The first case was a 25-year old male with left testis discomfort. He was originally treated with ciprofloxacin with no resolution. There was a question of a left testis mass on physical examination. Dr. Pierorazio recommended scrotal ultrasound (US) and tumor markers as a critical part of the initial workup. The scrotal US demonstrated a hypoechoic vascular mass in the left testis. The AFP level was 3630 and the HCG was 650. The pathology from his left radical orchiectomy was organ-confined mixed non-seminomatous germ cell tumor (NSGCT) with no evidence of lymphovascular invasion. The panel made the point that a PET scan is not indicated during the initial work-up for NSGCT. With regard to staging the chest, CT is recommended for NSGCT since skip lesions (i.e. pulmonary metastasis in the absence of retroperitoneal lymphadenopathy) are possible. The CT scan in this patient demonstrated a 2mm pulmonary nodule. Dr. Saylor would not initiate chemotherapy based on small pulmonary nodules preferring to observe whether the nodules grow over time. Five days after the orchiectomy, the patient’s tumor markers remained elevated at AFP of 1650 and HCG of 66. The point was made here that marker nadirs are critical as are knowledge of tumor marker half-lives. Therefore, the patient is most accurately staged as clinical stage 1a. Here, the panel universally recommended active surveillance in this patient without risk factors. The point was made that low dose CT can be used, but that MRI is not likely ready for prime time in the United States in this setting. After 15 months of surveillance a 1 cm para-aortic lymph node was discovered on abdominal CT scan. The options presented by Dr. Pierorazio and Dr. Saylor were primary RPLND versus induction chemotherapy. Indeed, a primary bilateral nerve-sparing RPLND was performed. Pathology demonstrated 3/56 lymph nodes positive for malignancy, but without extranodal extension (pN1). These patients have a risk of relapse of approximately 10-15%. Therefore, the panel did not recommend adjuvant therapy, as this would overtreat 85% of the patients.
The second case was a 28-year old male with a palpable mass in an atrophic left testis. The US demonstrates a hypoechoic, vascular mass in the left testis; however, the right testis also has a mass! Tumor markers and CT are normal. The primary point of emphasis here was to include semenalysis and sperm banking in the initial work-up when future fertility concerns arise. The left orchiectomy returned as seminoma. A partial orchiectomy was done on the right resulting in a Leydig tumor (benign). Therefore, the patient has a clinical stage 1 seminoma. Options for management include adjuvant chemotherapy versus active surveillance. Historically, tumor size greater than 4 cm and rete testis invasion have been used as risk stratifiers. Presently, however, all patients are considered eligible for active surveillance and the panel felt that this was the preferred management option.
Case 3 was a 33-year old patient who had an orchiectomy in 2002 for seminoma with adjuvant radiation therapy. In 2013, routine examination demonstrated a left testis mass and CT showed para-aortic lymphadenopathy. Dr. Beard suggested that radiation therapy could be done again if necessary, but she wouldn’t offer it as a primary management option. A discussion ensued about the merits of chemotherapy versus surgery in this setting. Dr. Sheinfeld argued that surgery has the lowest long-term risks and should be the preferred management strategy.
The final case was a 25-year old male with oligospermia and no other medical problems. A scrotal US demonstrated a 1.1cm right hypoechoic, vascular lesion and bilateral microlithiasis. The point was made that microlithiasis in the absence of other risk factors (e.g. history of undescended testis) is generally not felt to be a harbinger of future testis cancer. The patient was had a partial orchiectomy that demonstrated mixed NSGCT with diffuse intratubular germ cell neoplasia (ITGCN). Close follow-up was recommended, but the patient did not adhere. He presented back with severe groin pain and an elevated HCG to 8. CT demonstrated a pelvic mass and retroperitoneal lymphadenopathy. The panel recommended chemotherapy, which resulted in complete resolution of the pelvic and retroperitoneal lymphadenopathy. Completion orchiectomy was performed demonstrating residual ICGCN. This underscores the notion that ICGCN is generally not chemosensitive.
Moderator: Joel Sheinfeld, MD
Panelists: Phillip M. Pierorazio, MD, Phillip J. Saylor, MD, Clair J. Beard, MD, Michael A.S. Jewett, MD, FRCSC
Written By: Benjamin T. Ristau, MD, Fox Chase Cancer Center, Philadelphia, PA
at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA