November 2014

By: Shahrokh Paktinat

Testicular Neoplasms

IntroductionTesticular neoplasms span an amazing gamut of anatomic types.

They are divided into two major categories:

1) Germ cell tumors → Approximately 95% of testicular tumors 2) Sex cord–stromal tumors

Most germ cell tumors are aggressive cancers → capable of rapid & wide dissemination, although → current therapy most can be cured

In contrast → Sex cord–stromal tumors are generally benign

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Classification of Common Tumors Germ Cell Tumors Seminomatous germ cell tumors1. Seminoma → 50% of all testicular germ cell neoplasms 2. Spermatocytic seminoma Non-seminomatous germ cell tumors (NSGCT) Embryonal carcinoma Yolk sac (endodermal sinus) tumor Choriocarcinoma Teratoma

1.Sex Cord-Stromal Tumors Leydig cell tumor Sertoli cell tumor

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WHO histological classification of testicular tumors (simplified representation)

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Germ Cell Tumors Incidence of testicular tumors in the USA → 6 per 100,000 → 300

deaths per year

For unexplained reasons → worldwide increase in the incidence

In the 15- to 34-year age group, they constitute the most common tumor of men → 10% of all cancer deaths

In the USA → much more common in whites than in blacks

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Environmental Factors and Genetic Predisposition Testicular germ cell tumors are association of a spectrum of disorders known as

testicular dysgenesis syndrome (TDS) with including: Cryptorchidism → 10% of testicular germ cell tumors → the most important risk

factor Hypospadias Poor sperm quality

Some of these conditions → might be influenced by in utero exposures to pesticides & nonsteroidal estrogens.

Klinefelter syndrome (a TDS condition) → increased risk (50 times greater than normal) for the development of mediastinal germ cell tumors, but these patients do not develop testicular tumors.

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Family predispositionDevelopment of testicular germ cell tumors → strong family

predisposition

The relative risk of development of these tumors in fathers & sons → 4 times higher than normal, and 8-10 times higher between brothers

Genetic polymorphisms at Xq27 locus → may be responsible for this susceptibility

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Classification of Germ Cell Tumors Seminomatous tumors → cells ressemble PGC or early gonocytes Non-seminomatous tumors → may be composed of undifferentiated cells

→ resemble embryonic stem cells (embryonal carcinoma) → but malignant cells → can differentiate into various lineages generating yolk sac tumors, choriocarcinomas & teratomas

Germ cell tumors may have: Single tissue component Mixtures of seminomatous + non-seminomatous & multiple tissues → 60%

In teratomas → tissues of the three germ layers → result of differentiation of embryonal carcinoma cells

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PathogenesisMost testicular germ cell tumors originate from lesions called

intratubular germ cell neoplasia (ITGCN or IGCN) or ITGCN unclassified (ITGCNU or IGCNU)

However, ITGCN has not been implicated as a precursor lesion of pediatric yolk sac tumors and teratomas, or of adult spermatocytic seminoma.

ITGCN is believed to occur → in utero and stay dormant until puberty

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ITGCNThe lesion consists of: Atypical PGC with large nuclei and clear cytoplasm → twice the

size of normal germ cells.

Retain the expression of OCT3/4 and NANOG, which are associated with pluripontentiality

50% → develop invasive germ cell tumors within five years after diagnosis → practically all patients with ITGCN eventually develop invasive tumors.

ITGCN is essentially a type of carcinoma in situ (CIS), although the term CIS is not frequently used to refer to this lesion.

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Seminiferous tubules containing IGCNU (arrows) adjacent to tubules showing normal spermatogenesis (N)

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Unlike normal tubules (N), which have basement membranes of normal thickness and contain normal spermatogenic cells in their lumen, the tubules

containing IGCNU (arrows) have thickened basement membranes

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The neoplastic germ cells have enlarged, slightly polymorphic, centrally located nuclei surrounded by a clear cytoplasm, giving them the appearance of fried eggs. Normal tubules

(N). IGCNU do not show spermatogenesis.

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Immunohistochemistry with antibody to OCT3 shows strong reactivity of the nuclei of the neoplastic cells (brown in figure).

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ITGCN ITGCN share some of the genetic alterations found in germ cell tumors

such as the gain of additional copies of the short arm of chromosome 12 (12p) in the form of an isochromosome of its short arm, i(12p).

This change is invariably found in invasive tumors regardless of histological type.

Activating mutations of c-KIT, which may be present in seminomas, are also present in ITGCN.

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SeminomaMost common type of germ cell tumor (50%)

Peak incidence → 3rd decade & almost never occur in infants Identical tumor in ovary → dysgerminoma

Seminomas contain → an isochromosome 12p and express OCT3/4 & NANOG

25% of these tumors → c-KIT activating mutations c-KIT amplification has also been repeated, but increased c-KIT

expression may occur without genetic defects.

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MorphologySeminoma → uniform population of cellsSpermatocytic seminoma → nosologic similarity → a distinct tumor

Seminomas → produce bulky masses, sometimes 10 times the size of the normal testis.

Typical seminoma: Homogeneous, gray-white, lobulated cut surface Devoid of hemorrhage or necrosis

Generally Tunica albuginea → not penetrated → but occasionally extension to the epididymis, spermatic cord, or scrotal sac

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Fairly well-circumscribed, pale, fleshy, homogeneous mass

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MicroscopySheets of uniform cells divided into poorly demarcated lobules by

delicate septa of fibrous tissue containing a moderate amount of lymphocytes.

