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Metastatic Spermatocytic Seminoma
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0022-534 7/80 /1245-0739$02.00 /0
Vol. 124, November
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1980 by The Williams & Wilkins Co.
METASTATIC SPERMATOCYTIC SEMINOMA THOMAS W. SCHOBORG,* JOHN WHITTAKER AND CHARLES W. LEWIS From the Department of Urology, Georgia Baptist Medical Center, Atlanta, Georgia, and Department of Urology, Uniuersity Hospital of Jacksonville, Jacksonville, Florida
ABSTRACT
Spermatocytic semi.noma is for its relative infreqw.mcy of metastases. A case of metastatic ~"V'-''"""~v·v seminoma is reported in which there was evidence of tumor recurrence within an irradiated area. The need for aggTessive initial ..,~...~,...~,"'~·· and careful followup of patients with this is emphasized. Niost authors regard spermatocytic seminoma as an entity that
if ever, metastasizes and question the need for any
other than radical inguinal orchiectomy. a case of metastatic spermatocytic seminoma oncologists to reassess this which about 10 per cent of all seminomas. CASE REPORT
white man was hospitalized in November 1977 pa,amo"'" swelling of the right testicle 5 weeks in duration. examination failed to reveal any significant adenopain the neck and axillary adenopathy was not recorded. The testicle was 3 times normal size, firm and non-tender. human chorionic gonadotropin and a-fetoprotein were within normal limits, as was the chest x-ray. An excretory urogram revealed lateral deviation of the mid right ureter.
finely granular or delicately vacuolated. tumor necrosis and tumor-infiltrated Lymphangiography showed large nodes displacing the u:reters, appearing ~"'""'m, r consistent with metastatic disease (fig. 2). Therefore, a course of radiotherapy was started in December 1977. A total dose of 2,600 rad was administered to the right inguinal and para-aorhc nodes and 2,450 rad to the mediastinum and left anterior The mediastinal portal measured 19 x 13 cm. In April 1978 the patient presented with masses, approximately 5 cm. in diameter. chain human chorionic gonadotropin and a-1:et,onrot were within normal limits. A bone scan, liver scan, upper and lowm
FIG. l. Characteristic polymorphic pattern of spermatocytic seminoma. Predominantly medium sized cells are admixed with large cells and occasional small lymphocyst-like cells. H & E, reduced from X250.
A right radical orchiectomy was performed an mand microscopic examination features consistent with spermatocytic seminoma (confirmed by the Armed Forces Institute of Pathology). The tumor cells were rounded or ovoid generally and had large shaped hyperchromatic (figo 1). The tumor nuclei varied in size and giant forms were seen. Some of these had large dear spaces suggesting unusual nuclear vacuolization. The tumor cells had a fairly generous volume of eosinophilic cytoplasm, which in some areas was Accepted for publication January 11, 1980. * Current address: Atlanta Urological Group, 340 Blvd., Atlanta, Georgia 30312.
FIG. 2. Lymphangiogram shows ureterai displacement with large
nodes. 739
740
SCHOBORG, WHITTAKER AND LEWIS
gastrointestinal series, chest x-ray and bone marrow biopsy were within normal limits. Needle aspiration biopsy of the left axillary node showed a metastatic neoplasm with features consistent with the primary spermatocytic seminoma (fig. 3). On May 4 a course of chemotherapy, consisting of 1 mg. cyclophosphamide intravenously 2 times a month and 1 to 2 mg. vincristine intravenously monthly, was begun. However, in late May a nodule of the left buttock was noted with persistence of the axillary adenopathy. The patient was continued on cyclophosphamide and vincristine until July when metastatic lesions on the right cheek, right supraclavicular region and left anterior thigh were noted, along with enlargement of the right axillary node to 10 cm. The chest x-ray showed increasing bilateral perihilar adenopathy with interstitial infiltrates and a density in the left paravertebral region behind the heart (fig. 4). Chemotherapy was continued but cyclophosphamide was substituted with 30 mg. bleomycin intravenously 5 times daily. The patient had a rapid downhill course and he died in August. No autopsy was granted. DISCUSSION
Testicular seminomas have been associated classically with an 80 to 90 per cent survival rate, with the most successful form of therapy being radiotherapy alone for stages I, IIA and IIB, and combined with adjuvant chemotherapy (cyclophospham-
ide, vincristine, actinomycin D, chlorambucil) for stage 111. 1- 4 Retroperitoneal lymphadenectomy has been advocated only rarely. 5 Some investigators question whether any form of therapy other than radical orchiectomy alone is even indicated when dealing with spermatocytic seminoma, generally thought of as a non-metastasizing form of seminoma. 6 In a review of 18 radiotherapy failures of 132 patients treated for classic seminoma Doornbos and associates noted that only 1 patient had recurrent tumor within the irradiated area and the majority of failures were owing to extranodal metastases or tumor recurrence outside the treatment portals. 2 Our case not only represents an instance of metastatic spermatocytic seminoma but also is another case of seminoma that developed within the portals of radiotherapy (mediastinal adenopathy documented by a chest x-ray only). A retrospective analysis of the case revealed that survival may have been improved had ~1 of the following protocols been administered: 1) whole abdominal irradiation of 2,000 rad followed by an additional 1,000 to 2,000 rad directed through reduced portals to the residual nodal mass,2 2) higher dose (1.5 to 2.0 gm./m. 2) single injection cyclophosphamide therapy as recommended by Weitzman and Carey,4 and 3) combination chemotherapy, incorporating actinomycin D, cyclophosphamide, vincristine and chlorambucil, as outlined by Smith and associates. 3 However, not many authors would recommend a higher dose of prophylactic irradiation to the mediastinum than that administered to our patient. No matter what the retrospective analysis may be urologic oncologists must hereafter be aware of the shortcomings of radiotherapy and chemotherapy in treating classical seminoma, and of the hazards of assuming that spermatocytic seminoma is unlikely to metastasize. REFERENCES 1. Maier, J. G. and Sulak, N. H.: Radiation therapy in malignant testis
FIG. 3. Similar pattern is present in metastasis. H & E, reduced from X250.
