Spermatic Cord Invasion Research Articles

Low-cord orchidectomy for testicular cancer: what would be different?

IntroductionHigh cord radical orchidectomy (HRCO) is accepted as the standard surgical approach in testicular cancer, however low cord orchidectomy (LCRO) can reduce the morbidity of operation without worsening the oncological outcomes.MethodsWe retrospectively re-examined the specimens of men to determine the level of spermatic cord invasion (SCI). Men who had proximal SCI with negative surgical margins after HRCO were assumed to have de-novo residual tumour if LCRO was performed. Others were assumed as oncologically similar. We examined the relation between pre-operative variables and SCI and proximal SCI to determine whether prediction of proximal SCI is possible.Results196 patients were included. 22 (11%) had SCI and ten (5%) had proximal SCI. Four patients with proximal SCI had positive surgical margins even after HRCO and didn’t require additional local treatment. Six patients were assumed to have de-novo residual tumour if LCRO was performed. All six patients were metastatic and had systemic chemotherapy. High platelet count, tumour size, N stage, S stage and M stage were all significantly related with both SCI and proximal SCI (p < 0.05).ConclusionDue to low probability of SCI, we think LCRO can safely be performed to reduce morbidity in Stage 1 patients. Although there is a risk for residual tumour in Stage 2–3 patients, currently there is no data that residual tumour would impair the success of systemic chemotherapy. Therefore we can not assume that these patients would be negatively affected. Pre-operative data can be useful to predict the presence of proximal SCI and select appropriate patients for LCRO.

Histopathological Analysis in Testicular Tumors: 10 Years of Experience.

Introduction. This study aims to review the morphological and immunohistochemical features of testicular tumors and compare them with prognostic parameters. Methods. Testicular tumors diagnosed between January 2011 and September 2021 were reviewed. Patient age, tumor subtype, size, spread, lateralization, number of foci, and immunohistochemical results were recorded. Results. A total of 121 tumors were detected, of which 108 (89%) were germ cell tumors (GCTs). Of the germ cell tumors, 70 (65%) were found to be pure type, and 38 (35%) were mixed germ cell tumors. The ratio of pure seminoma among GCTs was 56/108 (52%). Lymphatic/vascular invasion (LVI) was detected in 48/121 (40%), rete testis invasion in 32/121 (26%), hilar soft tissue invasion in 10/121 (8%), epididymal invasion in 5/121 (4%), and spermatic cord invasion in 5/121 (4%) patients. Lymphatic/vascular invasion was observed in 6 (22%) of 27 germ cell tumors smaller than 3 cm in size, and rete testis invasion was observed in 2 (7%), while in 40 (55%) of the 73 germ cell tumors of 3 cm and above, lymphatic/vascular invasion was seen, and 26 (36%) of them had rete testis invasion. Immunohistochemical results contributed significantly to the determination of tumor components and rates, especially in mixed germ cell tumors. Conclusion. Most of the tumors were germ cell tumors, and the majority were seminomas. Lymphatic/vascular invasion and rete testis invasion rates increase as the tumor diameter increases, which is more evident when the 3 cm cut-off value is taken into account (P < 0.005).

A case report of large testicular mass: An Eastern Province report from KSA

Large testicular tumor is not a commonly seen entity in the modern era. While treatment of large testicular tumors is via inguinal radical orchiectomy, large testicular tumors carry the dilemma of delivering these large masses via the inguinal or scrotal approach. Here, we present a case of a 53-year-old male patient with a testicular tumor weighing 2.170 kg, measuring 22 cm × 16 cm × 12 cm, who was treated via inguinal orchiectomy with the extension of the surgical wound to the neck of the scrotum, with pathological report showing seminoma with no spermatic cord invasion. We review some case reports of such large tumors to illustrate this treatment dilemma.

Pathological predictors of metastatic disease in testicular non-seminomatous germ cell tumors: which tumor-node-metastasis staging system?

