). The sensitivity of testicular biopsies to detect testicular intraepithelial neoplasia was 0.95 (95% CI 0.887 to 0.984) and the overall accuracy of the biopsy was 0.997 (95% CI 0.994 to 0.999). To our knowledge 14 cases have been previously reported in the literature, including 2 treated with chemotherapy before testicular biopsy.

CONCLUSIONS

The overall proportion of false-negative biopsies for testicular intraepithelial neoplasia is as low as 0.3%. The main reason for diagnostic failure is probably the nonrandom distribution of testicular intraepithelial neoplasia within the testis. Previous chemotherapy and rare technical failures, in particular mechanical damage to the biopsy specimen, may also account for diagnostic failures. Surgical biopsy remains the gold standard for the diagnosis of testicular intraepithelial neoplasia.

[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.

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.

[Problems in diagnosis and therapy planning in a patient with retroperitoneal yolk sac tumor. Case report and review of the literature]

The case of a 26 years old patient with a primary paraaortic extragonadal yolk sac tumor is presented. After operative reduction of the tumor polychemotherapy with PEB was performed. Following chemotherapy testicular biopsy did not show histological changes typical for testicular intraepithelial neoplasia (TIN). Three years after the initial manifestation of the yolk sac tumor, a malignant tumor of the testis with components of undifferentiated teratoma and yolk sac tumor was observed. In this paper the problems of development of testicular malignancy after polychemotherapy and the validity of a small exploratory excision of testicular tissue in retroperitoneal germ cell tumors and following chemotherapy are discussed.

Knowledge-based system ADNEXPERT to assist the sonographic diagnosis of adnexal tumors

ADNEXPERT is a knowledge-based system for the computer-assisted ultrasound diagnosis of adnexal tumors. In a case-based approach, ADNEXPERT used histopathologic and sonographic data from 2,290 adnexal tumors. After an ultrasound examination, the gynecologist interacts with the system. A maximum of 15 questions are posed; all but one question (age) relate to the sonographic findings. The help system gives online access to an ultrasound image library. Once the dialogue is complete, ADNEXPERT assesses the adnexal tumor pathology and makes a histological classification. A certainty factor (CF) model is used for knowledge representation. The CFs of the knowledge base are computed from the case database. During system evaluation, the accuracy of ADNEXPERT was tested by 69 new adnexal tumor cases, for which verified histopathological diagnoses were available. ADNEXPERT accurately assessed pathology in 49 cases (71%); in 10 cases (14%) correct indications to pathology were given; no diagnostic hints were attained in 2 cases (3%); and 8 cases (12%) were falsely diagnosed. Based on the positive results of the evaluation, ADNEXPERT will be tested under clinical conditions.

Prevalence of contralateral testicular intraepithelial neoplasia in patients with testicular germ cell neoplasms

PURPOSE

Testicular intraepithelial neoplasia ([TIN], so-called carcinoma in situ of the testis) is hypothesized to be the precursor of testicular germ cell neoplasms. According to previous studies, it can be detected by testicular biopsy. Since patients with a unilateral testicular tumor are at high risk of a second testicular tumor, it seemed feasible to examine the prevalence of contralateral TIN in patients with testicular germ cell cancer and correlate it with the known prevalence of bilateral testicular tumors. The aim was to provide more evidence for the role of TIN as the preinvasive stage of testicular cancer.

PATIENTS AND METHODS

Nineteen hundred fifty-four consecutive patients with a unilateral testicular germ cell tumor underwent contralateral biopsy. All specimens were examined immunohistologically.

RESULTS

TIN was observed in 4.9% (95% confidence interval [CI], 3.95% to 5.91%). Testicular atrophy and a history of undescended testis were more frequently observed in patients with contralateral TIN, but only atrophy was shown to be independently associated by multivariate analysis. Patients with testicular atrophy have a 4.3-fold increased risk of having contralateral TIN. Sixty-four percent of TIN cases were found in normal testes. Patients with TIN were significantly younger than those without (P < .0017). Three patients developed a second testicular tumor despite a negative biopsy for TIN.

CONCLUSION

The prevalence of contralateral TIN corresponds well to the known prevalence of bilateral testicular tumors. Testicular atrophy is a strong indicator for the presence of TIN, but approximately 60% of TIN cases occur without atrophy. The present data are in accordance with the theory that TIN is an early step in the histogenesis of testicular germ cell neoplasms.