Seminoma cell → large and round to polyhedral, distinct cell membrane, clear or watery-appearing cytoplasm, a large central nucleus with 1-2 prominent nucleoli

Mitoses vary in frequency.

The cytoplasm contains varying amounts of glycogen. Seminoma cells → diffusely positive for c-KIT , (regardless of c-KIT

mutational status) OCT4, and placental alkaline phosphatase (PLAP), with sometimes scattered keratin-positive cells.

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(a) Clear seminoma cells divided into poorly demarcated lobules by delicate septa.

(b) Large cells with distinct cell borders, pale nuclei, prominent nucleoli, and a sparse lymphocytic infiltrate.

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The tumor is composed of polygonal cells that have round nuclei surrounded by clear cytoplasm. The fibrous septa contain lymphocytes (arrows).

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Immunohistochemistry with the antibody to antigen OCT3 shows strong nuclear reactivity in all tumor cells, which are arranged in nests. The unreactive areas between

the groups of tumor cells correspond to stroma infiltrated by lymphocytes.

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Microscopy15% → contain syncytiotrophoblasts → elevated serum HCG →

though not to the extent seen in patients with choriocarcinoma

May also be accompanied by an ill-defined granulomatous reaction, in contrast to the well-formed discrete granulomas seen with tuberculosis.

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(a) Marked edema and scattered syncytiotrophoblastic giant cells (arrows). (b) Edema and hemorrhage separating the tumor cells from one another and a

multinucleated syncytiotrophoblastic giant cell (arrow).

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Anaplastic seminoma Indicates greater cellular and nuclear irregularity with more

frequent giant cells & many mitoses.

Is not associated with a worse prognosis & is not treated differently

Most authorities do not recognize anaplastic seminoma as a distinct entity.

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Spermatocytic SeminomaUncommon tumor → 1-2% of all testicular germ cell neoplasms

Age of involvement → much later than for most testicular tumors → generally over age of 65 years

In contrast to classic seminoma → slow-growing, does not produce metastases → prognosis is excellent

In contrast to typical seminomas → lack lymphocytes, granulomas, syncytiotrophoblasts, extra-testicular sites of origin, admixture with other germ cell tumors, and association with ITGCN

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MorphologySoft, pale gray cut surface → sometimes mucoid cysts Contain → 3 cell populations, all intermixed: 1. Medium-sized or large cells , the most numerous, containing a

round nucleus and eosinophilic cytoplasm2. Smaller cells with a narrow rim of eosinophilic cytoplasm

resembling secondary spermatocytes3. Scattered giant cells, either uninucleate or multinucleate

Chromatin in some intermediate-sized cells → similar to that seen in the meiotic phase of non-neoplastic spermatocytes (spireme chromatin).

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Small cells (S) have nuclei resembling lymphocytes, large cells (L) have vesicular nuclei, and the giant cells (G) stand out because of their nuclei and

hyperchromasia.

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Embryonal CarcinomaOccur mostly in the 20- to 30-year age group. More aggressive than seminomas.Share some markers with seminomas → OCT 3/4 & PLAP, but

positive for cytokeratin & CD30, and negative for c-KIT

MorphologySmaller than seminoma → usually does not replace the entire testis. On cut surfaces: Often variegated, poorly demarcated at the margins, and

punctuated by foci of hemorrhage or necrosis Extension through the tunica albuginea → into the epididymis or

cord frequently occurs.

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In contrast to the seminoma, the embryonal carcinoma is a hemorrhagic mass.

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MicroscopyCells grow in alveolar or tubular patterns, sometimes with papillary

convolutions.Lack well-formed glands with basally situated nuclei and apical

cytoplasm seen in teratomas. More undifferentiated lesions → may display sheets of cells

Neoplastic cells → epithelial appearance, are large & anaplastic, have hyperchromatic nuclei with prominent nucleoli.

In contrast to seminoma → cell borders are usually indistinct, there is considerable variation in cell and nuclear size and shape.

Mitotic figures and tumor giant cells are frequently seen.

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Sheets of undifferentiated cells as well as primitive glandular differentiation. The nuclei are large and hyperchromatic.

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The entire tumor is composed of undifferentiated cells that have overlapping nuclei and scant cytoplasm. Tumor cells form solid nests with some slit spaces,

allowing for the focal formation of short papillae.

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Tumor cells form nests that may be solid (lower nest) or cavitated (upper nest). In the lower nest, there are single cells undergoing apoptosis and vacuolization

(arrows). The central cavity of the upper nest contains blood.

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Nonseminomatous germ cell tumor. Immunohistochemistry with antibody to OCT3 reacts selectively with a group of embryonal carcinoma cells. This figure

shows that OCT3 is an excellent marker for embryonal carcinoma cells.

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Yolk Sac TumorAlso known as endodermal sinus tumor , yolk sac tumor is of

interest because it is the most common testicular tumor in infants and children up to 3 years of age.

In this age group it has a very good prognosis.

In adults → pure form is rare → frequently occurs in combination with embryonal carcinoma.

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Morphology Non-encapsulated, homogeneous, yellow-white, mucinous appearance. Microscopic: Lacelike (reticular) network of medium-sized cuboidal or flattened cells. Papillary structures, solid cords of cells, and a multitude of other less

common patterns

50% → endodermal sinuses (Schiller-Duval bodies) → consist of a mesodermal core with central capillary and visceral and parietal layer of cells resembling primitive glomeruli.

