Search

In postoperative radiotherapy for seminoma, control of the testicular absorbed dose is important, since exposure of the testis can lead to temporary or permanent infertility. In this case, instead of using a dog-leg-shaped field, treatment using a field focused near the aorta was provided in several disease stages of seminoma. However, the precise need for testicular shielding during treatment and dose of testis exposure was not clear. We examined these questions by measuring the testicular absorbed dose with and without a testicular shield using two clinical treatment plans and a phantom. The distance from the testis phantom and the lower end of the irradiation field was varied. Where the total dose for the tumor was 20 Gy, the testicular absorbed dose was below 0.1 Gy, the threshold dose for temporary infertility. At this dosage, the distance between the testis phantom and the edge of the irradiation field was 14.6 cm without the shield and 9.99 cm with the shield. Using a testes shield, it was thus possible to reduce the dose by 58.5%.

Malignant mesothelioma of the tunica vaginalis is rare, and is usually not diagnosed until surgery is undertaken. We report here a case in a 62-year-old man with malignant mesothelioma tunica vaginalis testis. He was referred to our hospital with a painless swelling of the left scrotal contents. There is a thickening of mesothelia of the tunica vaginalis with left sided hydrocele by ultrasonography and computed tomography scan. The tumor was resected under the diagnosis of testicular malignant tumor. However, the pathologist reported malignant mesothelioma and positive margin. He received external beam radiation therapy at a total dose of 44 Gy. Disease progression was not apparent 2 years after treatment. To our knowledge, 26 cases of malignant mesothelioma in the perineum or intrascrotum have been reported in Japan and this case is thought to be the 27th case in Japan.

A 71-year-old man was admitted with a swelling of the left scrotum where Galium scintigraphy was positive. He had a history of malignant lymphoma of the right testis and had undergone an orchitectomy, with adjuvant CHOP (cyclophosphamide, doxorubicin, vincristine, predonisolone) chemotherapy and radiotherapy to the post-orchitectomy site and opposite testis. An open biopsy of his scrotum and left testis revealed relapse of the malignant lymphoma in the left scrotal skin.

Late relapse of testicular tumor is rare. We report a case of recurrence of seminoma at left inguinal lymph node 18 years after initial treatment. A 63-year-old man had a left orchiectomy for left testicular tumor (T1N0M0) in February 1985, with no past history of scrotal or inguinal surgery. Histological examination revealed seminoma (pT1), and prophylactic radiotherapy (34.2 Gy) to para-aortic and left hemi-pelvic regions was perfomed. In November 2003, the patient presented with left inguinal swelling, and was referred to our hospital with suspicion of metastasis to left inguinal lymph nodes. Serum markers (AFP, hCG, hCGbeta and LDH) were normal. Computerized tomography (CT) showed three masses in the left inguinal region, but no other abnormal mass was detected at chest, abdomen or pelvis. Lymphoidectomy of the left inguinal region was perfomed in January 2004, and the mass revealed to be metastasis of seminoma by histological examination.

Persistent Müllerian duct syndrome is associated with cryptorchidism and transverse testicular ectopia. Such gonads are at an increased risk of malignant transformation. Furthermore, most patients have azoospermia. Here in we report about two brothers with persistent Müllerian duct syndrome. The diagnosis was made during surgical operation for testicular cancer in younger brother. In the other one, persistent Müllerian duct syndrome was diagnosed during examination for infertility.

Since the advent of cisplatin-based chemotherapy in the 1970s, a majority of metastatic testicular cancer patients have been cured with chemotherapy and surgery. The high curability of testicular cancer, along with the young age of afflicted patients, can result in patients living for many years after the chemotherapy. Thus, the assessment of late effects of chemotherapy is clinically important in testicular cancer patients. This article summarizes the literature regarding the long-term side effects, and reviews approaches to the amelioration of these side effects.

Prostate cancer, bladder cancer, renal cancer and testicular cancer are common among urological cancers. The treatment strategy for testicular cancer using chemotherapy has been well established and has been shown to be successful. Chemotherapy and radiotherapy play important roles in multidisciplinary therapy for bladder cancer. Radiotherapy is often used as a radical treatment that is practically equivalent to surgery for prostate cancer. In addition, radiotherapy is useful in cases of bone or brain metastases. In the field of chemotherapy, the development of new agents that would make breakthroughs similar to that of cisplatin is awaited. Taxanes and gemcitabine are good candidates. In the field of radiotherapy, 3D conformal radiation therapy (CRT), which has excellent beam distribution, has recently come into wide use. Moreover, brachytherapy and proton and ion beam therapy are expected to prove useful in prostate cancer therapy.