Pathological risk factors for metastatic disease in patients with testicular non-seminomatous germ cell tumors are debated. The tumor-node-metastasis (TNM) classification eighth edition for testicular cancers includes divergent versions, by the International Union Against Cancer (UICC) and by the American Joint Committee for cancer (AJCC). We investigated pathological predictors of metastatic disease at presentation in 219 non-seminomatous germ cell tumors with reference to both classifications. Age, tumor size, percentage of embryonal carcinoma, lymphovascular invasion, invasion of stromal rete testis, hilar soft tissue, epididymis, spermatic cord, and tunica vaginalis, as well as tumor at spermatic cord margin, were assessed and correlated with clinical stage at presentation. Of the 219 NSGCT cases, 151 (69%) were clinical stage I, 68 (31%) were clinical stage II/III. On univariate analysis, tumor size (P = 0.028), percentage of embryonal carcinoma (P = 0.004), lymphovascular invasion (P = 0.001), stromal rete testis invasion (P = 0.001), hilar soft tissue invasion (P = 0.010), epididymis invasion (P = 0.010), direct spermatic cord invasion (P = 0.001), and tumor at spermatic cord margin ((P = 0.009) were associated with higher clinical stage. On multivariate analysis, lymphovascular invasion (P = 0.003), tumor size (P = 0.005), percentage of embryonal carcinoma (P = 0.005), stromal rete testis invasion (P = 0.008) remained significant. A tumor size of 6 cm and an embryonal carcinoma percentage of 70% were the significant cut-off values. We conclude that in addition to lymphovascular invasion, stromal rete testis invasion, tumor size, and embryonal carcinoma percentage are strong predictors of metastatic disease at presentation and their inclusion should be considered in any future TNM revision. Further, our results support the changes in the AJCC TNM eighth edition as invasion of the epididymis and hilar soft tissue were both univariately significant.

Testiküler Germ Hücreli Tümörlerin Prognostik Parametrelerine Olgularımız Eşliğinde Güncel Yaklaşım

Aim: Testicular germ cell tumors (TGCT) are solid neoplasms common in young adult men and an important cause of cancer-related deaths during this period. Revisions in histopathological classification and staging affect prognosis and treatment. The aim of this study was to analyze our TGCT cases, to review prognostic parameters, and their relationship between germ cell neoplasia in situ (GCNIS), intratubular and intertubular tumors.Material and Methods: In this study, Hematoxylin&amp;amp;Eosin-stained sections of 77 TGCTs were re-evaluated. The presence of GCNIS, intratubular and intertubular germ cell tumors were recorded. Histopathological classification and staging were revised based on the changes in the 8th edition of American Joint Committee on Cancer (AJCC).Results: The majority of the patients were diagnosed as seminoma (n=42), followed by mixed germ cell tumors (n=33) and spermatocytic tumors (n=2). Rete testis invasion in 30 cases, epididymal invasion in 6 cases, hilar soft tissue invasion in 10 cases, tunica vaginalis invasion in 1 case, spermatic cord invasion in 4 cases, and lymphovascular invasion in 22 cases were detected. Intertubular seminoma in 25 cases, intratubular carcinoma in 16 cases, and GCNIS in 73 cases were detected.Conclusion: The major criteria to determine treatment choices are histopathological diagnosis, pathological tumor stage, serum tumor markers and presence of metastasis. According to AJCC 8th edition, addition of hilar soft tissue invasion to staging has increased the number of our pT2 cases. Moreover, assuming discontinuous tumor invasion of spermatic cord by vascular invasion as pM1 has also increased the number of metastatic testis tumors.

Discrepancy in pathology reports upon second review of radical orchiectomy specimens for testicular germ cell tumors.

We sought to evaluate the discrepancies between primary pathology report and second pathology review of radical orchiectomy (RO) specimens. A retrospective review was performed of RO specimens from the Ontario Cancer Registry. All cases required both a primary pathology report and a second pathology review from another institution. Histopathological variables assessed included histological subtype and components of mixed germ cell tumor (GCT), pathological tumor (pT) stage, lymphovascular invasion (LVI), spermatic cord invasion, and surgical margin. Between 1994 and 2015, 5048 ROs were performed with 2719 (53.9%) seminoma and 2029 (40.2%) non-seminoma. Of these, 519 (10.3%) received a second pathology review. There was concordance between primary pathology report and second pathology review in 326 (62.8%) cases. The most common discrepancies involved a change in pT stage (n=148, 28.5%), with upstaging in 83 (16%) and downstaging in 65 (12.5%) cases relative to the original pT stage. The second most common discrepancy regarded the reporting of LVI (n=121, 23.3%), with 62 (11.9%) reporting presence of LVI when the primary pathology report did not. Other discrepancies included a change in the histological subtype in 28 (5.4%) cases and spermatic cord margin status in five (9.6%) cases. Only 10% of orchiectomy specimens underwent a second pathology review, with nearly 40% of reviews leading to a meaningful change in parameters. Such variation could lead to incorrect tumor staging, estimate of relapse risk, and inappropriate treatment decisions. Expert pathology review of RO specimens should be considered, as it has significant implications for decision-making.

