Malignant Degeneration of Cryptorchid Testes Following Orchiopexy

Vol. 112, September

THE JOURNAL OF UROLOGY

Printed in U.S.A.

Copyright © 1974 by The Williams & Wilkins Co.

MALIGNANT DEGENERATION OF CRYPTORCHID TESTES FOLLOWING ORCHIOPEXY G. GRANT GEHRING, FRANCISCO R. RODRIGUEZ

AND

DAVID M. WOODHEAD*

From the Urology Service, Department of Surgery, Wilford Hall United States Air Force Medical Center, Lackland Air Force Base, San Antonio, Texas

It has been established that the incidence of testicular malignancy in patients with cryptorchidism is higher than in individuals with normally descended testes. The presence of a cryptorchid testis increases the probability of malignant degeneration 20 to 40-fold. 1 · 4 An incidence of 3.6 to 11.6 per cent of testicular neoplasms has been reported to be associated with cryptorchidism 4 -• and Johnson, in his review of all reported series, found the over-all incidence to be 6.5 per cent. 7 Cunningham reported the first case of testicular malignancy arising in a previously cryptorchid testis subjected to orchiopexy. 8 Sumner, 9 Dow and Mostofi, 10 and Johnson and associates 11 have demonstrated that orchiopexy does not prevent malignant degeneration of the cryptorchid testis. However, only 3 cases of testicular tumor have been reported in individuals having undergone orchiopexy before they were 10 years old. 11 • 12 Noteworthy is the observation by Johnson that 1 of 5 cryptorchid-associated testicular malignancies arises in the normally descended contralateral scrotal testis. The records of 529 patients with testicular tumors of germinal origin have been reviewed and provide the basis for our report. Accepted for publication March 22, i974. * Deceased. 1 Hinman, F. and Benteen, F. H.: The relationship of cryptorchidism to tumor of the testis. J. Urol., 35: 378, 1936. 'Gilbert, J. B. and Hamilton, J. B.: Studies in malignant testis tumors; incidence and nature of tumors in ectopic testes. Surg., Gynec. & Obst., 71: 731, 1940. 'Thurzo, R. and Pinter, J.: Cryptorchism and malignancy in men and animals. Urol. Int., 11: 216, 1961. 4 Campbell, H. E.: The incidence of malignant growth of the undescended testicle: a reply and re-evaluation. J. Urol., 81: 663, 1959. 'Grove, J. S.: The cryptorchid problem. J. Urol., 71: 735, 1954. 'Collins, D. H. and Pugh, R. C. B.: Classification and frequency of testicular tumours. In: The Pathology of Testicular Tumours. Brit. J. Urol., suppl. 36, pp. 1-11 1964. ' 7 Johnson, D. E.: Testicular Tumors. New York: Medical Examination Publishing Co., Inc., 1972. 'Cunningham, J. H.: New growths developing in undescended testicles. J. Urol., 5: 471, 1921. 9 Sumner, W. A.: Malignant tumor of testis occurring 29 years after orchiopexy: case report and review of the literature. J. Urol., 81: 150, 1959. 10 Dow, J. A. and Mostofi, F. K.: Testicular tumors following orchiopexy. South. Med. J., 60: 193, 1967. "Johnson, D. E., Woodhead, D. M., Pohl, D. R. and Robison, J. R.: Cryptorchism and testicular tumorigenesis. Surgery, 63: 919, 1968. 12 Altman, B. L. and Malament, M.: Carcinoma of the testis following orchiopexy. J. Urol., 97: 498, 1967.