Since the advent of cisplatin-based chemotherapy in the 1970s, the majority of metastatic testicular cancer patients can be cured with chemotherapy followed by surgery. The high-curability of testicular cancer, along with young age of afflicted patients, can result in patients living for many years after the initial treatment. The development of second cancer represents one of the most severe long-term complications in these patients. Patients who have achieved a long-term disease-free status have an increased risk of developing germ-cell tumor in the contralateral testis. Late relapse (occurring more than 2 years after initial treatment) of germ-cell tumor at any site has also been found in approximately 3% of all patients. Patients receiving radiotherapy or chemotherapy for testicular cancer a have small, but clearly identifiable, risk of developing second malignancies. Radiotherapy is associated with a two- to threefold increased risk for second solid cancer. Chemotherapy, especially high-dose etoposide regimens, is associated with increased risk for second leukemia. Although the incidence of second malignancies is rather low, it is important to monitor the carcinogenic potential of therapy, and to develop a preventive approach for second cancer.

We evaluated the physical or psychosocial states of testicular cancer patients receiving orchiectomy, radiation therapy and chemotherapy to assess their quality of life during and after treatment. The subjects were 33 post-treatment patients with testicular cancer who responded to the questionnaire we mailed to them. The quality of life score during chemotherapy showed a decrease, which was accompanied by gastrointestinal symptoms induced by anti-cancer drugs. With regard to the difference in adjuvant treatment types, the surveillance group showed the highest score in the satisfaction of daily life. Moreover, married patients tended to be satisfied with daily life more than non-married patients. With regard to sexual or erectile function, scores of testicular cancer patients, especially in the retroperitoneal lymph node dissection group, were inferior to these of normal volunteers. In conclusion, the physical or psychosocial states after treatment for testicular cancer depend not only on treatment type but also marriage status.

The effects of local irradiation and intraperitoneal injection of cisplatinum (CDDP) and VP-16 were examined in the sequential 31P magnetic resonance spectroscopy (MRS) in testicular cancer (TC-1) and bladder tumor (BT-8) of human origin, serially transplanted in nude mice. In the early phase of tumor growth, high-energy phosphate metabolites such as phosphocreatinine (PCr), adenosine triphosphate (ATP) and phosphomonoester (PME) were detected in both grafted tumors. However, the relative value of inorganic phosphate (Pi) to PCr increased with the growth of the tumor. Irradiation had the most pronounced effect to inhibit growth, followed by CDDP in both strains. However, growth inhibition was not observed in the VP-16 group. The effect of irradiation on the tumor histology was severely expressed in the nucleus and cytoplasm on the 4th to 7th day. The high PCr/Pi ratio during 2 to 14 days after irradiation suggested reoxygenation in the tumors with a high hypoxic cell fraction. In the CDDP and VP-16 groups, without histological change, the changes of PCr and Pi were milder than that in the irradiation group. Thus the spectroscopic analysis is presumably expected to give us an earlier and more accurate information on the tumor than the conventional parameters.

The results of treatment by orchiectomy and radiotherapy for stage I testicular seminoma are excellent with cure rates exceeding 95% and relapse rates less than 5%. However, after the development of successful surveillance programs for stage I nonseminomatous testicular cancers, the role of radiotherapy has been questioned by some authors and they proposed a "surveillance policy" for these patients. The purpose of this study was to determine the percentage of patients cured by orchiectomy alone, percentage who ultimately required therapy for occult metastases, site of recurrence, and over-all cure rate and treatment morbidity. And these data were compared with those of adjuvant radiotherapy group retrospectively. Twenty seven patients were treated with adjuvant radiotherapy (RT group). Since 1986, 23 patients with stage I testicular seminoma entered the "surveillance only" protocol at our institution (S group) with a follow-up between 14 and 70 months (median 43 months). Informed consent for the policy of surveillance was obtained. Follow up consisted of physical examination, determination of serum tumor markers and chest X-ray bimonthly for 2 years, every 3 months for 1 year, every 6 months for 2 years and annually thereafter to 10 years. CT scans were performed every 4 months for 3 years, every 6 months for 2 years. Two patients in S group (8.7%) relapsed at 4 and 7 months after orchiectomy with nonbulky retroperitoneal disease (less than 5 cm in diameter), whereas only 1 (3.7%) irradiated patients did so after 4 months.

A 75-year-old man visited our clinic on November 11, 1982 with the complaint of a painless mass in the right scrotum. The mass was hen's egg sized and hard. Surgery was performed under the diagnosis of testicular tumor. Right hemiscrotectomy with right inguinal orchiectomy was performed because of a scrotal skin invasion of the tumor. The spermatic cord, testis and epididymis were grossly normal. The tumor was located just beneath the testis, and it was considered to be scrotal tunicus in origin. The tumor was elastic and hard, and the cut surface showed a yellowish white and lobulated appearance. The histological diagnosis was malignant fibrous histiocytoma. Postoperatively, radiotherapy for a total dosage of 4,910 rads was given. The patient is alive and well without any sign of recurrence 19 months after operation. The 20 cases reported in Europe, America and Japan, including our case, were tabulated and some discussion is made.