Within and outside cytoplasm → eosinophilic, hyaline-like globules with α-fetoprotein (AFP) & α1-antitrypsin activity.

AFP → highly characteristic → underscores differentiation to yolk sac cells.

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Yolk sac carcinoma components of NSGCT may present several histologic patterns. This figure illustrates the labyrinthine pattern formed by anastomosing

strands of flat or cuboidal cells.

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Labyrinthine pattern with micropapillary features. The micropapillae (arrows) have fibrovascular cores.

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Solid nests, but focally papillae (arrow) and papillary component.

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An endodermal sinus pattern is composed of complex cords and solid groups of cuboidal cells focally forming glomeruloid Schiller–Duval bodies (arrows).

Also present are a fibrous stroma and eosinophilic globules (asterisk).

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An endodermal sinus pattern with eosinophilic globules of hyalinized basement membrane material (arrows) is present.

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Glandular pattern

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A solid hepatoid pattern is characterized by solid nests or cords of clear cells and prominent hyaline globules.

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Solid nests of tumor cells stain focally with antibodies to a-fetoprotein.

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Yolk sac tumor of infancy. This tumor grows in a reticular pattern but also contains numerous glomeruloid structures (Schiller–Duval bodies, arrows).

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ChoriocarcinomaHighly malignant form of testicular tumor In its “pure” → rare → less than 1% of all germ cell tumors

MorphologyOften → no testicular enlargement → are detected only as a small

palpable nodule .

Typically → small → rarely larger than 5 cm in diameter.

Hemorrhage & necrosis → extremely common.

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Microscopy Contain two cell types:

1. Syncytiotrophoblastic → large and have many irregular or lobular hyperchromatic nuclei and an abundant eosinophilic vacuolated cytoplasm → HCG can be readily demonstrated in the cytoplasm

2. Cytotrophoblastic → more regular and tend to be polygonal, with distinct borders and clear cytoplasm → grow in cords or masses and have a single, fairly uniform nucleus

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Clear cytotrophoblastic cells (arrowhead) with central nuclei and syncytiotrophoblastic cells (arrow) with multiple dark nuclei embedded in

eosinophilic cytoplasm. Hemorrhage and necrosis are seen in the upper right field .

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Pure choriocarcinomas are rare and account for 1 in 1,000 testicular germ cell tumors. This tumor is composed of mononuclear cytotrophoblastic cells and multinucleate

syncytiotrophoblastic cells. No embryonal carcinoma cells, yolk sac components, or other tissues were identified

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This tumor is composed predominantly of mononuclear cytotrophoblastic cells and scattered syncytiotrophoblastic cells. No embryonal carcinoma cells, yolk sac

components, or other tissues were identified.

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TeratomaGroup of complex testicular tumors having various cellular or

organoid components reminiscent of normal derivatives from more than one germ layer.

Occur at any age from infancy to adult life.

Pure forms → fairly common in infants & children, second in frequency only to yolk sac tumors.

In adults → pure teratomas are rare → 2-3% of germ cell tumors Frequency of teratomas mixed with other germ cell tumors → 45%.

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MorphologyUsually large, ranging from 5-10 cm in diameterBecause they are composed of various tissues → gross

appearance is heterogeneous: solid, sometimes cartilaginous, and cystic areas.

Hemorrhage & necrosis → usually indicate admixture with embryonal carcinoma, choriocarcinoma, or both.

Composed of: Heterogeneous, helter-skelter collection of differentiated cells or

organoid structures ((e.g. neural tissue, muscle bundles, islands of cartilage, clusters of squamous epithelium, structures reminiscent of thyroid gland, bronchial or bronchiolar epithelium, and bits of intestinal wall or brain substance, all embedded in a fibrous or myxoid stroma))

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MorphologyElements may be mature (resembling various adult tissues) or

immature (sharing histologic features with fetal or embryonal tissue)

Common form in ovary → dermoid cysts and epidermoid cysts (with benign behavior) → but rare in testis.

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The variegated cut surface with cysts reflects the multiplicity of tissue found histologically.

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Teratoma of the testis consisting of a disorganized collection of lands,cartilage, smooth muscle, and immature stroma.

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This tumor is composed of mature somatic tissue, including squamous epithelium, fat, and bone.

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Immature teratoma. This tumor contains numerous immature nerve cell precursors arranged in neuroblastic tubelike rosettes and nests.

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Teratoma with malignant transformation

Rare → when malignancy exists in derivatives of one or more germ cell layers → thus → there may be a focus of squamous cell carcinoma, mucin-secreting adenocarcinoma, or sarcoma

Importance of recognizing non–germ cell malignancy arising in a teratoma → non–germ cell component does not respond to chemotherapy when it spreads outside of the testis

The only hope → resectability of tumor

Have an isochromosome 12p → similar to the germ cell tumors from which they arose

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Mixed Tumors60% of testicular tumors → composed of more than one of the

“pure” patterns.

Common mixtures include: Teratoma + embryonal carcinoma + yolk sac tumor; seminoma +

embryonal carcinoma; and embryonal carcinoma + teratoma (teratocarcinoma)

In most instances → prognosis is worsened by inclusion of the more aggressive element.

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Clinical Features of Germ Cell Testicular Tumors Painless enlargement of the testis is a characteristic feature of germ cell

neoplasms but → any solid testicular mass should be considered neoplastic unless proved otherwise.

