Unilateral Testicular Tumor Research Articles

Nomogram for predicting testicular yolk sac tumor in children based on age, alpha-fetoprotein, and ultrasonography.

To establish a predictive model for distinguishing testicular benign or yolk sac tumors in children. We retrospectively analyzed data for 119 consecutive patients with unilateral testicular tumors treated at a single institution from June 2014 to July 2020. The patients were divided into the benign (n = 90) and yolk sac (n = 29) tumor groups based on the pathological diagnosis. We recorded patient age, serum markers [serum alpha-fetoprotein (AFP), human chorionic gonadotropin], and tumor ultrasonic findings (maximum diameter, ultrasonic echo, blood flow signal). Predictive factors were identified using descriptive statistical methods. A nomogram was established for preoperative prediction. An additional 46 patients were used as a validation cohort to verify the model. Patients with testicular yolk sac tumors were younger (median age: 14.0 vs. 34.0 months, P = 0.001) and had a higher incidence of elevated AFP levels (93.1% vs. 2.2%, P < 0.001). Ultrasonography indicated that testicular yolk sac tumors tended to have larger maximum diameters (26.5 ± 11.3 vs. 16.6 ± 9.2 cm, P < 0.001), a higher proportion of hypoechoic masses (44.8% vs. 8.9%, P < 0.001), and a higher incidence of masses with strong blood flow signals (93.1% vs. 5.6%, P < 0.001). A nomogram based on age, AFP levels, and ultrasound blood flow signals effectively predicted the probability of yolk sac tumor in children, with an accuracy of 0.98 (95% confidence interval: 0.984-1.003). The Brier score of the nomogram was 0.0002. A nomogram based on age, AFP levels, and ultrasound blood flow signals can effectively predict the probability of testicular yolk sac tumor preoperatively, aiding in clinical decision-making and patient counseling.

Three Cases of Bilateral Metachronous Testicular Tumors

We present three cases of bilateral metachronous testicular tumors. The patient in case 1 had a history of left orchiectomy for undescended testis at the age of 19. The pathological findings revealed germ cell neoplasia in situ. Twenty-four years later (age＝43), he was diagnosed with right testicular tumor with lymph node and lung metastasis (stage IIIc). Right orchiectomy was performed, and the pathological finding showed nonseminomatous germ cell tumor. He underwent chemotherapy, followed by lymph node dissection and lung metastasectomy. The patient in case 2 had a history of left orchiectomy for testicular tumor at the age of 41. The pathological finding of the left testis revealed seminoma (stage IA). Nineteen years later (age＝60), he was diagnosed with right testicular tumor and underwent right orchiectomy. Herein, the pathological finding showed seminoma (stage IA). The patient in case 3 had a history of right orchiectomy for testicular tumor at the age of 25. The pathological findings revealed seminoma (stage IS), and he underwent adjuvant radiation of the para-aortic field without subsequent recurrence. Fourteen years later (age＝39), he was diagnosed with left testicular tumor and underwent left orchiectomy. The pathological finding revealed seminoma (stage IB). The patient underwent adjuvant carboplatin monotherapy to prevent recurrence. Due to the long interval between the occurrence of bilateral metachronous testicular tumors (mean＝19 years ; three cases), long-term observation is necessary to detect the possible occurrence of contralateral testicular tumors. Contralateral testicular biopsy might be considered at the time of orchiectomy for unilateral testicular tumor if associated with testicular atrophy and/or a history of undescended testis.

PSAT048 Management of a Unilateral Testicular Tumor in a Patient with Congenital Adrenal Hyperplasia – Malignancy or Testicular Adrenal Rest Tumor?

Abstract Male patients with Congenital Adrenal Hyperplasia (CAH) are at risk of developing testicular adrenal rest tumors (TART). Late presentations are rare and often misdiagnosed as primary testicular germ cell tumors or other more common benign testicular lesions. We describe the case of a patient with CAH and a unilateral testicular tumor with regression in size after initiation of dexamethasone. A 24-year-old male with salt-wasting form of 21-hydroxylase deficiency underwent testicular U/S for evaluation of TART. While aware of a painless firm nodule on the latero-posterior aspect of his left testicle, his main concern was new onset infertility as he had conceived previously. He denied personal or family history of malignancy. Testicular U/S showed a 1.1×0.7×0.8 cm ill-defined, heterogeneously hypoechoic lesion with scattered calcifications and internal vascularity. He was referred to urology to undergo evaluation for possible for testicular cancer. CT abdomen/pelvis showed no evidence of metastatic disease. AFP was less than 2.5 ng/mL (reference range &amp;lt; 9.0 ng/mL), hCG was less than 1.0 mIU/mL (reference range&amp;lt;5.0 mIU/mL), and LDH was 221 U/L (reference range 140-271 U/L). The patient declined surgical intervention at this point and requested medical management. After discussion with the patient, we opted to trial dexamethasone to help suppress the nocturnal surge of ACTH in addition to his physiological dose of prednisone and fludrocortisone for CAH. He was started on 0.25 mg of dexamethasone followed closely with serial imaging and labs. Prior to initiation of dexamethasone, ACTH was 90.3 pg/mL (reference range 7.2–63.3 pg/mL). Two months after initiation of dexamethasone, ACTH decreased to 10.0 pg/mL. LH after initiation of dexamethasone was 8.58 mIU/mL (reference range 1.24–8.62 mIU/mL), FSH was 11.90 (reference range 1.27–19.26 mIU/mL), and testosterone level was 177 ng/dL (reference range 259-818 ng/dL). Testicular U/S six months after starting dexamethasone showed a 50% reduction in size of the heterogeneous hypoechoic left testicular lesion measuring 0.5×0.5×0.4 cm consistent with TART. However, he continued to have concerns regarding infertility, with work-up currently underway. TARTs are thought to arise from aberrant adrenal cells that may descend with the testes during embryogenesis. High ACTH levels in CAH due to lack of negative feedback can cause proliferation of these undifferentiated adrenal cells. Infertility is a predominant symptom due to local mass effect on the testes. Treatment of TART to prevent infertility requires elucidating an optimal steroid regimen that suppresses ACTH production, without suppression of LH and FSH. Moreover, most of the TARTs (around 80%) are bilateral and never malignant. Our patient's testicular tumor poses a diagnostic challenge given the late and atypical presentation of a unilateral tumor. The response to dexamethasone is very reassuring but continued surveillance is warranted. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

A Survey of the Current Practice Patterns of Contralateral Testis Fixation in Unilateral Testicular Conditions

To query the current contralateral testis fixation (CTF) practice patterns among pediatric urologists in different clinical situations that could result in monorchism. An online survey was sent to members of the Urology Section of the American Academy of Pediatrics. The survey included questions addressing CTF practice patterns in 14 clinical scenarios. Responses were anonymously submitted, blindly reviewed, and analyzed. Among 53 respondents, 62.3% had academic appointments and 73.6% had an exclusive pediatric urology practice. All participants agreed on CTF necessity in testicular torsion beyond the neonatal period. CTF was advocated by 84.9% in prenatal torsion, 96.2% in postnatal torsion, and 94.3% in delayed torsion presentation. Emergent intervention was favored by 64.4% in prenatal and 98% in postnatal torsion. Only 1 participant (1.9%) preferred CTF with a unilateral testicular tumor and 5 (9.4%) in trauma substantiating an orchiectomy. There was less consensus on CTF in torsed undescended testis (79.3% in prepubertal and 81.13% in postpubertal), testicular nubbin in a child (40.4%), palpable atrophic undescended testis (13.2%), and unilateral bell-clapper anomaly (47.2%). In situations other than torsion, lack of strong evidence was the commonest reason not to perform CTF. The majority of responding pediatric urologists currently performs CTF in neonatal torsion. Although there is a general consensus on CTF in testicular torsion outside the neonatal period, CTF remains controversial in other clinical situations, warranting further research. The decision for CTF should involve patients, parents, and treating physicians.

Dynamics of hormonal disorders following unilateral orchiectomy for a testicular tumor

Testicular tumors and their treatment interfere with homeostasis, hormonal status included. The aim of the study was to evaluate hormonal disorders of the pituitary–gonadal axis in men treated for testicular tumors. One hundred twenty-eight men treated for a unilateral testicular tumor at our institution were included. The hormonal status was prospectively evaluated in 62 patients before orchiectomy, 120 patients 1 month after orchiectomy and 110 patients at least 1 year after the treatment. The concentrations of human chorionic gonadotropin (hCG), testosterone (T), estradiol, luteinizing hormone (LH), follicle-stimulating hormone (FSH) and prolactin were measured. The clinically significant testosterone deficiency was defined either as testosterone <2.31 ng/mL or testosterone within the range of 2.31–3.46 ng/mL but simultaneous with T/LH ratio ≤1. Changes in hormone levels were significant: LH and FSH rose in the course of observation, and the concentration of hCG, testosterone, estradiol decreased. PRL concentration was the lowest at 1 month after orchiectomy. In multivariate analysis, the risk of the clinically significant testosterone deficiency was 0.2107 (95% CI 0.1206–0.3419) prior to orchiectomy, 0.3894 (95% CI 0.2983–0.4889) 1 month after surgery and 0.4972 (95% CI 0.3951–0.5995) 1 year after the treatment. The estradiol concentration was elevated in 40% of patients with recently diagnosed testicular cancer and that was correlated with a higher risk of testosterone deficiency after the treatment completion. Hormonal disorders of the pituitary–gonadal axis in men treated for testicular tumors are frequent. The malignant tissue triggers paraneoplastic disorders that additionally disturb the hormonal equilibrium.

