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Organ preservation for the treatment of contralateral testicular seminoma
Radiotherapy and Oncology 53 (1999) 45±47 www.elsevier.com/locate/radonline
Organ preservation for the treatment of contralateral testicular seminoma q Ismail Kazem a,*, John F. Danella b a
Department of Radiation Oncology, Penn State Geisinger Medical Center, Danville, PA 17822, USA b Department of Urology, Penn State Geisinger Medical Center, Danville, PA 17822, USA Received 19 June 1999; received in revised form 12 July 1999; accepted 6 August 1999
Abstract Purpose: Local excision of germ cell tumor in the remaining testicle followed by a modest dose of irradiation is an alternative to orchiectomy. This organ sparing technique provides superior quality of life and reduces the need for lifelong hormone replacement. Materials and methods: We treated two patients with contralateral seminomas with organ preservation. Both patients received postoperative irradiation to the remaining testicle to a dose of 20 Gy in 10 fractions and 19.8 Gy in 11 fractions. Results: Both patients are alive with no evidence of disease more than 3 years since the completion of their treatments. They both have reduced but preserved androgen production and retained their virility. They both are azospermic. Conclusion: We conclude that organ preservation for the treatment of contralateral testicular seminoma is a superior alternative to orchiectomy of the remaining testicle. It preserves male hormone production with equal survival outcome expectations. q 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Testicular preservation; Contralateral seminoma; Testicular irradiation; Germ-cell tumors
1. Introduction Five percent of patients with testicular germ cell tumors will either present with or will develop contralateral tumors [4]. The standard practice of treatment is radical orchiectomy of the remaining testicle with hormone replacement for the rest of patient's life. An alternative to the standard practice is the local excision of the tumor followed by a modest dose of irradiation. This organ sparing technique provides better quality of life and reduces the need for life-long hormone replacement.
2. Patients and methods We treated two patients with contralateral seminomas with organ preservation. The ®rst patient, a 44-year-old man presented in July 1995 with a contralateral mass in the left testicle. This was con®rmed by scrotal ultrasonography. He had a right orchiectomy 15 years earlier for a Stage II seminoma of the right testicle. Following his right orchiectomy he underwent post-operative radiation therapy elsewhere. The para-aortic and ipsilateral pelvic nodes received q Poster presented at the 8th International Congress on Anti-Cancer Treatment, February 3rd±6th, 1998, Paris, France. * Corresponding author.
30 Gy in 3 weeks followed by a boost of 5 Gy to the involved right renal hilar nodes. One month later the patient received 20 Gy in 2 weeks to the mediastinum and supraclavicular nodes. The treatment was given through anterior posterior irregular ®elds on a 4 MV photon beam. On the 24th of July 1995 he underwent a transinguinal exploration of the left testicle with excision of a 2-cm mass in the lower pole of the left testicle. The microscopic description of the mass was that of in®ltrating tumor of irregular border consistent with a pure seminoma. Post-operatively the patient received a course of radiation therapy to a target volume encompassing the scrotum including the remaining left testicle and the left inguinal incision scar. The treatment was given on the 6 MV photon beam through anterior and posterior shaped ®elds. A total dose of 20 Gy was delivered in 10 equal fractions of 2 Gy over a period of 2 weeks. The treatment was completed on the 6th of September 1995. The second patient a 36 year old man who presented in September 1995 with a right scrotal mass. On the 12th of September 1995 testicular ultrasound examination showed a well circumscribed hypoehoic mass in the right mid to lower pole and another mass in the left upper pole. On the 20th of September 1995 the patient underwent a right transinguinal radical orchiectomy and a transinguinal exploration of the left testicle with excision of 1.5-cm mass in the upper pole.