Biopsy of a testicular neoplasm → risk of tumor spillage → would necessitate orchiectomy + excision of the scrotal skin → consequently, standard management of a solid testicular mass → radical orchiectomy based on the presumption of malignancy.

Common to all forms of testicular tumors is → Lymphatic spread In general first to be involved → retroperitoneal para-aortic nodes Possible subsequent spread → mediastinal and supraclavicular nodes.

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Hematogenous spread → primarily to lungs → but liver, brain, and bones may also be involved.

Histology of metastases → sometimes different from testicular lesion → two reasons:

1. Because all these tumors are derived from pluripotent germ cells → “forward” and “backward” differentiation seen in different locations is not entirely surprising.

2. Another explanation → minor components in primary tumor that were unresponsive to chemotherapy survive → resulting in the dominant metastatic pattern

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Seminomas Vs. NSGCTsSeminomas → tend to remain localized to testis for a long time →

70% present in clinical stage I. In contrast → 60% of NSGCTs → advanced clinical disease (stages

II and III). Metastases from seminomas → typically lymph nodes →

hematogenous spread occurs later in the course of dissemination. NSGCTs not only metastasize earlier → also use hematogenous

route more frequently.

From a therapeutic viewpoint:

Seminomas → extremely radiosensitive, whereas NSGCTs → relatively radioresistant → poorer prognosis

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Clinical stages3 clinical stages of testicular tumors in USA: Stage I: tumor confined to testis, epididymis, or spermatic cord.

Stage II: distant spread confined to retroperitoneal nodes below diaphragm.

Stage III: metastases outside retroperitoneal nodes or above diaphragm.

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Secretion of tumorsGerm cell tumors → often secrete polypeptide hormones and

certain enzymes that can be detected in blood by sensitive assays:HCG, AFP & lactate dehydrogenase → valuable in diagnosis and

management Lactate dehydrogenase → correlates with the mass of tumor cells

→ tool to assess tumor burden Elevated serum AFP or HCG → more than 80% of NSGCT at the time

of diagnosis

15% of seminomas → have syncytiotrophoblastic giant cells → minimal elevation of HCG levels → does not affect prognosis.

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Management In the context of testicular tumors, the value of serum markers is

fourfold: In the evaluation of testicular masses In the staging of testicular germ cell tumors. For example, after

orchiectomy, persistent elevation of HCG or AFP concentrations indicates stage II disease even if the lymph nodes appear of normal size by imaging studies.

In assessing tumor burden In monitoring the response to therapy. After eradication of tumors

there is a rapid fall in serum AFP and HCG. With serial measurements it is often possible to predict recurrence before the patients become symptomatic or develop any other clinical signs of relapse.

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Management Therapy and prognosis of testicular tumors depend on → clinical stage

and histologic type Seminoma → extremely radiosensitive & tends to remain localized for

long periods → the best prognosis More than 95% stage I and II → can be cured

Among NSGCTs → histologic subtype does not influence prognosis significantly, and hence these are treated as a group.

90% of NSGCTs → can achieve complete remission with aggressive chemotherapy → most can be cured

Pure choriocarcinoma → poor prognosis With all testicular tumors → distant metastases, if present, → usually occur

within the first 2 years after treatment

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Leydig Cell TumorsAre particularly interesting → because they may elaborate

androgens and in some cases both androgens and estrogens, and even corticosteroids.

Arise at any age → most cases occur between 20-60 years of age As with other testicular tumors → most common presenting feature

is testicular swelling → but in some patients gynecomastia may be the first symptom.

Hormonal effects in children → primarily as sexual precocity

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MorphologyForms circumscribed nodules, usually less than 5 cm in diameter. Distinctive golden brown, homogeneous cut surface.

Neoplastic Leydig cells → usually remarkably similar to their normal counterparts in that they are large and round or polygonal, abundant granular eosinophilic cytoplasm with a round central nucleus.

Cytoplasm frequently contains → lipid granules, vacuoles, or lipofuscin pigment, and, most characteristically → rod-shaped crystalloids of Reinke in 25%

10% in adults → invasive & metastatic but → most are benign71

(a) Uniform polygonal cells with round nuclei and well-developed eosinophilic cytoplasm. A fibrous capsule separates tumor from testicular tissue on the right side.

(b) Solid tumor growth pattern and uniformity of well-differentiated cells with abundant eosinophilic cytoplasm.

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Sertoli Cell TumorsMost are hormonally silent and present as a testicular mass.

MorphologyFirm, small nodules with a homogeneous gray white to yellow cut

surface.

Tumor cells → arranged in distinctive trabeculae that tend to form cordlike structures & tubules.

Most Sertoli cell tumors are benign, but occasional tumors ( 10%∼ ) pursue a malignant course.

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This tumor forms tubules lined by fetal-like Sertoli cells.

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(a) This large-cell calcifying variant of Sertoli cell tumor is typically fibrotic, focally calcified, and composed of large cells irregularly arranged in groups within loose connective stroma.

(b) Large-cell calcifying Sertoli cell tumor shows large cells with abundant cytoplasm and elongated nuclei forming abortive nests

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GonadoblastomaRare neoplasms containing a mixture of germ cells + gonadal

stromal elements → almost always in gonads with some form of testrcular dysgenesis

In some cases → germ cell component becomes malignant → giving rise to seminoma

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This tumor is composed of round germ cells and sex cord cells surrounding round globules composed of basement membrane material (arrows)

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Testicular Lymphoma Uncommon tumor of the testis → affected patients present with only a

testicular mass → mimicking other, more common, testicular tumors.