Testicular microlithiasis: case report and discussion of management under special consideration of testicular germ cell tumours

We report a case of testicular microlithiasis in a 24-year-old man who was referred to us for evaluation of unclear ultrasonographic appearance of his testes while being examined for bilateral varicocele and epididymal cysts. Since testicular microlithiasis has been found to be associated with testicular germ cell tumours we suggest a diagnostic work-up with testis biopsy to rule out testicular intraepithelial neoplasia (so-called carcinoma in situ) in otherwise normal appearing testis.

CD30 antigen in embryonal carcinoma and embryogenesis and release of the soluble molecule

The expression, serological detection, and possible functional role of the CD30 antigen in Hodgkin's disease and anaplastic large cell lymphoma is well documented. In embryonal carcinoma (EC), the expression of this cytokine receptor has been demonstrated only by immunohistology. Because the CD30 monoclonal antibody Ki-1 was found to cross-react with an unrelated molecule, we examined by in situ hybridization testicular germ cell neoplasms for the presence of CD30-specific transcripts. CD30 mRNA was detectable in the tumor cells of 9 of 9 cases of EC or mixed germ cell tumors with an EC component but in no other nonlymphoid tumors. Thus, the CD30 transcript expression pattern proved to be identical to the immunostaining pattern seen with the CD30-specific monoclonal antibody Ber-H2. By Northern blot analysis, CD30 transcripts could be demonstrated in the EC cell line Tera-2. Employing a highly sensitive second generation sandwich enzyme-linked immunosorbent assay, we could detect the soluble CD30 molecule in 8 of 8 sera from patients with a diagnosis of EC but not in 8 of 10 sera from patients with other testicular germ cell tumors. In fetal tissue, no CD30-expressing germ cells or epithelial cells could be observed. Thus, the cellularly expressed CD30 marker for testicular neoplasms of EC type. Moreover, the serum levels of soluble CD30 antigen seem to be a promising parameter for monitoring patients with EC.

Intratesticular effects of cisplatin-based chemotherapy

The question is addressed whether cisplatin-based chemotherapy for germ cell cancer has the same efficacy in intratesticular and in extragonadal sites. For this purpose, 7 patients with germ cell cancer, aged 16-35 years were analysed. Four of the patients had palpable testicular tumors, 3 had occult testicular tumors. All presented with advanced disease and therefore received chemotherapy as the first step of treatment. Orchiectomy was done in the later course. A significant clinical response to chemotherapy was observed at the intratesticular tumor site as well as at extragonadal sites in all patients. Orchiectomy specimens contained viable cancerous cells in 2 patients after two courses of chemotherapy while in 5 patients no invasive germ cell cancer was found. Severe depression of germ cells was observed in all specimens. Testicular intraepithelial neoplasia (TIN; carcinoma in situ) persisted in 4 patients, 1 of whom also had viable cancerous cells in the specimen. Cisplatin-based chemotherapy is also active in intratesticular tumors but there seems to be a slightly different response of metastatic germ cell cancer and intratesticular tumor. Tumor heterogeneity appears to be the most important reason for this different response. The lower response of TIN to chemotherapy as compared to invasive testicular cancer is probably due to a genetically determined lower sensitivity. The blood-testis barrier might contribute a minor part to this phenomenon by modulating the intratubular concentrations of cytostatic compounds. The efficacy of cisplatin-based chemotherapy on invasive intratesticular tumors is not compromised by the blood-testis barrier.(ABSTRACT TRUNCATED AT 250 WORDS)

Testicular dermoid cyst in a 10-year-old child: case report and discussion of etiopathogenesis, diagnosis, and treatment

The case of testicular dermoid cyst in a 10-year-old boy who presented for evaluation of a presumed testicular neoplasm is reported. The dermoid cyst was confirmed histologically on frozen section and local excision was performed. Only 5 cases of testicular dermoid cysts in children have been reported so far. We discuss the etiopathogenesis, diagnosis, and treatment.

Idiopathic calcinosis of the scrotum--a specific entity of the scrotal skin. Case report

A 69 year old patient with relapsing idiopathic scrotal calcinosis (ICS) is presented. Histological evaluation of the excised material showed the typical morphological features of calcified material within the corium. A review of the literature revealed 12 of 75 patients who had evidence of epithelial lining of the corial calcifications. Generally the calcified masses were surrounded by granulation tissue with mononuclear and foreign body giant cells. There is accumulating evidence for dystrophic calcification of cyst rather than an idiopathic genesis.