Within the last decade, progress in the management of testicular cancer has been remarkable. It has become a well-known fact that chemotherapy with or without excision of residual tumors can cure far-advanced disease. There are, as yet, unsolved problems such as the management of stage I disease, role of surgery in the treatment of stage III non-seminomatous testicular cancer and testicular damages by chemotherapy and so on. These problems will be discussed in this paper.

Seminoma is one of the most radiosensitive of the solid tumors. Radiotherapy provides a high cure rate for patients with stage I and II seminoma, but the survival rate of the patients with clinically advanced stage III seminoma is only about 30% in the literature. Our case of advanced metastatic seminoma was treated with cisplatinum, vinblastine and bleomycin. Metastatic tumors in the lung disappeared after chemotherapy but recurred shortly. Then regional radiation was given and the tumors disappeared completely. Subsequent prophylactic chemotherapy was given. In view of the observed chemosensitivity of seminoma, it appears that all patients who present initially with metastatic or bulky retroperitoneal disease should be treated with multiple drug chemotherapy including cis-platinum. Residual tumors can be treated by radiation and surgical resection, which will improve the cure rate of advanced metastatic seminoma.

Two cases of malignant lymphoma arising from the testis are reported. One was 45 years of age, with the complaint of left scrotal swelling with dull pain and the other was 68 years of age, with the complaint of painless swelling of right scrotal contents. Microscopic findings were both malignant lymphoma of the testis, large cell and immunoblastic type in case 1 and diffuse mixed, small and large cell type in case 2 (Working Formulation, 1982). Biomedical and radiographic examinations revealed no apparent involvement otherwise. For the period of 6 months in case 1 and 2 months in case 2 following radical orchiectomy with postoperative irradiation (Lineac 4,000 rad), the patients have been doing quite well without any clinical evidence of recurrence. The literature is also reviewed briefly.

During the past 21 years, 105 patients with germinal testicular tumor were treated in our hospital; 86 out of 105 patients were irradiated postoperatively. Late radiation injury was observed in 14 patients: Cutaneosigmoidal fistula in 1 patient, ileus (jejunum necrosis) in 1 patient, gastric ulcer in 1 patient, duodenal ulcer and stenosis in 1 patient, lung fibrosis in 1 patient, radiation cystitis in 1 patient, severe lymph edema of lower extremity in 1 patient, muscle atrophy of lower extremity in 1 patient, lower extremity growth disturbances in 3 children and severe abdominal cutaneosubcutaneal fibrosis in 3 patient. Two cases of late radiation injury are presented and discussed.

Between 1967 and 1985, 75 patients with pure seminoma of the testis were treated with radiation therapy for periaortic and ipsilateral iliac areas following orchiectomy at the Department of Radiology, Osaka University Hospital. All patients except three were followed at least 2 years. Concerning patients who received 28-30 Gy, all of 48 patients with N0 disease were controlled and alive 2 to 20 years after radiation therapy. All of four patients with N1 disease were controlled and alive 6 to 16 years after radiation therapy. Six of 7 patients with N2 disease were controlled and alive 6 to 19 years after radiation therapy but one patient with T1N2 disease who received 30 Gy to periaortic and ipsilateral iliac areas had recurrence in a paraaortic lymph node 11 months after radiation therapy. As for patients with N3 disease two patients were controlled after 38 Gy and 48 Gy, respectively. No complication was observed after radiation therapy. No sterility seemed to be induced by irradiation to periaortic and ipsilateral iliac areas. It may be concluded that dose of 30 Gy to periaortic and ipsilateral iliac areas is recommended for patients with N0 disease. However, for patients with N1 or N2 disease higher dose of 35 Gy or more is recommended.

Twenty-six cases of a pure seminoma of the testis that had been treated by postoperative radiotherapy have been reviewed. The overall 5-year survival rate was found to be 92.3%. Further, no severe adverse effects, including sterility, was found. Prophylactic mediastinal radiation is considered to be unnecessary, because supradiaphragmatic lymph node metastasis was seen in only 1 patient, who has remained disease-free 4.5 year after the treatment of a recurrence. Extranodal metastasis was seen 5 cases, 2 of these cases showing bone metastasis that was successfully treated, thereby achieving complete remission. A seminoma is considered to be one of the most curable malignant diseases, however, long-term follow up is a necessity since stage 1 seminoma has been found to show a generalized dissemination after a 16-year, disease-free interval.