0167-8140/99/$ - see front matter q 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0167-814 0(99)00112-7
46
I. Kazem, J.F. Danella / Radiotherapy and Oncology 53 (1999) 45±47
The microscopic description of the right testicle was that of a pure seminoma. The excised mass from left testicle also showed evidence of a pure seminoma with focal intratubular seminoma. Screening for nodal and/or distant metastases was negative. The patient received a course of post-operative radiation therapy to a target volume encompassing the para-aortic and right pelvic nodes through anterior and posterior shaped ®elds utilizing the 6 MV photon beam. A dose of 25.2 Gy was delivered in a daily fraction dose of 1.8 Gy over a period of 3 weeks. He also received a total dose of 19.8 Gy in 11 fractions of 1.8 Gy to a target volume encompassing the scrotum including the remaining left testicle and the left inguinal incision scar. The treatment was completed on the 14th of November 1995.
3. Results Both patients are alive and well with no evidence of disease more than 3 years since the completion of their treatments. They both have preserved but low androgen production and have retained their virility. They both are azospermic. Serial hormone pro®les were obtained including testosterone, LSH and FSH serum levels (Table 1). Their routine follow up included clinical examination, sonography every six month during the 1st year, and annually thereafter.
4. Discussion About 8000 new cases of testicular germinal tumors are diagnosed annually in the USA. With an incidence of 5% contralateral tumors, this translates into about 400 cases of involvement of the remaining testicle. The subject of bilateral testicular tumors and the need for contralateral testicular biopsy has been the focus of attention in recent literature [3,5,8,14]. Dieckmann et al. [5] obtained biopsies from the contralateral testicles of 1954 consecutive patients with unilateral testicular germ cell tumors. Testicular intraepithelial neoplasia (TIN) was observed in 95 patients (4.9%). According to Classen et al. [3], TIN has a 70% rate of progression to invasive cancer within 7 years. The question Table 1 Pre- and post-treatment hormone pro®les Pre-treatment
2-Years post-treatment
Normals
Patient 1 FSH: 29.6 LH: 15.8 Testosterone: 285
56.3 18.82 170
0.9±15 mIU/ml 1.3±12.9 mIU/ml 241±827 ng/dl
Patient 2 FSH: 9.1 LH: 3.7 Testosterone: 509
58.7 28.7 270
0.9±15 mIU/ml 1.3±12.9 mIU/ml 241±827 ng/dl
is how best to treat the contralateral tumor in the remaining testicle. The standard practice of surgical excision of the remaining testicle would result in total androgen deprivation requiring life-long hormone replacement. Richie [12], was the ®rst to report on the successful treatment of a patient with bilateral seminoma after what he described as `unorthodox management'. The patient had a radical orchiectomy on one side and a hemiorchiectomy on the other side followed by post-operative irradiation to 20 Gy. In his report he stated that a dose of 20 Gy was calculated to treat any remaining tumor but to preserve the Leydig cells for hormone production. Several reports have been published since about the favorable outcome of testicular sparing surgery [7,9,10,13,15]. Giwercman et al. [7], published an impressive clinical radiobiologic study on the effects on Leydig cell function and eradication of malignant germ cells in 20 patients treated with localized testicular irradiation. Follow-up testicular biopsies were performed 3 and 24 months after treatment. Hormonal evaluation was performed before as well as 3, 12, 24 and 36 months after treatment. All follow-up biopsies showed a uniform Sertoli cell-only pattern without the presence of carcinoma in situ or other germ cells. No qualitative changes in the Leydig cells were observed. Hormonal values determined after radiotherapy indicated signi®cant increase in FSH from 32.8 to 48.9 IU/l, whereas LH was reported as showing less signi®cant change. The baseline testosterone concentration decreased gradually during the follow-up period although the decrease was not statistically signi®cant. Heidenreich et al. [9], reported on six patients with bilateral testicular germ cell tumors, four seminomas and two non-seminomas, treated by organ sparing surgery followed by 20 Gy post-operative irradiation. Median follow-up was 43 months, all patients were free of disease and no androgen substitution was necessary. Weissbach [15] reported on 14 patients: seven with seminomas and seven with non-seminomas, ten had successful organ preserving surgery and two required ablation later for insuf®cient blood supply. All patients had no local recurrence. The author stresses the importance of the surgical technique and the importance of ultrasound early detection in patients with solitary testis. Other authors [1,4,13] have emphasized the importance of modern sonography both for early detection and as a guide for intraoperative exploration of the testicle. The surgical approach to enucleation of testicular tumor involves a standard inguinal incision, followed by vascular control of the spermatic cord. The testis and cord are then isolated with towels and the tunica albuginea is incised along the long axis of the testis to bivalve it. This allows enucleation of the tumor nodule as well as thorough inspection and palpation of the remaining parenchyma. The tunica is then closed with ®ne mono®lament suture and the testis replaced in the scrotum. The surgery should ideally be performed by surgeons experienced in treating testicular malignancies. It is suggested