MATERIAL

Cryptorchid-associated testicular malignancies occurred in 37 of 529 patients studied (7 per cent). Table 1 summarizes the occurrence of cryptorchid-associated malignancy as related to Dixon and Moore classification, 13 side of lesion relative to cryptorchidism and previous history of orchiopexy. Of 29 patients with unilateral cryptorchidism 22 had tumor on the ipsilateral side. Seven tumors (24 per cent) arose in the contralateral normally descended scrotal testis. Eight patients had bilateral cryptorchidism. Seven of these patients had unilateral tumors and 1 had bilateral tumors in the intra-abdominal testes. Thirteen of 21 patients with cryptorchidassociated seminoma had undergone orchiopexy. Nine of the orchiopexies were ipsilateral, 3 were contralateral and 1 was bilateral. The average patient age at orchiopexy was 13.4 years and at diagnosis it was 31. 7 years, and the average interval was 18.3 years. In 2 of 8 unoperated cryptorchid patients seminoma was found incidentally at the time of prophylactic orchiectomy when the subjects were 19 and 23 years old. Two more patients in this group had undergone orchiectomy for unilateral cryptorchidism prior to the occurrence of seminoma in the contralateral normally descended scrotal testis. All 6 patients with cryptorchid-associated embryonal carcinoma had undergone orchiopexy. Tumor was on the ipsilateral side in 4 cases and on the contralateral side in 1. The other occurred in a patient who had undergone bilateral orchiopexy. Average patient age at orchiopexy was 16 and at diagnosis it was 28, and the average interval was 12 years. Previous orchiopexy had been accomplished in 9 of 10 patients with cryptorchid-associated teratocarcinoma. The tenth patient had undergone orchiectomy for unilateral cryptorchidism 3 years prior to the diagnosis of teratocarcinoma in the normally descended contralateral testis. Bilateral cryptorchidism had been present in 5 of 10 cryptorchidassociated teratocarcinomas and in all 5 cases previous bilateral orchiopexies had been performed. In the entire group of 37 cryptorchidassociated tumors 8 patients had a history of bilateral cryptorchidism, 5 of which were histologi13 Hinman, F., Jr.: Optimum time for orchidopexy in cryptorchidism. Fertil. Steril., 6: 206, 1955.

354

355

MALIGNANT DEGENERATION OF CRYPTORCHID TESTES AFTER ORCHIOPEXY

cally teratocarcinoma. In the teratocarcinoma group the average patient age at orchiopexy was 1 L5 years and at diagnosis it was 25 years, and the average interval was 13.5 years. Table 2 lists the with cryptorchidassociated testicular malignancies upon whom orchiopexy had been performed before the subject was 13 years old. Almost a third (12) of the entire group of 37 cryptorchid-associated malignancies occurred in patients in this category. Six patients in the group (16 per had undergone orchiopexy before were 9 years old but no tumors were found in patients who had undergone orchiopexy before they were 6 years old. Of the 529 cases of testicular tumors was made in 6 patients before they were 6 years old but none had a history of cryptorchidism. Of related interest is the observation that 19 of the 529 patients (3.5 per cent) had undergone simple herniorrhaphies, unassociated with cryptorchidism. In 12 of 14 having undergone unilateral herniorrhaphy ipsilateral testis tumors after an average interval of 20 years. DISCUSSION

The results reported herein confirm an increased incidence of testicular malignancy in association

1

TABLE

-----------·· - - -

-·-------~

Con- Bilat. Totals !psi l at. tralat. Seminoma (type I)*:

Orchiopexy Retained Subtotals Embrrnnal carcinoma (type Orchiopexy Retained Subtotals

9 5 14

m··

:3 2

t:l 8

-~

2

21

0 -1

()

()

6 0 6

4

()

fj

9

()

1

()

I

4

;)

1()

22

8

:r;

4

Teratocarcinoma (type IV)*: Orchiopexy

Retained Subtotals Totals

* Dixon and l\1oore cla;;sification. TABLE

2

----

Pt.

Age at Orchi-

Age at Dia~-

opexy

I10SIS

Cn·pt. Side

Dixon-::\-Ioore Class. --------

.JC JS CW RW PM

MW

12 12

12 12 12 9

RG JB

8 8

RR B:"J

7 7 6 6

GH cJY

2:3 21 26

:Jl 28 21 28

26 28 27 24 39

Ipsilat. lpsilat. !psi lat. Bilat. !psi lat. Bilat. lpsilat. Contralat. !psi lat. Bilat. Contralat. lpsilat.

