A Case of Synchronous Bilateral Testicular Seminoma

Box 1.

Guidelines for the Implementation of a Testis-sparing Approach to Testicular Cancer.^[16]

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Author(s)

Matthew J. Resnick, MD

second-year Resident in Urology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania

Disclosures

Disclosure: Matthew J. Resnick, MD, has disclosed no relevant financial relationships.

Daniel Canter, MD

fourth-year Resident in Urology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania

Disclosures

Disclosure: Daniel Canter, MD, has disclosed no relevant financial relationships.

Benjamin M. Brucker, MD

third-year Resident in Urology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania

Disclosures

Disclosure: Benjamin M. Brucker, MD, has disclosed no relevant financial relationships.

Alexander Kutikov, MD

Chief Resident in Urology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania

Disclosures

Disclosure: Alexander Kutikov, MD, has disclosed no relevant financial relationships.

Thomas J. Guzzo, MD

Fellow in Urologic Oncology, Johns Hopkins Medical Center, Baltimore, Maryland

Disclosures

Disclosure: Thomas J. Guzzo, MD, has disclosed no relevant financial relationships.

Alan J. Wein, MD

Chief of Urology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania

Disclosures

Disclosure: Alan J. Wein, MD, has disclosed no relevant financial relationships.

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Treatment and Management

After careful discussion of his treatment options, the current patient opted for left orchiectomy. The treating physician recommended this approach on the basis of the size of the principal lesion and the multifocality of the presumed tumor. Intraoperative frozen section analysis of the left testis produced equivocal results, and right orchiectomy was deferred until after pathologic analysis confirmed the presence of left seminoma. While frozen section analysis is usually able to identify malignancy, it can occasionally fail to provide a definitive intraoperative diagnosis. In a series of 80 patients that investigated the utility of frozen section analysis for testicular malignancy, one case was reported as inconclusive and two malignant samples were misclassified as benign. The overall sensitivity and specificity of frozen section analysis for malignancy was found to be 96.1% and 89.3%, respectively.^[10] In the current patient, the presence of two left-sided lesions, one of which was 2.5 cm in size, necessitated left orchiectomy despite equivocal intraoperative results. These features also precluded a left testis-sparing approach to treatment.

While bilateral orchiectomy is standard practice for patients with synchronous bilateral seminoma, some data support the use of testis-sparing techniques to avoid the sequelae of this treatment, which include infertility, dependence on androgen replacement therapy, and the psychological effects of castration. The current patient had no further desire to father children and, as such, fertility was not a central issue in this case. Some authors have advocated a testis sparing approach in men with tumors larger than 2 cm with a high testis:tumor size ratio; however, this was not the practice of the treating institution. Additionally, in the present case, the patient’s right-sided tumor was centrally located, which would have made a testis-sparing approach technically challenging, if not impossible.

For patients with typical, unilateral stage I seminoma, the presence of either a tumor greater than 4 cm in size or involvement of the rete testis indicates a risk of retroperitoneal recurrence that warrants adjuvant therapy.^[11] In this setting, some evidence supports the use of postorchiectomy surveillance for compliant patients with normal levels of serum tumor markers following orchiectomy, with relapse rates of 6–19%.^[12] In patients who have neither a tumor greater than 4 cm in size nor involvement of the rete testis, a recurrence rate of 6%, with 100% cause-specific survival, has been observed.^[12] Outcomes of surveillance for synchronous bilateral stage I seminoma, however, are largely unknown, as the vast majority of patients described in large series were treated with adjuvant chemotherapy or radiation.

In the present case, counseling the patient as to the risk of recurrence with surveillance alone proved difficult because of the paucity of data on bilateral seminoma. While active surveillance was presented as a therapeutic strategy, it became clear after thorough discussion that the patient and his family were not interested in pursuing a surveillance protocol, so he was offered adjuvant chemotherapy or radiation therapy instead. Adjuvant therapy with one cycle of carboplatin has been found to achieve rates of relapse-free survival comparable to those of prophylactic radiation therapy in patients with clinical stage I seminoma.^[13] This treatment strategy is particularly attractive for patients with bilateral disease, as the second malignancy can be treated without any dose escalation. The current patient did not wish to pursue adjuvant chemotherapy because of concerns over tolerability, and he opted instead to undergo abdominal radiation therapy at a dose of 2,520 cGy to the bilateral para-aortic nodes and left renal hilum. This radiation field encompassed bilateral drainage and included lymphatic drainage from the left testis to the left renal vein. Indeed, there is little difference between the radiation field utilized in this case and that used for a solitary left-sided testicular tumor.

Testis-sparing Surgery

The organ-preserving approach to testicular malignancy was first described by Weissbach^[14] and was adapted from the treatment of benign testicular tumors and infantile teratomas. Heidenreich et al.^[15] subsequently reported on six patients who underwent tumor enucleation, with or without adjuvant radiation therapy, for bilateral testicular tumors. At a median followup of 43 months, no patient had any evidence of disease recurrence or requirement for androgen supplementation. More recently, the German Testicular Cancer Study Group has reported the largest series in this regard, which comprised 101 patients with metachronous (71.3%) or synchronous (22.8%) bilateral testicular germ cell tumors or testicular cancer in a solitary testis (5.9%). At a median follow-up of 80 months, 99% of patients had no evidence of disease, and one patient had died as a result of systemic progression. Four patients who did not receive adjuvant radiation therapy experienced local recurrence, and all survived after undergoing salvage radical orchiectomy. Testosterone levels were normal in 83.1% of patients, with 9.7% developing hypogonadism and 6.3% remaining at their preoperative, depressed testosterone levels. On the basis of their results, the investigators suggested guidelines for the implementation of a testis-sparing approach to testicular cancer ( Box 1 ).^[16]

The organ-sparing approach does, however, necessitate close observation to ensure timely detection of any metachronous tumor. The above study noted that 82.3% of patients who underwent tumor enucleation with testicular biopsy were found to harbor testicular intraepithelial neoplasia. Most (82.1%) of these individuals received adjuvant local radiation therapy at a dose of 18–20 Gy. Of the 12 patients who refused local radiation therapy, recurrence was seen in 3 patients at 6, 12, and 165 months. While testis-sparing approaches offer patients the opportunity to avoid androgen supplementation, the high likelihood of testicular intraepithelial neoplasia and the ensuing need for adjuvant radiation therapy continues to limit patient fertility, and this fact should be made clear during consultation.