Testis sparing surgery in a case of small unilateral testicular cancer

A 22-year-old male presented at our institution with an incidentally ultrasound-detected testicular tumor. Magnetic resonance imaging showed a contrast-enhanced right intratesticular mass over 1 cm in size. The patient underwent testis sparing surgery. Pathologic examination revealed seminoma. A follow-up nine months later showed no residual tumor, a normal contour of the testis and no evidence of atrophy. Testis sparing surgery is an option for patients with small unilateral testicular tumors even in the presence of a healthy contralateral testis.

640 TESTIS SPEARING SURGERY (TSS) IN THE TREATMENT OF BILATERAL TESTICULAR GERM CELL TUMORS (BTGCT)

You have accessJournal of UrologyPenis/Testis/Urethra: Benign & Malignant Disease II1 Apr 2010640 TESTIS SPEARING SURGERY (TSS) IN THE TREATMENT OF BILATERAL TESTICULAR GERM CELL TUMORS (BTGCT) Nebojsa Bojanic, Sava Micic, Aleksandar Vuksanovic, Aleksandar Janjic, Ivan Vukovic, Cane Tulic, Otas Durutovic, and Djordje Nale Nebojsa BojanicNebojsa Bojanic More articles by this author , Sava MicicSava Micic More articles by this author , Aleksandar VuksanovicAleksandar Vuksanovic More articles by this author , Aleksandar JanjicAleksandar Janjic More articles by this author , Ivan VukovicIvan Vukovic More articles by this author , Cane TulicCane Tulic More articles by this author , Otas DurutovicOtas Durutovic More articles by this author , and Djordje NaleDjordje Nale More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1014AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Retrospective analysis of indications, results and follow-up of patients subjected to TSS in treatment of BTGCT. METHODS The total of 26 patients with BTGCT (19 metachronous and 7 synchronous BTGCTs) were treated in the period 1996-2009. After standard preparation with TSH level determination and echo verification of the testicular tumor change, TSS was performed during warm and cold ischemia. None of the patients underwent local radiation therapy subsequent to TSS. RESULTS Thirteen TSS were performed in 12 patients; 8/19 patients with metachronous and 4/7 patients with synchronous BTGCT. One of the patients developed testicular atrophy with progression of the disease (retroperitoneal lymphadenopathy) 4 months subsequent to TSS and he underwent radical orchiectomy and adjuvant CHT according to PEB protocol; one patient had local relapse of the disease 65 months after TSS and he underwent radical orchiectomy and follow-up; one patient underwent repeated TSS due to tumor relapse 13 months after the initial TSS. All treated patients had no evidence of the disease over the 18-month follow-up period (range 4-79). TIN was evidenced in 9 out of 12 patients subjected to TSS, while adjuvant therapy was applied in 7 out of 12 patients after TSS. None of the patients underwent adjuvant irradiation therapy of the testicle after TSS and CHT. CONCLUSIONS TSS is a highly effective surgical method in treatment of BTGCT, unilateral testicular tumors and it may and should be applied whenever possible. TSS is highly effective from the oncological point of view and it enables for life-long hormone substitution to be avoided. Avoiding of local irradiation therapy of the testicles enables preservation of fertility and reduces the risk of local relapse and progression of the disease, however follow-up examinations should be carried out in shorter time intervals. Belgrade, Yugoslavia© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e251 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nebojsa Bojanic More articles by this author Sava Micic More articles by this author Aleksandar Vuksanovic More articles by this author Aleksandar Janjic More articles by this author Ivan Vukovic More articles by this author Cane Tulic More articles by this author Otas Durutovic More articles by this author Djordje Nale More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Tumor testicular bilateral sincrónico con focos de neoplasia intratubular de células germinales: presentación de un caso