PD19-08 DISCREPANCY IN PATHOLOGY REPORTS UPON SECOND REVIEW OF RADICAL ORCHIECTOMY SPECIMENS FOR TESTICULAR GERM CELL TUMORS

INTRODUCTION AND OBJECTIVE: Accurate pathological reporting is important in testis cancer due to the implications for treatment after radical orchiectomy (RO). The aim of this study was to evaluate the discrepancies between primary pathology report and second pathology review of RO specimens in Ontario. METHODS: A retrospective review was performed of RO specimens performed from the Ontario Cancer Registry All cases required both a primary pathology report and a second pathology review from another institution. Histopathological variables assessed for comparison included histological subtype and components of mixed germ cell tumor (GCT), pathologic tumor (pT) stage, lymphovascular invasion (LVI), spermatic cord invasion, and surgical margin. RESULTS: Between 1994 and 2015, 5048 RO were performed with 2719 (53.9%) seminoma and 2029 (40.2%) nonseminoma. Of these 519 (10.3%) received a second pathology review. There was concordance between primary pathology report and second pathology review in 326 (62.8%) cases. The most common discrepancies involved a change in pT stage (n=148, 28.5%) with upstaging in 83 (16%) and down-staging in 65 (12.5%) cases relative to the original pT stage. The second most common discrepancy regarded the reporting of LVI (n=121, 23.3%) with 62 (11.9%) reporting presence of LVI when the primary pathology report did not. Other discrepancies included a change in the histological subtype in 28 (5.4%) cases and spermatic cord margin status in 5 (9.6%) cases. CONCLUSIONS: Only 10% of orchiectomy specimens for testicular germ cell tumors in Ontario underwent a second pathology review with nearly 40% of reviews leading to a meaningful change in parameters. Such variation could lead to incorrect tumor staging, estimate of relapse risk and inappropriate treatment decisions. Expert pathology review of radical orchiectomy specimens should be considered as it has significant implications for decision making. Source of Funding: None

Rete Testis Invasion Is Consistent With Pathologic Stage T1 in Germ Cell Tumors.

Rete testis invasion by germ cell tumors is frequently concomitant with lymphovascular or spermatic cord invasion (LVI/SCI); independent implications for staging are uncertain. In total, 171 seminomas and 178 nonseminomatous germ cell tumors (NSGCTs; 46 had 1%-60% seminoma component) came from five institutions. Metastatic status at presentation, as a proxy for severity, was available for all; relapse data were unavailable for 152. Rete direct invasion (ReteD) and rete pagetoid spread (ReteP) were assessed. ReteP and ReteD were more frequent in seminoma than NSGCT. In seminoma, tumor size bifurcated at 3 cm or more or less than 3 cm predicted metastatic status. Tumors with ReteP or ReteD did not differ in size from those without invasions but were less than with LVI/SCI; metastatic status or relapse did not show differences. In NSGCT, ReteP/ReteD did not correlate with size, metastatic status, or relapse. Findings support retaining American Joint Committee for Cancer pathologic T1 stage designation for rete testis invasion and pT1a/pT1b substaging of seminoma.

Testicular cancer: The usage of central review for pathology diagnosis of orchiectomy specimens

BackgroundRadical orchiectomy specimens present a unique set of challenges for pathology assessment owing to their rarity and complexity. This study compares second opinion pathology reports generated at a single, large academic institution to primary reports from outside hospitals. MethodsA database search was conducted for orchiectomy cases that were sent to our institution for management of testicular cancer from 2014 to 2015. Cases sent for consultation without a finalized diagnosis from the outside hospitals were excluded. A total of 221 consecutive cases were evaluated for comparison of final diagnoses between the outside institution and central pathology review. ResultsThis study revealed significant discrepancy involving multiple parameters between original and second opinion pathology reports. Of 221 cases of germ cell tumors assessed, 31% showed some discrepancy of histologic subtype. Overall, reporting of lymphovascular invasion changed in 22% of cases; of those, initially called positive 23% were changed to negative and of those initially called negative 12% were changed to positive. Although the overall discrepancy for spermatic cord invasion was 9%, an initial positive diagnosis was negated 35% of the time. The pathologic stage was altered in 23% of cases, mostly secondary to differences interpreting lymphovascular and spermatic cord invasion. ConclusionPathologists evaluating orchiectomy specimens should be aware of the major pitfalls in classification and staging, many of which may affect patient management.

Scrotal recurrence of germ cell tumour in a non-violated scrotum.

Testicular cancer is the most common cancer diagnosis in males aged 15-30 years. For over a century, radical inguinal orchiectomy has been the standard of care for initial treatment of testicular cancer. This approach is preferred over trans-scrotal interventions, in an effort to avoid tumour seeding, spermatic cord invasion, and disturbance to lymphatic drainage. Scrotal violation is defined as any trans-scrotal intervention that may impact spread of disease in testicular cancer, including scrotal orchiectomy, fine-needle aspiration, and testicular biopsy. Studies have shown statistically significant differences in local recurrence rates between patients who undergo the standard inguinal surgical approach and cases with scrotal violation. Over 95% of testicular cancers are curative, often with surgery alone. Recurrence of disease is divided into two categories: local and distant sites. Local recurrence of testicular cancer involves the scrotal and inguinal regions, including superficial inguinal lymph nodes. More commonly, local recurrence is seen in cases of testicular cancer with scrotal violation. We describe a case of local recurrence of testicular cancer in a non-violated scrotum, a finding that has not been previously reported in the literature.

Surveillance des séminomes testiculaires de stade I : résultats oncologiques sur 20 ans

The objective of this study was to assess the oncological results of a population of patients which undergo surveillance after diagnosis of stage I testicular seminoma (2, 5 and 8 years overall, specific and recurrence free survival). We also research recurrence risk factors. We have looked at the data of all patients treated in our center since 1993 for a grade I testicular seminoma. We focused on age at diagnosis, biological (tumoral markers) and pathological (tumor size, rete testis, lymphovascular, tunica albuginea or spermatic cord invasion) data. During surveillance, we noted the number, the localization and the interval until recurrence and death. We calculated 2, 5 and 8 years overall, specific and recurrence-free survival and searched recurrence risk factors. Sixty-nine patients (mean age: 37) were followed during a mean time of 97 months. Sixty-three per cent of the tumours were less than 4 cm (50 lesions). Lymphovascular, rete testis, spermatic cord and tunica albuginea invasion were present in respectively 21%, 33%, 4% and 29% of the cases. LDH and HCG were above normal rate in respectively 44 and 27% of the cases. Eighteen patients (23%) relapsed at a mean time of 12 months. Recurrence-free survival was respectively 81%, 77% and 77% at 2, 5 and 8 years. Tumor size<4 cm (P = 0.002), rete testis invasion (P = 0.03) and stage ≥ pT2 (P = 0.012) were associated with recurrence in univariate analysis. Using multivariate analysis, only tumor size >4 cm was a recurrence risk factor (risk multiplied by 3). At the end of the study, 77 patients are alive (97.5%). Overall and specific survival was 97.5% at 2, 5 and 8 years. We show here the interest of surveillance in case of stage 1 testicular seminoma. The overall and specific survivals are the same as after chemotherapy or radiotherapy. Furthermore, we confirm the role of tumor size to stratify recurrence risk.

Clinicopathologic Analysis of Choriocarcinoma as a Pure or Predominant Component of Germ Cell Tumor of the Testis