Present status of multidisciplinary treatment for advanced testicular tumors was reviewed. Recently dramatic changes have occurred in the management of the disease, resulting substantial improvement in ultimate survival. Many developments in chemotherapy, particularly the introduction of cis-platinum, have been largely responsible for the dramatic change in treatment and prognosis. Therapy depends a large extent upon the histological type and stage of tumors. Surgical excision of primary tumors followed by combination chemotherapy is primary mode of treatment in advanced testicular tumors. Standard chemotherapy involves either cis-platinum, vinblastine, and bleomycin (PVB therapy), or the above 3 drugs combined with actinomycin D and cyclophosphamide (VAB-6 therapy). These therapies have produced complete remission rates of 50%-70% and improved the frequency of long-term survival. Furthermore, post-chemotherapy residual tumors should be treated by aggressive combined therapy with mainly surgery, radiation, and added chemotherapy. The treatment goal for this disease is the achievement of disease free status, namely complete cure.

A combination regimen consisting of cis-platinum, vinblastine and bleomycin was evaluated in two patients with huge metastasis to the retroperitoneal lymph nodes. Both cases were seminoma histologically. Preliminary or subsequent therapy included radiotherapy and salvage surgery. The two patients achieved complete remission. They have been free of disease for more than six and more than 30 months, respectively.

Two patients with advanced germ cell tumor who entered complete remission following intensive combination chemotherapy, radiation therapy and surgical intervention are reported. A 28-year-old businessman presented with abdominal pain and masses associated with an elevated HCG level for which he underwent exploratory laparotomy. Large retroperitoneal masses were found and microscopical examination of the masses were revealed seminoma. Three courses of combination chemotherapy consisting of CDDP, VLB and PEP were given to the patient followed by radiation therapy to the parailiac, paraaortic, mediastinal and supraclavicular lymph nodes with boost irradiation to the paraaortic lymph nodes where the large masses were located. The other patient was a 21-year-old student who developed sharp precordial chest pain which proved to be due to a large mediastinal mass accompanied by an elevated AFP level. He was treated with radiation therapy to the mediastinum, surgical resection and combination chemotherapy. However, he showed recurrence in the lungs associated with rising AFP levels, and was given a salvage chemotherapy consisting of 3 courses of CDDP, ADR, PEP and Etoposide. Both patients were successfully treated with combined modalities of treatment including intensive chemotherapy and have been off therapy without recurrence for over 12 and 4 months, respectively.

Thirteen patients with advanced testicular tumors (seminoma 2, non-seminoma 11) were treated with combination chemotherapy involving BLM, vinca alkaloid and CDDP (BVP) as induction therapy and followed with CPM, VCR and CDDP as maintenance therapy. BVP and COP administration was repeated every 3 and 4 to 8 weeks for 1 year, if there were no serious side effects. The overall response rate (CR + PR) was 92% with a 69% CR rate. At a mean follow-up of 30 months (7-52 month range), 54% of the patients were alive with no evidence of disease. Bulky metastases, failure to respond to prior chemotherapy and teratomatous metastases were considered to be poor prognostic factors. The toxicity of BVP was similar to that reported for CDDP, except that allergic reaction occurred in 3 patients after several courses of treatment. Two of the 3 went into anaphylactic shock.

Testicular cancer is divided pathologically into two categories; seminoma and non-seminomatous germ cell tumor (NSGCT). Seminoma is a radio-sensitive tumor, so that radiation has been mainly used for stages I and II. Stage III seminoma is treated in the same way as NSGCT. Several years ago stages I and II NSGCT were treated primarily by retroperitoneal lymph node dissection. These days, chemotherapy, such as PVB, or VAB-6 therapy, is adopted as the first choice of treatment, followed by surgical intervention to elucidate the remaining bulky mass if present. Stage III NSGCT is also managed by chemotherapy. By these procedures 70-90% CR of patients with NSGCT is obtained. Prostatic cancer has been treated mainly according to its stages. As for stage A cancer palliative therapy has been shown to yield good results. However, in the case of poorly-differentiated tumors, local irradiation with anti-androgenic treatment should be employed. Stage B cancer should be treated by radical surgery. Local lymph node dissection is usually indicated. In addition local irradiation and anti-androgenic therapy should be considered. Most stage C or D patients do well for a while with antiandrogenic therapy. Within two or three years, however, drug resistance ensues, recessitating a change in the therapeutic modality. Treatments of choice include in chemotherapy, radiotherapy, and others. Treatment of penile cancer involves chemotherapy with bleomycin and irradiation, which result in considerable improvement.