Aggressive non-Hodgkin lymphomas → 5% of testicular neoplasms → most common form of testicular neoplasms in men over the age of 60.

In most cases → is already disseminated at the time of detection.

Most common testicular lyphomas → diffuse large B cell lymphoma, Burkitt Lymphoma, and EBV-positive extranodal NK/T cell lymphoma.

Testicular lymphomas → higher incidence of CNS involvement than those similar tumors located elsewhere

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(a) This B cell lymphoma infiltrating interstitial spaces of testis has destroyed most of seminiferous tubules; those that remain are damaged and show no signs of spermatogenesis.

(b) Higher magnification shows atypical lymphocytes infiltrating testis.

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Granulosa cell tumor. (a) This tumor forms a nest and cord composed of small cells with scant cytoplasm, resembling its ovarian counterpart.

(b) Cords and follicular nesting of cells similar to those observed in granulosa cell tumor of ovary.

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The Effect of Cancer Therapies on Sperm: Current Guidelines

Introduction Advanced diagnostic techniques and better treatment modalities →

Improved survival rates of young men suffering from cancers Greater attention is → patients’ quality of life The most common malignancies diagnosed in men of reproductive age: Testicular germ cell tumors Lymphoma Leukemia Growing concern for cancer survivors → Infertility problems stemming

from cancer diagnosis as well cancer therapy

Many cancer patients → sperm quality is already impaired Damaging effects of chemotherapy or radiotherapy → Further temporary

or permanent deterioration in semen and endocrine parameters83

Introduction While our understanding of gonadotoxic effects of specific cancer

therapy regimens is improving → it is impossible to predict with any degree of certainty:

Which patients will have impaired spermatogenesis Which patients will have improvement in their gonadal function to

reestablish normal spermatogenesis

As such, preservation of fertility potential and use of ART have become increasingly important in the long term management of cancer patients of reproductive age.

There is some controversy as to the safety of ART when using sperm from irradiated or postchemotherapeutic patients.

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Overview of Spermatogenesis Ap spermatogonia → responsible for replenishing their own populations

+ entire spermatogenic process Ad spermatogonia → rarely divide → dormant reserve germ cells

When the number of Ap spermatogonia is diminished (e.g. after irradiation)→ Ad spermatogonia become active → transform into Ap spermatogonia → then start to proliferate

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Hormonal assay Elevated serum levels of LH and FSH + depressed levels of testosterone,

have been associated with impaired spermatogenesis.

In particular, elevated FSH → marker for impaired Sertoli-cell function.

Recently, Inhibin B → marker for Sertoli-cell function, especially in prepubertal boys and male adolescents

Serum Inhibin B → may be an important marker of seminiferous tubule function in men treated with chemotherapy and should be interpreted in the context of serum FSH.

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Role of testosterone Normal spermatogenesis → requires high intratesticular testosterone However, the role of intratesticular testosterone in return of

spermatogenesis in impaired testes is more complicated:

High intratesticular testosterone → can be detrimental to spermatogonial differentiation

Suppression of testosterone → required to promote spermatogonial development in irradiated rodents and mouse models of juvenile spermatogonial depletion

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Cancer in male patients The most common cancers in men of reproductive age are:1. Testicular germ cell tumors 2. Lymphoma3. Leukemia

4. Various solid and hematologic cancers → semen parameters such as sperm count, motility, and semen volume were significantly lower

5. Determination of patients’ pretreatment fertility potential → important to better understand how their cancer and its treatment will affect their fertility potential in the future.

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Hormonal alterations Reproductive hormones may be low in some patients as a result of:

1. Physiologic stress associated with the cancer state2. Downregulation by endocrine substances produced by some tumors3. Direct tumor invasion of endocrine organs

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Metabolic and other conditions1. Malnutrition caused by malignancy → deficiencies in vitamins,

minerals, and trace elements needed for gonadal function

2. Constitutional symptoms, especially fevers (in hematologic malignancies like Hodgkin’s lymphoma) → spermatogenesis

3. Antisperm antibodies as a result of disruption of blood–testis barrier by cancer → poor semen analysis results

4. Tumor-released cytokines (ILs & TNF) → affect spermatozoal function, resulting in low sperm motility

5. This effect may be local → highest in the tissue closest to the tumor, while spermatogenesis is uniform in orchiectomy samples that have benign tumors.

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Pretreatment fertility potentialNo concrete evidence supports the hypothesis that pretreatment

spermatogenic function predicts posttreatment spermatogenic function.

Purpose → determine whether semen cryopreservation prior to initiation of therapy can provide sperm of adequate quality to allow for use with ART in → if fertility potential is not restored at conclusion of therapy

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Testicular Cancer Patients with testicular germ cell carcinoma → lower sperm counts

50–75% of patients with unilateral carcinoma are subfertile (below 10 million/mL) at time of diagnosis.

10% with testicular cancer → history of cryptorchidism

24% of biopsies from contralateral testes in men who underwent orchiectomy for unilateral testicular germ cell tumor → severe abnormalities

8% → no sperm production 16% → varying degrees of spermatogenesis 5% → carcinoma in situ (CIS)

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Patients who develop testicular carcinoma in one testis → 500–1,000 times more likely to develop carcinoma in contralateral testis

Metachronous tumors → more common than bilateral synchronous

While bilateral radical orchiectomy remains the standard of care for these patients, there is growing enthusiasm for testis-sparing surgery

In theory → testis-sparing surgery should be associated with improved fertility and endocrine function.