Management of contralateral testicular intraepithelial neoplasia in patients with testicular germ-cell tumor

Contralateral biopsies from 1810 consecutive patients with testicular germ-cell tumor were examined immunohistologically by staining for placental alkaline phosphatase. Contralateral testicular intraepithelial neoplasia (TIN; carcinoma in situ) was found in 89 patients (4.9%; 95% confidence interval, 3.9%-5.9%). Testicular atrophy was present in 45.9% of patients with TIN and in 13.1% of those without TIN (P < 0.01). There was a history of cryptorchidism in 16.2% of patients with TIN versus only 8.5% of those without TIN (P < 0.05). Patients with contralateral TIN presented at an earlier age (30.8 versus 33.3 years). In all, 23 patients with contralateral TIN had no specific risk marker. In 14 patients with contralateral TIN who had received local radiotherapy of 18-20 Gy to the testis, rebiopsy revealed the disappearance of TIN in all cases. Serum testosterone levels were within or above the normal range in 7 of 13 patients examined after local radiotherapy. Of 9 patients with contralateral TIN who had received chemotherapy, 2 were shown to have persistent TIN at rebiopsy. We conclude that all patients with testicular germ-cell tumor should be offered a contralateral biopsy. Local radiotherapy of the testis is the treatment of choice in patients with contralateral TIN.

Epidermoid cyst of the testis: a review of clinical and histogenetic considerations

OBJECTIVE

To review the records of patients with epidermoid cysts and those with germ cell tumours to determine the most appropriate method of treatment.

PATIENTS AND METHODS

The records of the patients treated for epidermoid cysts and testicular germ-cell tumours in a period covering 22 years were analysed retrospectively. Nine specimens with an epidermoid cyst were examined by immunohistology for the presence of testicular intraepithelial neoplasia (TIN) (or carcinoma in situ of the testis).

RESULTS

Ten patients with a simple epidermoid cyst and 481 patients with testicular germ-cell tumour were treated during the observation period. The relative incidence of epidermoid cysts in relation to the number of patients with testicular germ-cell tumours was 2.1% (95% confidence interval 0.8-3.35%). The mean age of the 10 patients with an epidermoid cyst was 24.1 years. The right testis was affected in seven patients and the left in three. Six of these patients received conservative surgery with excellent cosmetic results. No relapse had occurred after a median observation period of 30 months. Immunohistological staining for placental alkaline phosphatase disclosed the absence of TIN in the parenchyma surrounding the cysts.

CONCLUSION

The absence of TIN calls into question the common assumption that an epidermoid cyst constitutes a monodermal teratoma. Two distinct entities of epidermoid cyst are proposed--one occurring in conjunction with a teratoma or a germ cell tumour (a 'complex' or 'mixed' epidermoid cyst) and the other a 'simple' epidermoid cyst without TIN in the adjacent tissue and thus representing a benign neoplasm that is not a teratoma. The absence of TIN near a simple epidermoid cyst justifies testis-sparing surgery.

Response of metastasized sex cord gonadal stromal tumor of the testis to cisplatin-based chemotherapy

A 34-year-old man underwent left hemicastration for malignant unclassified sex cord gonadal stromal tumor. At 6 months pulmonary metastases developed and the patient received 3 courses of chemotherapy consisting of cisplatin, bleomycin and etoposide. A residual focus in the right lung was excised and proved to be viable tumor. He then received 2 adjuvant courses of cisplatin, etoposide and ifosfamide. Six months later he was without evidence of disease. A review of the literature revealed 21 previous cases of malignant unclassified sex cord gonadal stromal tumor. Although chemotherapy usually fails in treating Leydig cell tumors our case corroborates 6 previous reports of favorable response to cisplatin-based chemotherapy. This finding suggests that different subtypes of sex cord gonadal stromal tumor respond differently to chemotherapy.

Granulomatous orchitis--an analysis of clinical presentation, pathological anatomic features and possible etiologic factors

Granulomatous orchitis is an inflammatory change of the testis, rarely bilaterally, which cannot be distinguished from testis cancer with clinical modalities and therefore the diagnosis is usually made after orchiectomy. We reviewed our experience with 5 cases of granulomatous orchitis all treated with orchiectomy for suspected testicular cancer. Patients' age ranged from 52 to 69 years; three times the right side was affected, histologically intratubular and interstitial type were identified as well as complete testicular destruction. Testicular intraepithelial neoplasia was not detected in any of the specimens.

Metachronous germ cell and Leydig cell tumors of the testis. Do testicular germ cell tumors and Leydig cell tumors share common etiologic factors?

BACKGROUND

Testicular germ cell neoplasms occur bilaterally in approximately 2-5% of patients. Bilateral testicular tumors of different histogenesis are extremely rare, and the study of such cases may offer clues to the pathogenesis of both tumor entities.

METHODS

A report of a case and review of the literature are presented.