tumors. Part I: seminoma; II: carcinoma. Cancer, 32: 1212, 1973. 2. Doornbos, J. F., Hussey, D. H. and Johnson, D. E.: Radiotherapy for pure seminoma of the testis. Radiology, 116: 401, 1975. 3. Smith, R. B., deKernion, J.B. and Skinner, D. G.: Management of advanced testicular seminoma. J. Urol., 121: 429, 1979. 4. Weitzman, S. A. and Carey, R. W.: High dose cyclophosphamide as an adjunct to radiotherapy for advanced seminoma. J. Urol., 117: 613, 1977. 5. Lindsey, G. M. and Glenn, J. F.: Germinal malignancies of the testis; experience, management and prognosis. J. Urol., 116: 59, 1976. 6. Mostofi, F. K. and Price, E. B.: Tumors of the male genital system. In: Atlas of Tumor Pathology. Washington, D. C.: Armed Forces Institute of Pathology, 2nd series, fasc. 8, 1973.
FIG. 4. Before (A) and after (B) irradiation chest x-rays show increased perihilar adenopathy
0022-534 7/80 /1245-0739$02.00 /0
Vol. 124, November
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1980 by The Williams & Wilkins Co.
METASTATIC SPERMATOCYTIC SEMINOMA THOMAS W. SCHOBORG,* JOHN WHITTAKER AND CHARLES W. LEWIS From the Department of Urology, Georgia Baptist Medical Center, Atlanta, Georgia, and Department of Urology, Uniuersity Hospital of Jacksonville, Jacksonville, Florida
ABSTRACT
Spermatocytic semi.noma is for its relative infreqw.mcy of metastases. A case of metastatic ~"V'-''"""~v·v seminoma is reported in which there was evidence of tumor recurrence within an irradiated area. The need for aggTessive initial ..,~...~,...~,"'~·· and careful followup of patients with this is emphasized. Niost authors regard spermatocytic seminoma as an entity that
if ever, metastasizes and question the need for any
other than radical inguinal orchiectomy. a case of metastatic spermatocytic seminoma oncologists to reassess this which about 10 per cent of all seminomas. CASE REPORT
white man was hospitalized in November 1977 pa,amo"'" swelling of the right testicle 5 weeks in duration. examination failed to reveal any significant adenopain the neck and axillary adenopathy was not recorded. The testicle was 3 times normal size, firm and non-tender. human chorionic gonadotropin and a-fetoprotein were within normal limits, as was the chest x-ray. An excretory urogram revealed lateral deviation of the mid right ureter.
finely granular or delicately vacuolated. tumor necrosis and tumor-infiltrated Lymphangiography showed large nodes displacing the u:reters, appearing ~"'""'m, r consistent with metastatic disease (fig. 2). Therefore, a course of radiotherapy was started in December 1977. A total dose of 2,600 rad was administered to the right inguinal and para-aorhc nodes and 2,450 rad to the mediastinum and left anterior The mediastinal portal measured 19 x 13 cm. In April 1978 the patient presented with masses, approximately 5 cm. in diameter. chain human chorionic gonadotropin and a-1:et,onrot were within normal limits. A bone scan, liver scan, upper and lowm
FIG. l. Characteristic polymorphic pattern of spermatocytic seminoma. Predominantly medium sized cells are admixed with large cells and occasional small lymphocyst-like cells. H & E, reduced from X250.