I. Kazem, J.F. Danella / Radiotherapy and Oncology 53 (1999) 45±47
that all patients with contralateral testicular tumors be entered in a central tumor registry to allow compilation of data from multiple centers of this rather infrequent tumors. A recent report [11], suggests that single-agent carboplatin chemotherapy following organ sparing surgery for seminoma in the solitary testis may succeed not only in preserving hormonal but also reproductive function. The question is how successful this approach would be in eradicating residual microscopic disease. Chong et al. [2] reported on 16 patients with advanced germ cell cancer who underwent initial chemotherapy followed by delayed orchiectomy. Residual viable tumor was found in 4 patients (25%). The authors concluded that there is differential response of germ cell tumors in the primary and metastatic sites. Fossa et al. [6] examined the hypothesis that systemic chemotherapy eradicates carcinoma in situ in patients with testicular germ cell tumors. They looked up the records of 781 patients with germ cell cancer. Fourteen patients developed a contralateral testicular cancer. The incidence was not related to the treatment of the ®rst germ cell cancer. In particular, adequate cisplatin-based chemotherapy did not reduce the risk of developing a second testicular tumor. One might also argue whether a radiation dose less than 20 Gy would be adequate for the control of residual microscopic disease after tumor enucleation. So far the published experience recommends the dose initially applied by Dr Richie [12]. Until long term evidence of the ef®cacy of a lower dose is proven, we recommend 20 Gy as an effective and safe dose.
5. Conclusion Organ sparing surgery followed by 20 Gy irradiation is an effective treatment of early germ cell carcinoma in the remaining testicle. Our experience with two patients reported above con®rms published reports.
47
References [1] Buckspan MB, Klotz PG, Gold®nger M, Stoll S, Fernandes B. Intraoperative ultrasound in conservative resection of testicular neoplasms. Urology 1989;141:326±327. [2] Chong C, Logothetis CJ, von Eschenbach A, Ayala A, Samuels M. Orchiectomy in advanced germ cell cancer following intensive chemotherapy: a comparison of systemic to testicular response. Urology 1986;136:1221±1223. [3] Classen J, Dieckman KP, Loy V, Bamberg M. Testicular intraepithelial neoplasms (TIN). An indication for radiotherapy? Strahlenther. Onkol. 1998;174:173±177. [4] Dieckmann KP, Boeckmann W, Brosig W, Jonas D, Bauer HW. Bilateral testicular germ cell tumors. Report of nine cases and review of literature. Cancer 1986;57:1254±1258. [5] Dieckmann KP, Loy V. Prevalence of contralateral testicular intraepithelial neoplasia in patients with testicular germ cell neoplasms. Clin. Oncol. 1996;14:3126±3132. [6] Fossa SD, Aass N. Cisplatin-based chemotherapy does not eliminate the risk of a second testicular cancer. Br. J. Urol. 1989;63:531±534. [7] Giwercman A, von Der Maase H, Berthelsen JG, Rorth M, Bertelsen A, Skakkenbaek N. Localized irradiation of testes with carcinoma in situ: effects on leydig cell function and eradication of malignant germ cells in 20 patients. Clin. Endocrinol. Metab. 1991;73:596±603. [8] Harland ST, Cook PA, Fossa SD, et al. Intratubular germ cell neoplasia of the contralateral testis in testicular cancer: de®ning a high risk group. Urology 1998;160:1353±1357. [9] Heidenreich A, Bon®g R, Derschum W, von Vietsch H, Wilbert DM. A conservative approach to bilateral testicular germ cell tumors. Urology 1995;153:10±13. [10] Heidenreich A, Holtl W, Albrecht W, Pont J, Engelmann UH. Testispreserving surgery in bilateral germ cell tumors. Br. J. Urol. 1997;79:253±257. [11] Ng RSH. The reproductive imperative: a case report highlighting the possibility of using chemotherapy to conserve the testis in patients with testis cancer. Clin. Oncol. 1997;9:334±337. [12] Richie JP. Simultaneous bilateral tumors with unorthodox management. World J. Urology 1984;2:74. [13] Rushton HG, Belman AB, Sesterhenn I, Patterson K, Mosto® FK. Testicular sparing surgery for prepubertal teratoma of testis: a clinical and pathological study. Urology 1990;144:726±730. [14] Wander EH, Fossa SD, Tretli S. Risk of a second germ cell cancer after treatment of a primary germ cell cancer in 2201 Norwegian male patients. Eur. J. Cancer 1997;33:244. [15] Weissbach L. Organ preserving surgery of malignant germ cell tumors. J. Urol. 1995;153:90±93.
