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Orchiectomy after chemotherapy in patients with metastatic testicular cancer. Is it indicated?
P D Simmonds1, G M Mead, A H Lee
1Wessex Medical Oncology Unit, Royal South Hants Hospital, Southampton, United Kingdom.
Background:
A small proportion of patients with testicular germ cell tumors present with widely metastatic disease and are treated initially with chemotherapy. Little is known about the efficacy of systemic chemotherapy in eradicating the primary testicular germ cell cancer; however, there is concern that the testis may act as a sanctuary site for germ cell cancer in these patients, and orchiectomy, is, therefore, recommended after chemotherapy.
Methods:
The results from a clinical and pathologic review of 24 patients who underwent delayed orchiectomy after chemotherapy are presented. The testicular pathologic findings are correlated with those in extragonadal masses and also with a blinded review of postchemotherapy testicular ultrasound scans.
Results:
The most common testicular pathological finding was a dense fibrous scar that was found in all patients. Three patients had persistent testicular germ cell cancer, six had mature teratoma, and one had carcinoma in situ. There was a strong concordance between the major testicular pathologic findings and those in the resected extragonadal masses. All three patients with persistent testicular germ cell cancer subsequently had disease progression in the extragonadal sites. Testicular ultrasound examination did not distinguish accurately between residual tumor or scar in the testis.
Conclusion:
Persistence of the primary testicular germ cell cancer is most likely due to the same heterogeneous response to chemotherapy observed in different metastatic sites. Because current imaging techniques cannot identify accurately those patients with residual testicular germ cell cancer or related testicular abnormalities that may predispose to subsequent relapse, orchiectomy after chemotherapy remains appropriate.
Insights
Chemotherapy may not eliminate all testicular germ cell tumors, as the testis can be a sanctuary site. Delayed orchiectomy after chemotherapy is recommended to remove residual cancer and prevent relapse.
Area of Science:
- Oncology
- Urology
Background:
- Testicular germ cell tumors can present with widespread metastases requiring initial chemotherapy.
- The efficacy of chemotherapy in eradicating the primary testicular tumor is uncertain, with concerns about the testis acting as a sanctuary site.
- Orchiectomy (surgical removal of the testis) is often recommended post-chemotherapy for these patients.
Purpose of the Study:
- To evaluate the pathological findings in testes after chemotherapy for metastatic germ cell tumors.
- To correlate testicular pathology with extragonadal disease and imaging findings.
- To determine the appropriateness of orchiectomy after chemotherapy.
Main Methods:
- Clinical and pathological review of 24 patients who had delayed orchiectomy post-chemotherapy.
- Correlation of testicular pathology with extragonadal masses.
- Blinded review of post-chemotherapy testicular ultrasound scans.
Main Results:
- The most common finding was dense fibrous scarring in all patients.
- Persistent testicular germ cell cancer was found in 3 patients, mature teratoma in 6, and carcinoma in situ in 1.
- Testicular ultrasound could not reliably differentiate residual tumor from scar tissue.
- Patients with persistent cancer showed subsequent disease progression in extragonadal sites.
Conclusions:
- Persistent primary testicular germ cell cancer after chemotherapy is likely due to heterogeneous treatment response.
- Current imaging is insufficient to accurately identify residual testicular cancer or pre-cancerous abnormalities.
- Orchiectomy post-chemotherapy remains a crucial step to manage residual disease and prevent relapse.