Although well recognized in the literature, the contemporary clinicopathologic data regarding choriocarcinoma (CC) as a pure or the predominant component of a testicular germ cell tumor (GCT) are limited. Herein, we present a series of pure CC and predominant CC in mixed GCT of the testis obtained from a single oncology institution. A comprehensive histologic review of 1010 orchiectomies from 1999 to 2011 yielded 6 (0.6%) pure CC and 9 (0.9%) mixed GCT cases with a predominant CC component. Patients' ages ranged from 20 to 39 years (median 29 y). All patients had markedly elevated serum β-hCG levels (median 199,000 IU/mL) at presentation. All tumors were unilateral and involved the right (9/15) and left (6/15) testis. The mean tumor size was 6.5 cm (range, 1.5 to 8 cm). Histology was similar for pure CCs and the CC component of mixed GCTs. CC commonly showed expansile hemorrhagic nodular cysts surrounded by variable layers of neoplastic trophoblastic cells (mononucleated trophoblasts and syncytiotrophoblasts). The syncytiotrophoblasts usually covered columns of mononucleated trophoblasts and occasionally formed plexiform aggregates and pseudovillous protrusions. Immunohistochemical stains suggested a mixture of cytotrophoblasts (p63+, HPL_) and intermediate trophoblasts (p63-, HPL weak +/-) in the columns of mononucleated cells. In the 9 mixed GCTs, CC comprised 50% to 95% (7/9 were ≥80% CC) of the tumor; 7 were combined with 1, and 2 were combined with 2 other GCT components. The non-CC components included teratoma (5/9), seminoma (2/9), yolk sac tumor (2/9), and embryonal carcinoma (2/9). Lymphovascular invasion, spermatic cord invasion, and tunica vaginalis invasion were present in 15/15, 5/15, and 1/12 cases, respectively. In mixed GCTs, these locally aggressive features were attributed to the CC component, except in 1 tumor in which it was also exhibited by the embryonal carcinoma component. Lymphovascular invasion was multifocal to widespread in 73% of tumors. The stages of the 15 tumors were: pT2 (10), pT3 (5); NX (1), N1 (4), N2 (5), N3 (5); and M1a (2) and M1b (13). Distant organ metastasis mostly involved the lungs (11) and liver (10). Follow-up information was available in 14 patients, all of whom received cisplatin-based chemotherapy. All 6 pure CC patients were dead of disease (range, 6 to 14 mo, median 9.5 mo). Follow-up of 8 patients with predominant CC (range, 10 to 72 mo, median 27 mo) showed that 5 died of the disease, and 1 was alive with disease and 2 were alive with no evidence of disease at 60 and 72 months of follow-up, respectively; these latter 2 patients were the only ones with M1a disease on presentation. This series confirms the proclivity for high-stage presentation including presence of distant metastasis, hematogenous spread, and poor outcome of testicular CC. Mixed GCT with a predominant CC component has similar tendency for high-stage presentation, marked elevation of serum β-hCG levels, and aggressive behavior compared with pure CC. This study also showed that distant metastasis by CC when only involving the lungs (M1a) may not be uniformly fatal with chemotherapy. The mononucleated trophoblastic columns in testicular CC appear to be a mixture of cytotrophoblasts and intermediate trophoblasts, similar to that described in gestational CC.

Testicular hilum and vascular invasion predict advanced clinical stage in nonseminomatous germ cell tumors

Clinical staging is a critical step in the management of testicular germ cell tumors. Up to one-third of nonseminomatous germ cell tumors of the testis present with metastatic disease (clinical stages II and III). We investigated the predictors of metastatic disease at presentation in a cohort of 148 consecutive nonseminomatous germ cell tumors of the testis, over a 10-year period. The following clinical and pathologic features were evaluated: age, tumor size, dominant tumor histology, coagulative necrosis, vascular invasion, rete testis invasion and tumor extension into tunica vaginalis, hilar soft tissue, epididymis, or spermatic cord. Studied parameters were correlated with the clinical stage at presentation. Of the 148 patients with nonseminomatous germ cell tumors of the testis, 94 (63%) were clinical stage I, 26 (18%) were stage II, and 28 (19%) were stage III at presentation. Mean patient age was 31 years (range, 17–83). Mean tumor size was 4.1 cm (range, 0.6–19). On univariate analysis, the following parameters showed statistically significant association with the advanced clinical stage at presentation: vascular invasion (P<0.001), rete testis invasion (P<0.001), hilar soft tissue invasion (P<0.001), epididymis invasion (P=0.005), spermatic cord invasion (P=0.005), and coagulative necrosis (P=0.062). On multivariate analysis, only vascular invasion (P=0.011) and invasion into the rete testis and the hilar soft tissues (P=0.007 and P=0.017, respectively) demonstrated significant association with advanced clinical stage at presentation. We conclude that in addition to vascular invasion, tumor invasion into the hilum (rete testis or hilar soft tissue) is also strongly associated with metastatic disease at presentation and should be part of the routine pathology reporting.

Clinical relevance of specialist pathologic testicular tumor review.