However, a major concern when sparing a tumor-bearing testis is the high prevalence of adjacent foci of CIS.

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Given the exquisite radiosensitivity of CIS, supporters of organ-preserving surgery → generally recommend → every patient undergoing partial orchiectomy be treated with adjuvant local radiation therapy to the testicular parenchyma→ Minimize the risk of local recurrence, invariably

arrests spermatogenesis and culminates in infertility.

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CIS CIS → in contralateral testis of 5% of patients with testicular germ cell

cancer.

Management of CIS is important → majority – if not all – will eventually progress to invasive disease.

Seminiferous tubules containing CIS → devoid of spermatogenesis, and neighboring tubules → often severely impaired spermatogenesis as well

This explains the frequent finding of oligospermia or azoospermia, in combination with elevated serum LH and FSH levels in patients with CIS.

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Lymphoma Hodgkin’s lymphoma → all ages, first incidence peak 18-40 years

5-year survival from the disease is around 90%. Infertility → one of the most significant side effects in long-term survivors

of Hodgkin’s lymphoma

pretreatment fertility exists in Hodgkin’s lymphoma patients.

patients with lymphoma vs. leukemia → No difference in semen parameters (count & motility) → but patients with Hodgkin’s lymphoma had significantly lower sperm quality compared with non-Hodgkin’s lymphoma.

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Semen quality in Hodgkin’s lymphoma patients: 70% → inadequate semen quality, with 21% → severe damage such as

azoospermia or oligoasthenoteratozoospermia

Advanced stage → greater likelihood of having semen abnormalities, possibly because advanced Hodgkin’s lymphoma is a biologically active disease

Only 20% → normozoopermia in pretreatment analysis, with 11% → azoospermia and 69% → dyspermia

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Survivors of Hodgkin’s lymphoma treated in childhood with alkylating agents → significantly lower levels of inhibin B, compared to men not treated with these agents.

Inhibin B → stronger and more independent determinant of sperm concentration compared to FSH → recommended as a screening tool to detect gonadal damage in men treated for Hodgkin’s

lymphoma in childhood.

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Leukemia Like testicular carcinoma & Hodgkin’s lymphoma, patients with leukemia

→ significant pretreatment impairment of spermatogenesis.

Patients with leukemia → significantly lower prefreeze & postthaw sperm motility, motile sperm count, and curvilinear velocity

Type of leukemia → no effect on prefreeze or postthaw semen quality

Most importantly, the quality of the postthaw sperm → was sufficient for

use with ICSI, and therefore, cryopreservation of sperm was recommended for leukemia patients despite the abnormalities noted in the analysis.

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Other Solid Tumors Although much less frequent → impairment exists in tumors involving

other organs, ranging from carcinomas and sarcomas to CNS tumors.

Men with testicular tumors → significantly lower sperm concentration & motility than hematologic malignancy, or other cancers.

Men with other solid tumors → semen quality abnormalities similar to patients with hematologic malignancies, but significantly better than testicular cancer.

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Cancer-Associated Therapies Treatment options for patients depending on type of malignancy:1. Surgical intervention2. Chemotherapy3. Radiotherapy 4. Multimodal therapy

Chemotherapy & radiation → interfering with rapidly dividing cells

Recovery for surviving germ cells can happen → but unpredictable & often lengthy

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Interestingly, some patients who are azoospermic prior to cancer therapy → normal sperm parameters after treatment → suggestion → mechanism of infertility before treatment is reversible and distinct from mechanism following treatment for cancer.

Therefore, even in patients with preexisting impairment of spermatogenic function, it is still worthwhile to select the least gonadotoxic treatments possible.

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Treatment for patients with testicular cancer: Radical orchiectomy, followed by retroperitoneal lymph node dissection

(RPLND), chemotherapy, or radiation, based on the histopathology and stage of the germ cell tumor.

Patients with lymphoma & leukemia → primarily candidates for chemotherapy, with or without radiation, with a variety of regimens.

Patients who undergo bone marrow transplantation (BMT) for hematological malignancies → subject to combination of chemotherapy & total body irradiation (TBI) → increasing risk of gonadotoxicity

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Surgery Radical orchiectomy → gold standard for surgical treatment of

testicular germ cell carcinoma, followed by RPLND or chemotherapy or radiotherapy → histopathology

Radical orchiectomy for testicular cancer → decrease in postoperative sperm concentrations → decrease from 20 million/mL before orchiectomy to 10 million/mL after orchiectomy

Azoospermia → 10–56% of men after orchiectomy

Fertility is nevertheless possible in men after orchiectomy. 74% unilateral & 40% bilateral → able to achieve paternity after their first

orchiectomy, with or without use of ART104

The most common complications of RPLND: Loss of ejaculation & retrograde ejaculation → due to interruption of the

retroperitoneal sympathetic nerves.

Frequency of these complications → reduced recently from 75% to 33%

Nerve-sparing techniques → greater preservation of ejaculatory function

While surgical treatment for testicular cancer→ can certainly impact fertility → not as great as that of chemotherapy and radiation therapy

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Chemotherapy Most severely affect Type B spermatogonia

Recovery of spermatogenic function → depends on survival of Type A spermatogonia.