Organ preservation for the treatment of contralateral testicular seminoma q Ismail Kazem a,*, John F. Danella b a
Department of Radiation Oncology, Penn State Geisinger Medical Center, Danville, PA 17822, USA b Department of Urology, Penn State Geisinger Medical Center, Danville, PA 17822, USA Received 19 June 1999; received in revised form 12 July 1999; accepted 6 August 1999
Abstract Purpose: Local excision of germ cell tumor in the remaining testicle followed by a modest dose of irradiation is an alternative to orchiectomy. This organ sparing technique provides superior quality of life and reduces the need for lifelong hormone replacement. Materials and methods: We treated two patients with contralateral seminomas with organ preservation. Both patients received postoperative irradiation to the remaining testicle to a dose of 20 Gy in 10 fractions and 19.8 Gy in 11 fractions. Results: Both patients are alive with no evidence of disease more than 3 years since the completion of their treatments. They both have reduced but preserved androgen production and retained their virility. They both are azospermic. Conclusion: We conclude that organ preservation for the treatment of contralateral testicular seminoma is a superior alternative to orchiectomy of the remaining testicle. It preserves male hormone production with equal survival outcome expectations. q 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Testicular preservation; Contralateral seminoma; Testicular irradiation; Germ-cell tumors
1. Introduction Five percent of patients with testicular germ cell tumors will either present with or will develop contralateral tumors [4]. The standard practice of treatment is radical orchiectomy of the remaining testicle with hormone replacement for the rest of patient's life. An alternative to the standard practice is the local excision of the tumor followed by a modest dose of irradiation. This organ sparing technique provides better quality of life and reduces the need for life-long hormone replacement.
2. Patients and methods We treated two patients with contralateral seminomas with organ preservation. The ®rst patient, a 44-year-old man presented in July 1995 with a contralateral mass in the left testicle. This was con®rmed by scrotal ultrasonography. He had a right orchiectomy 15 years earlier for a Stage II seminoma of the right testicle. Following his right orchiectomy he underwent post-operative radiation therapy elsewhere. The para-aortic and ipsilateral pelvic nodes received q Poster presented at the 8th International Congress on Anti-Cancer Treatment, February 3rd±6th, 1998, Paris, France. * Corresponding author.
30 Gy in 3 weeks followed by a boost of 5 Gy to the involved right renal hilar nodes. One month later the patient received 20 Gy in 2 weeks to the mediastinum and supraclavicular nodes. The treatment was given through anterior posterior irregular ®elds on a 4 MV photon beam. On the 24th of July 1995 he underwent a transinguinal exploration of the left testicle with excision of a 2-cm mass in the lower pole of the left testicle. The microscopic description of the mass was that of in®ltrating tumor of irregular border consistent with a pure seminoma. Post-operatively the patient received a course of radiation therapy to a target volume encompassing the scrotum including the remaining left testicle and the left inguinal incision scar. The treatment was given on the 6 MV photon beam through anterior and posterior shaped ®elds. A total dose of 20 Gy was delivered in 10 equal fractions of 2 Gy over a period of 2 weeks. The treatment was completed on the 6th of September 1995. The second patient a 36 year old man who presented in September 1995 with a right scrotal mass. On the 12th of September 1995 testicular ultrasound examination showed a well circumscribed hypoehoic mass in the right mid to lower pole and another mass in the left upper pole. On the 20th of September 1995 the patient underwent a right transinguinal radical orchiectomy and a transinguinal exploration of the left testicle with excision of 1.5-cm mass in the upper pole.