A right radical orchiectomy was performed an mand microscopic examination features consistent with spermatocytic seminoma (confirmed by the Armed Forces Institute of Pathology). The tumor cells were rounded or ovoid generally and had large shaped hyperchromatic (figo 1). The tumor nuclei varied in size and giant forms were seen. Some of these had large dear spaces suggesting unusual nuclear vacuolization. The tumor cells had a fairly generous volume of eosinophilic cytoplasm, which in some areas was Accepted for publication January 11, 1980. * Current address: Atlanta Urological Group, 340 Blvd., Atlanta, Georgia 30312.
FIG. 2. Lymphangiogram shows ureterai displacement with large
nodes. 739
740
SCHOBORG, WHITTAKER AND LEWIS
gastrointestinal series, chest x-ray and bone marrow biopsy were within normal limits. Needle aspiration biopsy of the left axillary node showed a metastatic neoplasm with features consistent with the primary spermatocytic seminoma (fig. 3). On May 4 a course of chemotherapy, consisting of 1 mg. cyclophosphamide intravenously 2 times a month and 1 to 2 mg. vincristine intravenously monthly, was begun. However, in late May a nodule of the left buttock was noted with persistence of the axillary adenopathy. The patient was continued on cyclophosphamide and vincristine until July when metastatic lesions on the right cheek, right supraclavicular region and left anterior thigh were noted, along with enlargement of the right axillary node to 10 cm. The chest x-ray showed increasing bilateral perihilar adenopathy with interstitial infiltrates and a density in the left paravertebral region behind the heart (fig. 4). Chemotherapy was continued but cyclophosphamide was substituted with 30 mg. bleomycin intravenously 5 times daily. The patient had a rapid downhill course and he died in August. No autopsy was granted. DISCUSSION
Testicular seminomas have been associated classically with an 80 to 90 per cent survival rate, with the most successful form of therapy being radiotherapy alone for stages I, IIA and IIB, and combined with adjuvant chemotherapy (cyclophospham-
ide, vincristine, actinomycin D, chlorambucil) for stage 111. 1- 4 Retroperitoneal lymphadenectomy has been advocated only rarely. 5 Some investigators question whether any form of therapy other than radical orchiectomy alone is even indicated when dealing with spermatocytic seminoma, generally thought of as a non-metastasizing form of seminoma. 6 In a review of 18 radiotherapy failures of 132 patients treated for classic seminoma Doornbos and associates noted that only 1 patient had recurrent tumor within the irradiated area and the majority of failures were owing to extranodal metastases or tumor recurrence outside the treatment portals. 2 Our case not only represents an instance of metastatic spermatocytic seminoma but also is another case of seminoma that developed within the portals of radiotherapy (mediastinal adenopathy documented by a chest x-ray only). A retrospective analysis of the case revealed that survival may have been improved had ~1 of the following protocols been administered: 1) whole abdominal irradiation of 2,000 rad followed by an additional 1,000 to 2,000 rad directed through reduced portals to the residual nodal mass,2 2) higher dose (1.5 to 2.0 gm./m. 2) single injection cyclophosphamide therapy as recommended by Weitzman and Carey,4 and 3) combination chemotherapy, incorporating actinomycin D, cyclophosphamide, vincristine and chlorambucil, as outlined by Smith and associates. 3 However, not many authors would recommend a higher dose of prophylactic irradiation to the mediastinum than that administered to our patient. No matter what the retrospective analysis may be urologic oncologists must hereafter be aware of the shortcomings of radiotherapy and chemotherapy in treating classical seminoma, and of the hazards of assuming that spermatocytic seminoma is unlikely to metastasize. REFERENCES 1. Maier, J. G. and Sulak, N. H.: Radiation therapy in malignant testis
FIG. 3. Similar pattern is present in metastasis. H & E, reduced from X250.
tumors. Part I: seminoma; II: carcinoma. Cancer, 32: 1212, 1973. 2. Doornbos, J. F., Hussey, D. H. and Johnson, D. E.: Radiotherapy for pure seminoma of the testis. Radiology, 116: 401, 1975. 3. Smith, R. B., deKernion, J.B. and Skinner, D. G.: Management of advanced testicular seminoma. J. Urol., 121: 429, 1979. 4. Weitzman, S. A. and Carey, R. W.: High dose cyclophosphamide as an adjunct to radiotherapy for advanced seminoma. J. Urol., 117: 613, 1977. 5. Lindsey, G. M. and Glenn, J. F.: Germinal malignancies of the testis; experience, management and prognosis. J. Urol., 116: 59, 1976. 6. Mostofi, F. K. and Price, E. B.: Tumors of the male genital system. In: Atlas of Tumor Pathology. Washington, D. C.: Armed Forces Institute of Pathology, 2nd series, fasc. 8, 1973.
FIG. 4. Before (A) and after (B) irradiation chest x-rays show increased perihilar adenopathy