Synchronous bilateral testicular germ cell tumor: role of conservative surgery. Case report and literature review.

Alessandro Samuelli1, Paolo Parma1, Bruno Dall'Oglio1, Francesco Colpani2, Angelo Cassisa2
  • 1 Azienda Ospedaliera Carlo Poma, Divisione di Urologia (Mantova)
  • 2 Azienda Ospedaliera Carlo Poma, Divisione di Anatomia Patologica (Mantova)

Objective

The aim of this study is to describe incidence, clinical and histological findings, of bilateral testicular germ cells tumors and to define through the literature review, a correct therapeutic approach in the management of patients with synchronous bilateral testicular germ cell tumor with discordant histologies. We present the case of a 25 years old patient with right mixed germinal cell of 30 mm and left synchronous seminoma of 20 mm in diameter respectively. The patient underwent right inguinal orchiectomy and simultaneous excision of the left testicular cancer. According to European guidelines, we propose a regimen applicable in similar cases, covering the need for conservative surgery.

Methods and results

We performed a literature review in pubmed. Search terms we used are: bilateral testicular tumor, bilateral testicular neoplasm, bilateral testicular germ cell tumor, synchronous testicular tumors. The majority of studies consists of sporadic case reports. We focused on systematic reviews and retrospective studies of larger groups of patients, in order to define a correct therapeutic approach. We present the case of a patient of 25 years with ultrasound findings of bilateral testicular cancer, respectively 3 cm to the right testicle and 2 cm to the left testicle. The patient underwent preoperatively, to fine-needle aspiration with evidence of germ cell carcinoma. Previously performed cryopreservation of seminal fluid. CT scan preoperatively was negative for lymph node metastases. Tumor markers (AFP and b-HCG), were higher in the preoperative period ; LDH and testosterone was in normal range. We have performed a right inguinal orchiectomy, and a left tumor excision. After tumor enucleation, we performed 6 extemporaneous biopsies, tested negative for intratubular germ testicular neoplasm. Margins were free of disease. The definitive histological examination showed a mixed nonseminomatous germ cells carcinoma of right testicle ( 60% embrionary carcinoma, 38% mature teratoma , 2% yolk sac) , and a pure seminoma of the left one. TNM stage was pT1 Nx S1.
It is observed a progressive halving of the markers, up to a complete normalization of b-HCG, after one month (b HCG 2.0 ug / ml). Patient developed lower levels of testosterone (testosterone: 1.2 ng / ml, FSH 92.7 mIU / ml, LH 48.2 mIU / ml), which required therapy with exogenous testosterone.The patient was subjected to cycle of adjuvant chemotherapy for nonseminomatous germ form (PEBx3).

Discussion

The testicular cancer is the most common cancer in males between the ages of 15 and 44 years. The incidence is increased by approximately 50% over the past 30 years, although the cause of this phenomenon remains controversial [1] [2]. The likelihood of developing a second cancer in the contralateral testis at same point of life, reaches 5% of cases of previous testicular cancer. About 35% of these patients present with synchronous tumor, 65% present with metachronous tumors. The germinal form (Testicular Germ Cell Tumors: TGCTs) represents the majority of testicular tumors (95%) [3]. The role of a possible genetic predisposition is supported by the increased likelihood of developing cancer in germ cells, in siblings with bilateral cancer [2]. A review of the literature led to two large series of patients with bilateral synchronous testicular cancer with different histological types [3] [4]. In a study of 175 patients, 50% had synchronous bilateral seminoma, 34% discordant histologies, and the remaining 16% bilateral nonseminomatous germ cell carcinoma [3]. In synchronous bilateral testicular tumours, metachronous contralateral tumours, or in a tumour in a solitary testis with normal pre-operative testosterone levels, organ preserving surgery can be performed when the tumour volume is less than 30% of the testicular volume and surgical rules are respected. Some autors suggests 20 mm as a limit measure for conservative treatment. In those cases, the rate of associated TIN is high (at least up to 82%), and all patients must be treated with adjuvant radiotherapy (16-20 Gy) at some point (5). Wether Cisplatin –based chemotherapy may eradicate testicular TIN is a matter of debate in the review of the literature. Infertility will result after radiotherapy and the risk of long-term Leydig cell insufficiency after radiotherapy of a solitary testis is increased (6). Radiation treatment may be delayed in fertile patients who wish to father children. The option must be carefully discussed with the patient and surgery performed in a centre with experience (7,8). In our report , according with patient will of paternity, we decided to perform an organ sparing surgery. According to Weissbach protocol we performed 6 tri-planar biopsies after tumor enucleation, negative for TIN (intratubular testicular neoplasm) . After assuring negative tumor margins the tunica was closed with an absorbable suture on the testicle, delivered back to the scrotum.
The treatment of synchronous tumors should be planned according to the form of more aggressive disease. This figure is even more true in the case of nonseminomatous germ cells cancer, as the treatment for this form histological covers the need for treatment for other histological forms. Finding this principle patients underwent to adjuvant chemotherapy ( PEB x 3). Follow-up includes: CT scan, testicular ultrasound and tumor markers sampling. In the aftermath of chemotherapy PET CT is not recommended due to the high number of false positives findings. Conservative surgery for testicular cancer may represent the "gold standard" treatment, provided that they meet the inclusion criteria of Weissbach protocol, currently adopted in the EAU guidelines.

References

1. American Cancer Society. Cancer Facts et Figures 2010. Available at: http//www.cancer.org/Researc Cancer Facts Figures 2010/ Cancer-Facts-and-Figures- 2010.Accessed 22 January,2011
2. Stenio de Cassio Zequi, Walter Henriques da Costa et al. Bilateral, testicular germ cell tumors: a systematic review. BJU international 2012; 110: 1102-1109
3. Fossa SD, Chen J, Schonfeld SJ et al. Risk of controlateral testicular cancer: a population-based study of 25,515 U.S. man. J Natl Cancer Inst 2005;97: 1056-66.
4. Holzbeierlein JM, Sogagni PC, Scheinfeld J: Histology and clinical outcomes in patients with bilateral testicular germ cell tumors: The memorial Sloan Kettering Cancer Center experience 1950 to 2001. J Urol 2003; 169:2122-2125.
5. Heidenreich A, Weissbach L, Holth W, et al. German Testicular Cancer Study Group. Organ sparing surgery for malignant germ cell tumour of the testis. J Urol 2001 Dec;166(6):2161-5 http://www.ncbi.nlm.nih.gov/pubmed/11696727
6. Petersen PM, Giwercman A, Daugaard G, et al. Effect of graded testicular doses of radiotherapy in patients treated for carcinoma-insitu in the testis. J Clin Oncol 2002 Aug;20(6):1537-43. http://www.ncbi.nlm.nih.gov/pubmed/11896102
7. Heidenreich A, Höltl W, Albrecht W, et al. Testis-preserving surgery in bilateral testicular germ cell tumours. Br J Urol 1997 Feb;79(2):253-7. http://www.ncbi.nlm.nih.gov/pubmed/9052478
8. Weissbach L. Organ preserving surgery of malignant germ cell tumours. J Urol 1995 Jan;153(1):90-3 http://www.ncbi.nlm.nih.gov/pubmed/7966800

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