To report one case of bilateral synchronic testicular tumor with germ cell intratubular neoplasia foci affecting both testicles. We describe the case of a 29-year-old male presenting with a painless tumor in the left testicle for a month. With the suspect of testicular tumor scrotal ultrasound, tumor markers and extension study to rule out metastasis were performed. Ultrasound showed a hypertrophic left testicle with a lesion suspect for neoplasia, and incidental diagnosis of a hypoechoic lesion with augmented Doppler flow within the right testicle. Bilateral orchyectomy was performed with the pathologic diagnosis of classic seminoma with germ cell intratubular neoplasia foci in both testicles. Treatment was completed with two cycles of chemotherapy. Bilateral synchronic testicular tumors are very rare. The most frequent histological type is classic seminoma. The diagnosis and treatment are similar to unilateral testicular tumors except certain cases in which partial excision of the testicle may be considered.

精巣腫瘍患者の非腫瘍側精巣にみられた超音波断層法による精巣内微小石灰化症と Carcinoma in situ の関連性について

To determine the prevalence of testicular microlithiasis (TM) in the contralateral testis of patients with unilateral testicular tumor, and evaluate the association of TM with carcinoma in situ (CIS) MATERIALS AND METHODS: In a period of 12 years, ultrasonography was performed in 41 patients with unilateral testicular tumor. TM was defined as multiple small hyperechogenic foci. Only images of the tumor-free testis were reviewed. In addition, archived biopsy specimens of the contralateral testicle were reviewed after immunostaining for placental alkaline phosphatase (PLAP) as a marker for CIS. TM was diagnosed in 11 (26.8%) patients. Of them, microliths were pathologically confirmed in only 2. Prevalence of CIS was higher in patients with TM (2 of 11 patients) than in those without TM (0 of 30 patients, p = 0.017) TM was associated with testicular tumor. TM in the contralateral testis of patients with unilateral testicular tumor may increase the risk of CIS.

Testicular Superoxide Dismutase Activity, Heat Shock Protein 70 Concentration and Blood Plasma Inhibin-.ALPHA. Concentration of Dogs with a Sertoli Cell Tumor in a Unilateral Cryptorchid Testis

The proportions of Sertoli cell tumor (SCT), seminoma and Leydig cell tumor in 50 dogs with unilateral testicular tumors were 52%, 36% and 12%, respectively. The rate of occurrence of SCT in the cryptorchid testis was very high (71%). The testicular superoxide dismutase (SOD) activity, testicular heat shock protein (HSP) 70 concentration and peripheral blood plasma inhibin (INH)-alpha concentration of 10 dogs with a unilateral cryptorchid testis and no testicular tumors, 10 dogs with SCT in a unilateral cryptorchid testis and 10 normal dogs, all aged 5-15 years, were measured in order to identify high risk factors for the occurrence of SCT in the canine cryptorchid testis. The mean SOD activity in cryptorchid testes and SCTs was significantly lower and higher, respectively, than in normal testes (both P<0.01). The mean HSP 70 concentration in both cryptorchid testes and SCTs was significantly higher than in normal testes (both P<0.01). The mean plasma INH-alpha concentration of the cryptorchid and SCT dogs was significantly lower and higher, respectively, than in normal dogs (P<0.05 and 0.01, respectively). The low SOD activity in the cryptorchid testis, low blood plasma INH-alpha concentration of the cryptorchid dogs and high HSP 70 concentration in the SCTs may be related to the occurrence of SCT and tumor cell proliferation in canine cryptorchid testes.

Testicular microlithiasis identified ultrasonographically in Japanese adult patients: Prevalence and associated conditions

Objectives To determine the prevalence of testicular microlithiasis (TM) seen by testicular ultrasonography (US) in Japanese adult men referred for andrologic symptoms and evaluate associations of TM with pathologic conditions. Methods For 7 years, US was performed in 969 patients (mean age 40.9 years) at one institution. The patients were divided into groups with infertility (n = 550), unilateral testicular tumor (n = 46), or other andrologic conditions (n = 373). TM was identified as multiple small hyperechogenic foci. In the tumor group, only images of the tumor-free testis were reviewed. Patients with TM accompanying tumor or infertility completed follow-up questionnaires and US examinations. Results TM was diagnosed in 46 patients (mean age 38.5 years, range 23 to 75). The prevalence of TM was 17.4% in the tumor group, 5.6% in the infertility group, and 1.9% in the other-conditions group. TM was associated with testicular tumor and infertility, but not with other conditions. In patients with unilateral testicular germ cell tumor, the prevalence of carcinoma in situ in the contralateral testis was greater when TM was present in that testis (2 of 8 patients) than when TM was absent (0 of 32, P = 0.0037). No new testicular tumor developed subsequently. In the infertility group, the 31 patients with TM showed no subsequent testicular tumor development, and neither patient undergoing testicular biopsy had carcinoma in situ. Conclusions TM, as demonstrated by US, was associated with infertility, as well as testicular tumor. TM in a testis contralateral to a unilateral testicular germ cell tumor may increase the risk of carcinoma in situ.