4599 Background: Therapeutic options in stage IA/B testicular cancer include surveillance, retroperitoneal lymph node dissection, and adjuvant chemotherapy/radiotherapy; clinician and patient choice is guided by recurrence risk. Specialist pathologic review is important in informing this decision as it may alter diagnosis and staging. Methods: Analysis of a prospective supraregional database of 627 testicular tumors diagnosed in Oxford or referred for central review between 2004 and 2012. Tumor histology, stage (AJCC 7th ed.), and other factors predictive of relapse were compared between referring and final pathology reports. Results: Of 402 cases referred from 11 hospitals during the study period, 370 primary testicular tumors with an informative initial pathology report were analysed. There was a discrepancy between referring and final reports in 116 cases (31.4%), with significant variation between referring units in the frequency of discordance (20.0-89.9%, p&lt;0.0001, x2). Changes to histological diagnosis in 34 cases (9.2%) were minor alterations in type and proportion of non-seminomatous germ cell tumor (NSGCT) elements of no clinical significance, with exception of one classical seminoma reclassified as spermatocytic seminoma. For seminomas (n=201) the commonest discrepancies were in identification of rete testis invasion (RTI) (15.9%); lymphovascular invasion (LVI) (9.5%); and spermatic cord invasion (SCI) (5.0%). RTI was more frequently under-reported (14.4%), and LVI over-reported (8.0%) on initial assessment. Disparity of tumor size in 2 cases (1.0%) was of no clinical significance. For NSGCT (n=150) the commonest discrepancies were in RTI (9.3%), LVI (7.3%) and SCI (6.7%), with LVI typically over-reported (4.0%) and RTI and SCI under-reported (6.7%, 5.3% respectively) on primary analysis. Central review resulted in change of primary tumor stage in 45 cases (12.1%). 12 (6.0%) and 16 (8.0%) seminomas, and 12 (8.0%) and 5 (3.3%) NSGCTs were upstaged and downstaged respectively. Conclusions: Central pathology review results in frequent alteration of factors predictive of relapse in stage IA/B testicular cancer. Particular attention should be directed to review of RTI, LVI and SCI to ensure accurate prognostication.

精巣非セミノーマ加療後１４年目に対側精巣に発生した異時性セミノーマの１例

A 32-year-old man was admitted to our hospital with a complaint of right scrotal swelling. He had a past history of left testicular nonseminomatous germ cell tumor (NSGCT), stage IIB 14 years ago. He had undergone chemotherapy with 3 courses of PEP and retroperitoneal lymphnode dissection revealing pathological CR. He was diagnosed as having right testicular tumor. He underwent right high orchiectomy. Imaging studies and pathological studies revealed pure seminoma with spermatic cord invasion, stage I, pT3N0M0. He underwent chemotherapy with 3 courses of VIP. Herein we present a case of metachronous bilateral testicular germ cell tumor with a review of literatures.

Importancia de microlitiasis en ultrasonido de neoplasias de células germinales de testículo

IntroductionTesticular microlithiasis (TM) is an infrequent finding in testicular ultrasound and its clinical importance has not been completely defined. We analyzed the ultrasounds of patients with testicular germ cell tumors in order to analyze the correlation between TM, histological findings and clinical variables. Methods and materialsFifty-seven patients with germ cell tumors and radical orchiectomy were included. Clinical, pathological, and echographic data were analyzed. ResultsTM was observed in 27 men (48.27%) and was absent in 30 (52.6%). Patients with TM had a greater likelihood of nonseminomatous germ cell tumors (NSGCT) vs seminomatous (55.6% vs 30%, p=0.05), stage II/III testicular cancer (51.8% vs 16.7%, p=0.005), positive surgical margins (18.5% vs 0%, p=0.021), and spermatic cord invasion (14.8% vs 0%, p=0.048). No significant difference was found in respect to other histopathological variables. ConclusionThis study showed that TM in testicular tumors is associated to NSGCT, advanced clinical stage, positive surgical margins, and spermatic cord invasion.