If cytotoxic therapy destroys both A & B spermatogonia spermatogonia → permanent azoospermia

Time to impairment of spermatogenesis after initiation therapy → few weeks

Recovery of spermatogenesis after cessation of therapy → few years

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Sertoli cell damage → may be a contributory factor to chemotherapy-induced azoospermia, in addition to germ cell damage.

Staining testicular biopsy specimens for specific cell-differentiation factors → mixed histologic pattern consistent with dedifferentiation of Sertoli cells in a patient who had undergone chemotherapy for testicular carcinoma

Sertoli cells → involved in maintaining blood–testis barrier → damage to even a fraction of Sertoli cells → disproportionately larger impact on spermatogenesis.

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The testes → highly sensitive to alkylating agents Regimens including these agents → more gonadotoxic than those that

do not contain alkylating agents.

After six cycles of MOPP (nitrogen-mustard, vincristine, procarbazine & prednisone) or a comparable regimen → 90–100% prolonged azoospermia

In sharp contrast, regimens like ABVD (adriamycin, bleomycin, vinblastine & dacarbazine) → transient azoospermia in a third of patients → usually make a full recovery.

For this very reason, chemotherapy cocktails used in the treatment of non-Hodgkin’s lymphoma are much less gonadotoxic than those used for Hodgkin’s lymphoma.

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Elevated FSH in 60% treated with alkylating chemotherapy, 8% with

nonalkylating and 3% with nonpelvic radiotherapy.

Recovery of spermatogenesis is, however, often associated with a normalization of FSH level.

If alkylating → less likely to return to normal FSH levels than nonalkylating Recovery, if it did occur → considerably longer in alkylating vs.

nonalkylating and dependent on the dose of agents

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Standard treatment for testicular cancer → platinum-based combination

chemotherapy including BEP (bleomycin, etoposide, and cisplatin ).

Cisplatin → induction of DNA cross-linking Etoposide → interaction with Topoisomerase II

Shortly after initiation of chemotherapy, semen analysis demonstrates: Oligospermia Decreased sperm motility Decreased chromatin integrity Increased abnormal morphology

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Gonadotoxicity of the BEP for testicular cancer → less than alkylating agents

While individual responses may be quite variable following chemotherapy for testis cancer, spermatogenesis, if it recovers, will do so in the majority of patients within 4 years.

Risk of permanent azoospermia after chemotherapy → drug-specific & dose-dependent:

Cumulative doses of >400 mg/m2 of Cisplatin given to testicular cancer patients → irreversible impairment of gonadal function

Similarly, gonadal dysfunction is well documented in over 80% of patients who receive >300 mg/m2 of cyclophosphamide.

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Radiation Therapy Radiotherapy → inducing double-strand DNA breaks not amenable to

repair → lethal cell damage to most tissues Like chemotherapy → dose-dependent → speed of onset of this

damage, chance of reversal, and time to recovery of spermatogenesis

1. Spermatogonia can be affected by doses as small as 0.15 Gy2. Spermatogenesis has been shown to recover at doses of up to 1–3 Gy3. Permanent azoospermia can be seen at doses exceeding 4 Gy

A possibility → men with germ cell neoplasia → more vulnerable to effects of irradiation because spermatogenic function is already abnormal before irradiation

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Leydig cells → more resistant to radiation, and doses exceeding 20 Gy → produce hypogonadism.

Graded doses of radiation therapy (14–20 Gy) in testicular germ cell neoplasia → gradual & continued decline in testosterone → 3.6% per year

40% → required androgen supplementation

In men with CIS in the contralateral testis, treatment with fractionated radiotherapy (20 Gy given in ten fractions of 2 Gy) → led to eradication not only of the CIS, but also of germ cells.

Sertoli and Leydig cells → preserved in this patient population.

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Radiotherapy has a much more deleterious effect on fertility than chemotherapy.

Cumulative conception rates → much lower for patients treated with radiotherapy compared chemotherapy

Recovery of sperm production following radiotherapy → up to 60–80 weeks after a dose of 0.32 Gy (up to 9 years in some cases)

However, most patients → can expect spermatogenic recovery within 2 years of radiation.

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Multimodal Therapy Recovery of spermatogenesis → best in patients receiving single 90% or

dual-agent chemotherapy 50% followed by patients receiving chemotherapy + irradiation (17%).

Single alkylating agent → also better sperm quality & faster recovery of spermatogenesis compared to the other two groups of patients.

Combination of chemotherapy + radiation, recovery of spermatogenesis was delayed as much as 9 years after cessation of therapy in some cases.

Limiting radiation dose in multimodal therapy → may improve posttreatment gonadal function.

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Fertility Following Cancer Treatment Although conception is unlikely while patients are on cytotoxic therapy

→ contraception is recommended for at least 6 months following

therapy → theoretical risk of teratogenic effects of treatment

FISH → evaluate aneuploidy in sperm DNA from testicular cancer & Hodgkin’s lymphoma → increased aneuploidy frequency prior to & up to 2 months from the start of chemotherapy.

Recommendation → delayed attempts at conception 2 years after the end of treatment

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Fertility Preservation Any discussion of fertility in cancer survivors must involve both biologic

and psychosocial considerations.

Survivors may be less likely to find a partner, or less inclined to want children because of the psychological effects of the disease or treatment, or because of fear of an increased risk of congenital malformation in the offspring of parents who have received cytotoxic therapy.

Recent report → 51% of men with cancer expressed their wish to preserve their capacity for procreation in the future, including 77% of men who were still childless when their cancer was diagnosed.