0167-8140/99/$ - see front matter q 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0167-814 0(99)00112-7
46
I. Kazem, J.F. Danella / Radiotherapy and Oncology 53 (1999) 45±47
The microscopic description of the right testicle was that of a pure seminoma. The excised mass from left testicle also showed evidence of a pure seminoma with focal intratubular seminoma. Screening for nodal and/or distant metastases was negative. The patient received a course of post-operative radiation therapy to a target volume encompassing the para-aortic and right pelvic nodes through anterior and posterior shaped ®elds utilizing the 6 MV photon beam. A dose of 25.2 Gy was delivered in a daily fraction dose of 1.8 Gy over a period of 3 weeks. He also received a total dose of 19.8 Gy in 11 fractions of 1.8 Gy to a target volume encompassing the scrotum including the remaining left testicle and the left inguinal incision scar. The treatment was completed on the 14th of November 1995.
3. Results Both patients are alive and well with no evidence of disease more than 3 years since the completion of their treatments. They both have preserved but low androgen production and have retained their virility. They both are azospermic. Serial hormone pro®les were obtained including testosterone, LSH and FSH serum levels (Table 1). Their routine follow up included clinical examination, sonography every six month during the 1st year, and annually thereafter.
4. Discussion About 8000 new cases of testicular germinal tumors are diagnosed annually in the USA. With an incidence of 5% contralateral tumors, this translates into about 400 cases of involvement of the remaining testicle. The subject of bilateral testicular tumors and the need for contralateral testicular biopsy has been the focus of attention in recent literature [3,5,8,14]. Dieckmann et al. [5] obtained biopsies from the contralateral testicles of 1954 consecutive patients with unilateral testicular germ cell tumors. Testicular intraepithelial neoplasia (TIN) was observed in 95 patients (4.9%). According to Classen et al. [3], TIN has a 70% rate of progression to invasive cancer within 7 years. The question Table 1 Pre- and post-treatment hormone pro®les Pre-treatment
2-Years post-treatment
Normals
Patient 1 FSH: 29.6 LH: 15.8 Testosterone: 285
56.3 18.82 170
0.9±15 mIU/ml 1.3±12.9 mIU/ml 241±827 ng/dl
Patient 2 FSH: 9.1 LH: 3.7 Testosterone: 509
58.7 28.7 270
0.9±15 mIU/ml 1.3±12.9 mIU/ml 241±827 ng/dl
is how best to treat the contralateral tumor in the remaining testicle. The standard practice of surgical excision of the remaining testicle would result in total androgen deprivation requiring life-long hormone replacement. Richie [12], was the ®rst to report on the successful treatment of a patient with bilateral seminoma after what he described as `unorthodox management'. The patient had a radical orchiectomy on one side and a hemiorchiectomy on the other side followed by post-operative irradiation to 20 Gy. In his report he stated that a dose of 20 Gy was calculated to treat any remaining tumor but to preserve the Leydig cells for hormone production. Several reports have been published since about the favorable outcome of testicular sparing surgery [7,9,10,13,15]. Giwercman et al. [7], published an impressive clinical radiobiologic study on the effects on Leydig cell function and eradication of malignant germ cells in 20 patients treated with localized testicular irradiation. Follow-up testicular biopsies were performed 3 and 24 months after treatment. Hormonal evaluation was performed before as well as 3, 12, 24 and 36 months after treatment. All follow-up biopsies showed a uniform Sertoli cell-only pattern without the presence of carcinoma in situ or other germ cells. No qualitative changes in the Leydig cells were observed. Hormonal values determined after radiotherapy indicated signi®cant increase in FSH from 32.8 to 48.9 IU/l, whereas LH was reported as showing less signi®cant change. The baseline testosterone concentration decreased gradually during the follow-up period although the decrease was not statistically signi®cant. Heidenreich et al. [9], reported on six patients with bilateral testicular germ cell tumors, four seminomas and two