Em hryonal Ca ( Ill Teratoca. !IV) Teratoca. !IV)

Teratoca. i!Vi Seminoma (IJ

Teratoca. 1IV1 Teratoca. (!Vi Serninoma ill Seminoma (IJ

Teratoca. (IV) Seminoma ill Seminorna II)

TABLE

3. Hemiorrhaph_v cases lpsilat.

Seminoma (type])* Embryonal Ca Ill* Teratoca. (t,·pe Totals

Contralat.

8 :J

12

Bilat.

Touils

;)

1-t

()

-1

0

0

2

;)

19

* Dixon and Moore classification.

with cryptorchidism. Of 529 patients with testicu Jar tumors 37 (7 per cent) had associated testicular tumors. This number close agreement with the over-all 6.5 per incidence reported by Johnson. 7 Also in dose agreement with Johnson's 1: 5 ratio was a 24 per cent incidence of testicular malignancy occurring in the contralateral normally descended scrotal testis. Sohval suggested that testicular in cryptorchid testes may account for the relative susceptibility to malignant degeneration. 14 son similarly postulated that dysgenetic tissue in the contralateral normally descended testis explain the increased incidence of that testis.' Bilateral cryptorchidism had been present in 22 per cent of the cryptorchid-associated cies. Not previously observed, this series suggests that teratocarcinomas may occur more than other germinal tumors in these Previously, only 3 patients less than 10 years old when they underwent orchiopexy in whom tumors developed have been described. We scribe 7 patients in this category. However, none of the 529 patients had orchiopexy before they years old. This observation suggests a rationale m addition to the enhancement of fertility for tbe early performance of orchiopexy. 13 · 1.s-is Ipsilateral development of testis tumors hm; been observed in 12 of 14 with tumors and a prior history of unilateral herniorrhaphy. When patients with a history of bilateral herniorrhaphies are included, 17 of 19 patients had testis tumors on the side of a previous operation (table 3). These observations add possible substance to the the ory that tumorigenesis may be related to prim trauma 7 or possibly this again reflects an element of dysgenesis as postulated by Sohval for the overtly cryptorchid testis. 14 Sohval, A. R.: Testicular dysgenesis as an etiologic factor in cryptorchidism. J. Urol., 72: 693, 1954 .. "Charney, C. W. and Wolgin, W.: Cryptorch1sm. Nevv York: Paul B. Hoeber, Inc., 1957. 16 Leeson, C. R.: An electron microscopic cryptorchid and scrotal human testes, with special ence to pubertal maturation. Invest. Urol., 3: 17 Giarola, A.: Protection of reproductive factor in therapy for undescended testicle. 18: 375, 1967. 1 ' De la Baize, F. Mancini, R. A., Andrada, J. A., Vilar, Gurtman, A. I. and . 0. W.: Puberal maturation of the normal human testis. histologic study. J. Clin. Endocr., 20: 266, 1960.

356

GEHRING, RODRIGUEZ AND WOODHEAD SUMMARY

Thirty-seven patients with cryptorchidassociated testicular tumors, comprising 7 per cent of 529 consecutive germinal neoplasms, are reported. Tumors arose in the contralateral normal descended testis in 24 per cent of the cases. Teratocarcinoma seems to occur more frequently than other tumors in patients who have had bilateral cryptorchidism. Almost a third of the cryptorchid-associated tumors occurred in patients

with a history of orchiopexy when they were between 6 and 12 years old. No tumor occurred in patients who had undergone orchiopexy before they were 6 years old. This observation supports previous evidence leading to the recommendation for orchiopexy in the unilateral cryptorchid patient before he is 6 years old and for orchiectomy in similar cases after that time. Seventeen of 19 patients had testis tumors in a side previously subjected to herniorrhaphy.