Correlation Between Primary Tumor Pathologic Features and Presence of Clinical Metastasis at Diagnosis of Testicular Seminoma

To compare several risk factors in the testicular biopsy of patients with pure seminoma with and without clinical metastasis at diagnosis. We performed a retrospective study of patients with pure seminoma. The retroperitoneum was staged with computed tomography and the thorax with simple radiography and/or computed tomography, taking into account the original reports and clinical stage. The previous reports and original pathology plates were reviewed by pathologists who were unaware of the clinical stage of the patients. Patients with beta-human chorionic gonadotropin greater than 800 mUI/mL were excluded. A total of 86 patients had sufficient data and comprised the study cohort. Of the 86 patients, 62 had clinical Stage I (72%), 20 had Stage II (23%), and 4 had Stage III (5%). On univariate analysis, tumor size greater than 4 cm (P = 0.0135), testicular vascular invasion (P = 0.0042), rete testis invasion (P = 0.0002), tunica albuginea penetration (P = 0.00001), base of the spermatic cord invasion (P = 0.0002), epididymis invasion (P = 0.001), and vascular invasion of the cord (P = 0.024) were predictive of metastasis. On multivariate analysis, tumor size greater than 6 cm (odds ratio 6.9, 95% confidence interval 1.3 to 35, P = 0.02) and rete testis invasion (odds ratio 6.1, confidence interval 1.2 to 30, P = 0.025) remained as important predictors of metastasis (tumor size less than 6 cm was not significant on multivariate analysis). The results of this study have demonstrated that rete testis invasion and tumor size correlate independently with the presence of clinical metastasis at diagnosis of testicular seminoma.

Testicular tumors in children

Purpose: The aim of this study was to present an updated picture of surgical management of pediatric testicular tumors based on our 30 years' experience, which consisted of one of the largest noncollected series treated in a single medical center. Methods: Records of children who were treated for testicular tumor in our unit from 1970 to 1999, inclusive, were reviewed retrospectively. Information recorded for each patient included age, sex, past medical history, clinical characteristics, diagnostic procedures, treatment methods, histopathologic findings, and outcome. Results: Fifty-one patients with a mean age of 3.8 ± 0.5 years were treated for testicular tumors. Of these, 35 (69%) had germ cell testis tumor (GCT) and 16 (31%) had non–germ cell testis tumor (NGCT). Endodermal sinus tumor and paratesticular rhabdomyosarcoma were the dominant histologic subtypes in each group, respectively. The most common mode of presentation was painless scrotal mass. At initial presentation, retroperitoneal (n = 5), both retroperitoneal and lung (n = 2), and retroperitoneal and liver (n = 3) metastases were recorded in 10 (19%) patients. Initial operative procedures were radical inguinal orchiectomy (RIO) (n = 29), scrotal orchiectomy (SO; n = 9), bilateral RIO (n = 2), both RIO and unilateral retroperitoneal lymph node (RPLN) excision (n = 6), testis-sparing enucleation of the tumor (n = 5). SOs were performed elsewhere, and these patients underwent high ligation (n = 4) and both high ligation plus RPLN excision (n = 5) in our unit. Histopathologically, spermatic cord invasion and RPLN involvement were present in 10 patients. Scrotal recurrences were encountered in 2 patients who had scrotal orchiectomy initially. Retroperitoneal recurrences were noted in a patient presenting with stage I embryonal carcinoma and in 2 patients presenting with group IV paratesticular rhabdomyosarcoma. The mean follow-up period was 89 ± 10 months. Four patients with stage IV embryonal carcinoma (n = 2) and group IV paratesticular rhabdomyosarcoma (n = 2) died of progression of the disease. All remaining patients were alive and disease free at their last outpatient appointment. No significant difference was noted with regard to 5-year survival rates between (1) malignant GCT and paratesticular rhabdomyosarcoma patients (91% v 80%) and (2) patients treated by RIO (88%), SO plus high ligation (87%), and RIO plus RPLN excision (80%). Five-year survival rates were 100% for stage I, II, III patients and 33.3% for stage IV and group IV patients presenting with malignant testicular tumors (P < .05). Conclusions: Childhood testicular tumors deserve special attention from the therapeutic point of the view. A solid scrotal mass should be considered malignant until proved otherwise. Any suspicion of the testicular tumor warrants an inguinal approach to prevent scrotal violation by the tumor. Current trends emphasize that testis-sparing surgery should be performed for benign lesions such as teratoma, leydig cell tumor, and epidermoid cyst based on frozen biopsy findings. Literature findings and our experience suggest that RIO is the accurate treatment for stage I malignant GCT and group I and IIa paratesticular rhabdomyosarcoma. RPLN excision is not of benefit either as a staging or therapeutic procedure in stage I and group I and IIa diseases of these tumors. RPLN excision should be reserved for (1) malignant GCT patients who have persistent elevation of alpha-fetoprotein after orchiectomy in the presence of normal total body CT scan, and for patients presenting with stage II and III disease with definitive abnormality on CT scans, and (2) group IIb, IIc, and III paratesticular rhabdomyosarcoma patients with radiologic evidence of retroperitoneal involvement on CT scans. High ligation should be done as a complementary procedure after SO to increase the survival rates. J Pediatr Surg 36:1796-1801. Copyright © 2001 by W.B. Saunders Company.