Semen cryopreservation for patients with malignant or non-malignant disease: our experience for 10 years.

We report our experience in 10 years of sperm cryopreservation to reveal the present state of the cryopreservation project. 42 germ cell tumor, 110 non-germ cell tumor and 2 non-malignant disease patients who visited our clinic for semen cryopreservation were retrospectively analyzed. Only 7 (20%) out of 35 unilateral testicular tumor patients who had received no chemotherapy met the WHO criteria for sperm concentration and motility. However, there were no patients with azoospermia. Three testicular tumor patients with previous chemotherapy and 4 retroperitoneal germ cell tumor patients had poor sperm concentrations and motilities. Twenty (52%) out of 38 non-germ cell tumor patients without previous chemotherapy met the WHO criteria. In contrast, only 9 patients (13%) met the WHO criteria among 72 patients with previous chemotherapy. Twenty-nine patients (40%) with chemotherapy were azoospermia. Totally, 74 (96%) of 77 tumor patients' semen without chemotherapy and 34 (45%) of 75 with chemotherapy were cryopreserved. Sperm from a patient with testicular torsion were cryopreserved. Most cancer patients without previous chemotherapy, regardless of underlying disease, had abundant motile sperm. However, half of the patients who had received chemotherapy did not have suitable sperm for freezing. It is important to inform young cancer patients of the cryopreservation project immediately after the diagnosis is made.

Contralateral testicular biopsy procedure in patients with unilateral testis cancer: is it indicated?

About 5% of all patients with unilateral testis cancer harbor testicular intraepithelial neoplasia (TIN) in their contralateral testicle, which will progress into an invasive germ-cell tumor over time. Accurate diagnosis of TIN by a random surgical testis biopsy examination and effective therapy by local radiation has led to the concept of a contralateral screening biopsy procedure in all testis cancer patients. Screening and preventive treatment, however, only are indicated if (1) therapeutic outcome of the screened population is improved and (2) physiologic function of the affected organ might be maintained. Based on a critical review of the literature, some drawbacks of this policy have to be considered and the routine indication for contralateral testis biopsy procedure has to be questioned: (1) all TIN-negative patients still have to undergo meticulous follow-up evaluation for metachronous testis cancer owing to a false-negative biopsy diagnosis rate of 0.3%; (2) testis biopsy procedure is associated with a 15% to 20% complication rate, which might a negative impact on endocrine and exocrine testicular function; (3) local radiation of TIN results in irreversible infertility owing to eradication of spermatogenesis; (4) local radiation of TIN results in an impairment of endocrine Leydig cell function in 25% of patients; (5) therapeutic outcome and prognosis will not be improved in irradiated patients as compared with patients on surveillance; (6) local tumor resection for the management of metachronous testicular cancer represents an effective and viable option. The current literature does not support the strategy to perform contralateral testis biopsy procedures in all patients with unilateral testicular germ-cell tumors. Testis biopsy procedures might, however, be offered to high-risk (34%) patients for contralateral TIN with a testicular volume less than 12 mL, a history of cryptorchidism, and an age less than 30 years.

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

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

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.

Hormone profiles and contralateral testicular histology in Down's syndrome with unilateral testicular tumor.

Hormonal profiles and testicular histology were studied in two patients with Down's syndrome with unilateral testicular tumor. Plasma levels of LH and FSH were elevated above normal ranges in both cases. In case 1, plasma testosterone level was abnormally low, but prolactin level in plasma was within the normal range. Case 2 showed elevated concentration of plasma prolactin and normal level of plasma testosterone. The administration of LH-RH resulted in low response of plasma gonadotropins. The response of plasma testosterone to the administration of HCG was abnormally suppressed in both cases. Testicular histology showed reduction of Johnsen score count and tubular diameter, and an increase in wall thickness. These results indicated that male patients with Down's syndrome have an abnormality in hypothalamo-pituitary-gonadal axis.