RESULTS

A 33-year-old man had a right-sided testicular neoplasm consisting of teratoma, embryonal carcinoma, and yolk sac tumor. Retroperitoneal lymph node metastases were excised, and, subsequently, adjuvant abdominal radiation therapy was administered. The patient later received six cycles of cisplatin-based chemotherapy for pulmonary relapse. When he was 40 years of age, a contralateral Leydig cell tumor (LCT) was treated by testis-sparing excision. This is the first observation of testicular germ cell tumor (GCT) and contralateral LCT. Three cases of germ cell neoplasm and concurrent ipsilateral LCT have been reported previously.

CONCLUSIONS

The association of GCT and LCT in one patient is quite unusual because both entities are rare. Sharing of common etiologic factors by both entities is a possible explanation.

[Degree of familiarity with carcinoma in situ of the testis. A study of a representative selection of established urologists]

METHOD

By a telephone poll conducted among 143 selected representative urologists in private practice throughout the west German Länder.

BASIC REMARKS

Via a search for carcinoma in situ of the testicles (CIS, or testicular intra-epithelial neoplasia, TIN), active early detection of testicular germ cell tumors is now possible.

RESULTS

Among 143 urologists questioned, 62 claimed to be familiar with testicular CIS. However, only 52% were able correctly to answer one question as to its significance, and only 33% could correctly answer a question on the diagnosis of CIS. Only 28% of all those questioned were able to answer correctly 2 questions about CIS. Knowledge about CIS proved to be inversely correlated with the interval in years since obtaining a licence to practice as a specialist.

CONCLUSION

The poll reveals that, at the present time, too few urologists are familiar with carcinoma in situ of the testicles, and the possibilities of active early detection of testicular tumors.

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.

Prevalence of contralateral testicular intraepithelial neoplasia (carcinoma in situ) in patients with testicular germ cell tumour. Results of the German multicentre study

Contralateral biopsies taken from 1,188 patients with testicular germ-cell tumour were examined immunohistologically by staining for placental alkaline phosphatase. Testicular intraepithelial neoplasia (TIN; carcinoma in situ) was detected in 53 patients (4.5%; 95% confidence interval 3.3-5.7%). Testicular atrophy was found in 45.7% of cases with TIN and in 14.1% of cases without TIN (p < 0.01). History of undescended testis was present in 21.3% of cases with TIN and in only 9.3% in cases without (p < 0.05). Patients with contralateral TIN presented at an earlier age (31.0 vs. 33.7 years). Twenty cases with contralateral TIN had no specific risk marker. It is concluded that all patients with testicular germ cell tumour should be offered a contralateral biopsy.

Unusual differential diagnosis of testis tumor: intrascrotal sarcoidosis

We report 2 cases of sarcoidosis with extrapulmonary manifestations in the testis, epididymis and spermatic cord. Each patient presented with an intrascrotal mass of unknown origin that suggested a testicular tumor. Sarcoidosis was confirmed in case 1 by radical orchiectomy and further small sarcoid foci were detected in 1 of the lacrimal glands. In case 2 sarcoidosis was confirmed by biopsy and there were no further extrapulmonary indications. Both cases were stage II disease so no specific therapy was applied. The patients were without signs of progression at 2 and 10 years, respectively, after initial diagnosis.

Prostate Cancer in Nonurological Patients with Normal Prostates on Digital Rectal Examination

Random systematic ultrasonographically guided transrectal core biopsies of the prostate were performed in 73 patients with pulmonary malignancies to exclude prostate cancer as a primary malignant neoplasm. Of the patients 41 had normal prostates as judged by digital rectal examination, 27 had firm prostates and 5 had clinical stage B nodules. Hypoechoic areas were seen on transrectal ultrasonography in 14 of the 41 patients (34%) with normal prostates. Biopsy of the hypoechoic areas in this subgroup detected only 1 grade II prostate cancer. In another patient with normal transrectal ultrasound grade I cancer was detected by mapping of the prostate with 6 systematic ultrasonographically guided transrectal core biopsies. Of the remaining 39 patients with normal prostates transrectal ultrasound detected no hypoechoic defect in 26, a specificity for the detection of prostate cancer of 67%. Multiple core biopsies revealed prostate cancer in 15 of the 32 cases of palpably abnormal prostates, including 12 that were hypoechoic. Prostate cancer is a rare histopathological finding in men with normal prostates on rectal examination. Transrectal ultrasound detected only 1 of 2 low volume prostate cancers in our study group. Thus, ultrasound seems to have little use in patients with prostates that appear normal on digital examination, and its specificity is low.