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Two strategies of fertility preservation: Pre- & Postcytotoxic therapy

Semen cryopreservation prior to initiation of cancer therapy → cornerstone for fertility preservation in the majority

Recent research → improving posttreatment fertility

Alternatives to semen cryopreservation: Testicular stem cell transplantation Testicular tissue transplantation

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Pretreatment Options Significant percentage of patients → do not bank sperm before

undergoing treatment. Based on the: Type of malignancy Treatment modality Availability of resources Urgency to treat Knowledge of the oncologist regarding reproductive technology1. Options of sperm cryopreservation are not always discussed with

patients.

Furthermore → in prepubertal or young adolescents → obtaining mature sperm for cryopreservation is not always possible or appropriate.

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Even patients who chose cryopreservation are not always able to pursue it → if spermatogenesis is sufficiently impaired due to the underlying malignancy.

Nevertheless, pretreatment sperm cryopreservation → only means of ensuring semen availability → good result up to 15 years after initial preservation.

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TESE prior to the onset of therapy → successful sperm retrieval with no delay in initiating cancer treatment.

Down-regulation of spermatogenesis prior to the initiation of cytotoxic therapy → proposed as a means of preventing the deleterious effects of cancer therapies on sperm production

Hormonal inhibition may require several weeks to completely inhibit sperm production (duration of cycle), thereby delaying cancer therapy → not technically feasible

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Posttreatment Options Azoospermia long after chemotherapy are not sterile → sperm retrieval is

possible using microdissection TESE

Even in men previously treated for testicular germ cell tumors → despite the presence of a solitary testis, the sperm retrieval rate with TESE is 67%

In a report → TESE followed by ICSI → Sperm retrieval accomplished in 45% with biochemical pregnancy & clinical pregnancy & live deliveries

Other report → sperm recovery rates → higher in testicular cancer than hematological malignancies (67% vs. 20%) & → sperm were more often retrieved from patients treated with chemotherapy alone or with RPLND, compared to chemotherapy + irradiation

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From a histopathological point of view → sperm were retrieved from:1. Sertoli cell-only syndrome2. Severe hypospermatogenesis3. Maturation arrest

For patients suffering from persistent azoospermia after cytotoxic cancer therapy → combination of TESE & ICSI → new opportunities for fertility

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Spermatogenesis restoration by hormone treatment after cytotoxic therapy → in animal models using GnRH agonists → suppression of FSH & testosterone secretion has been shown to remove the block in spermatogenesis

However, only one of seven trials using hormone suppression to prevent gonadotoxicity in humans showed a positive result → the value is uncertain.

Germ cell transplantation → new tool for fertility preservation in cancer → but in primates, no recovery of sperm counts → experimental technique in humans

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In the same vein, testicular tissue allograft → proposed as a treatment to restore fertility if no recovery of spermatogenesis can be established after cessation of cytotoxic therapy → but human studies to date are lacking

One concern possibility, albeit small → reintroducing malignant cells

via the transplanted testicular tissue

For example, as few as 5 reintroduced cells → sufficient for leukemia to recur

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In vitro culture & maturation of spermatogonial cells in specific stages of development have also been described.

One study → cultured primary spermatocytes in premeiotic arrest to

produce morphologically abnormal but developmentally competent gametes → then used for successful ICSI.

Majority of researches → are not currently tangible or reproducible.

Use of ART → still remains the leading option for interested patients.

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Ethical Considerations Concerns raised about the safety of IVF and ICSI → in patients

who have received chemotherapy or radiation therapy. DNA damage induced by cytotoxic therapies → genetic errors that

cannot be repaired in late-stage spermatids and spermatocytes → increase the risk of:

Congenital malformations Growth disturbances Cancer in offspring of cancer patients

DNA and chromosomal aberrations that can be transmitted by sperm: Aneuploidy Structural aberrations Epigenetic modifications Nucleotide repeats Gene mutations

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Controversy exists as to the degree and reversibility of DNA damage secondary to chemotherapy & radiation therapy.

Unfortunately → most studies are very limited in size

In testicular cancer treated with BEP chemotherapy → an abnormally high percentage of DNA-damaged sperm

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Increased rates of human sperm aneuploidy → up to 18–24 months following initiation of chemotherapy

On the contrary → it has been shown that → despite a reduction in sperm concentration → the sperm produced by cancer patients carries as much healthy DNA as the sperm produced by healthy, age-matched controls.

Other authors → chromosomal aneuploidies after alternative chemotherapy regimens → but transient & self-limited

Based on current evidence → recommending a delay from the cessation of treatment to attempt pregnancy of 18–24 months is prudent.

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To date → NO increased risk of congenital anomalies, genetic diseases, or chromosomal abnormalities in the offspring of male cancer survivors in reported.

These studies do have shortcomings.

Majority individual cases or small sample sizes & most of the children in these studies were conceived spontaneously.

IVF and ICSI → chance of passing on a defect to the next generation

Long-term follow-up of these children is needed to better answer the concern for genetic transmission of germline mutations.

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Summary Most cancer patients → impairment of spermatogenesis. Further harmful effects of cytotoxic therapy → agents & dose delivered.

Prediction is impossible → spermatogenesis will return or not Therefore → greater attention → prevent gonadotoxity to the extent

possible.

Sperm cryopreservation → discuss with all men → prior to therapy Using of TESE and ICSI → improved Fertility rates

Current evidence → no increased biologic or genetic risk to offspring

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