Stage I testicular seminoma following orchidectomy—to treat or not to treat

ADJUVANTPOSTORCHIDECTOMY radiationhasbeenstandardcare for stage I seminoma since the early decades of this century [ 1, 21 and a wealth of experience shows this policy to be effective and safe [3]. In bygone days when there was no curative alternative to radiotherapy, faith in radiographic retroperitoneal staging procedures was never sufficient to risk disease progression by withholding radiotherapy from patients with stage I disease. And, since the morbidity of retroperitoneal lymph node dissection contra-indicated its use in this disease, the true incidence of micrometastatic nodal involvement in stage I was never elucidated. Thus, it was uncertain what proportion of patients actually benefited from adjuvant irradiation. Now, with the additional armamentarium of effective chemotherapy [4, 51, surveillance has emerged as an investigational possibility and several preliminary studies have been reported [6-81. In this issue of the European ~oumal of Cancer (pp. 1931-1934), the report by von der Maase et al. is the Iirst such study, substantial both in the number of patients and in their follow-up, to afford a reliable appraisal of the virtues and limitations of surveillance as a management policy and to provide insights into the pathobiology of this disease. Whereas pathological findings in the primary tumours have little prognostic significance for patients receiving adjuvant radiotherapy, they assume some importance if treatment is withheld. Von der Maase et al. delineate tumour size, histological subtype, tumour necrosis and invasion of the rete as significant determinants of metastatic propensity. In multivariate analysis, tumour size was the only feature independently correlated with disease relapse. Patients whose primary tumour was 6 cm or larger (25% of all) had a relapse frequency of 34%, compared with a frequency of 14% in those with smaller tumours. Indirect confirmatory evidence that certain features of the primary tumour are indeed markers of biological aggression comes from studies that show a higher incidence of larger tumours [9], more frequent rete and cord invasion [9, lo] and a higher incidence of vascular invasion [9] in stage II than in stage I seminoma. Unpublished data in the University of Texas M.D. Anderson Cancer Center database reveal that the primary tumour was significantly larger in stage II disease (21 patients, size range 2-19 cm, mean size 7.1 cm, median size 6.5 cm) than in stage I disease (137 patients, size range 1-12.5 cm, mean size 4.9 cm, median size 4.4 cm) (P = 0.001). This supports the conclusion of von der Maase et al. that larger tumours are more likely to have metastasised than smaller ones. However, the authors make no mention of spermatic cord invasion, which we reported to occur more often in stage II than in stage I disease, and to have an adverse effect on the outcome of irradiated patients with stage I disease [lo]. It is hoped rhat this factor, as well as data on preand postorchidectomy chorionic gonadotrophin levels will be

Testicular Seminoma: The M. D. Anderson Experience. An Analysis of Pathological and Patient Characteristics, and Treatment Recommendations

We treated 240 patients with testicular seminoma at our institution between January 1960 and December 1982. The over-all 5-year survival free of disease for these patients regardless of stage was 93.6per cent. The 165 patients (69per cent) with stage I disease had a 95.5per cent 5-year survival free of disease that remained constant at 20 years. Stage II cancer was diagnosed clinically in 62 patients (26per cent), while 13 (5per cent) presented with more advanced (stages III and IV) disease. The 5-year survival rate free of disease for all patients with stage II cancer was 85per cent. There were 14 pathological and patient characteristics analyzed, 4 of which were statistically significant. All but 1 of these factors (spermatic cord invasion) was related to tumor volume (stage, palpable mass and hydronephrosis). Based on the data of this retrospective review, the Canadian experience without prophylactic mediastinal irradiation and the development of effective chemotherapy, we recommend radiation therapy without prophylactic mediastinal irradiation for patients with stage I or IIA disease and chemotherapy for patients with stage IIB, III or IV disease. In an attempt to improve our results in the latter patients we recently instituted adjunctive radiotherapy for those with a persistent radiographic mass. Our current guidelines for the staging evaluation and followup of patients with this neoplasm also are discussed.