non-seminomas, treated by organ sparing surgery followed by 20 Gy post-operative irradiation. Median follow-up was 43 months, all patients were free of disease and no androgen substitution was necessary. Weissbach [15] reported on 14 patients: seven with seminomas and seven with non-seminomas, ten had successful organ preserving surgery and two required ablation later for insuf®cient blood supply. All patients had no local recurrence. The author stresses the importance of the surgical technique and the importance of ultrasound early detection in patients with solitary testis. Other authors [1,4,13] have emphasized the importance of modern sonography both for early detection and as a guide for intraoperative exploration of the testicle. The surgical approach to enucleation of testicular tumor involves a standard inguinal incision, followed by vascular control of the spermatic cord. The testis and cord are then isolated with towels and the tunica albuginea is incised along the long axis of the testis to bivalve it. This allows enucleation of the tumor nodule as well as thorough inspection and palpation of the remaining parenchyma. The tunica is then closed with ®ne mono®lament suture and the testis replaced in the scrotum. The surgery should ideally be performed by surgeons experienced in treating testicular malignancies. It is suggested
I. Kazem, J.F. Danella / Radiotherapy and Oncology 53 (1999) 45±47
that all patients with contralateral testicular tumors be entered in a central tumor registry to allow compilation of data from multiple centers of this rather infrequent tumors. A recent report [11], suggests that single-agent carboplatin chemotherapy following organ sparing surgery for seminoma in the solitary testis may succeed not only in preserving hormonal but also reproductive function. The question is how successful this approach would be in eradicating residual microscopic disease. Chong et al. [2] reported on 16 patients with advanced germ cell cancer who underwent initial chemotherapy followed by delayed orchiectomy. Residual viable tumor was found in 4 patients (25%). The authors concluded that there is differential response of germ cell tumors in the primary and metastatic sites. Fossa et al. [6] examined the hypothesis that systemic chemotherapy eradicates carcinoma in situ in patients with testicular germ cell tumors. They looked up the records of 781 patients with germ cell cancer. Fourteen patients developed a contralateral testicular cancer. The incidence was not related to the treatment of the ®rst germ cell cancer. In particular, adequate cisplatin-based chemotherapy did not reduce the risk of developing a second testicular tumor. One might also argue whether a radiation dose less than 20 Gy would be adequate for the control of residual microscopic disease after tumor enucleation. So far the published experience recommends the dose initially applied by Dr Richie [12]. Until long term evidence of the ef®cacy of a lower dose is proven, we recommend 20 Gy as an effective and safe dose.
5. Conclusion Organ sparing surgery followed by 20 Gy irradiation is an effective treatment of early germ cell carcinoma in the remaining testicle. Our experience with two patients reported above con®rms published reports.
47
References [1] Buckspan MB, Klotz PG, Gold®nger M, Stoll S, Fernandes B. Intraoperative ultrasound in conservative resection of testicular neoplasms. Urology 1989;141:326±327. [2] Chong C, Logothetis CJ, von Eschenbach A, Ayala A, Samuels M. Orchiectomy in advanced germ cell cancer following intensive chemotherapy: a comparison of systemic to testicular response. Urology 1986;136:1221±1223. [3] Classen J, Dieckman KP, Loy V, Bamberg M. Testicular intraepithelial neoplasms (TIN). An indication for radiotherapy? Strahlenther. Onkol. 1998;174:173±177. [4] Dieckmann KP, Boeckmann W, Brosig W, Jonas D, Bauer HW. Bilateral testicular germ cell tumors. Report of nine cases and review of literature. Cancer 1986;57:1254±1258. [5] Dieckmann KP, Loy V. Prevalence of contralateral testicular intraepithelial neoplasia in patients with testicular germ cell neoplasms. Clin. Oncol. 1996;14:3126±3132. [6] Fossa SD, Aass N. Cisplatin-based chemotherapy does not eliminate the risk of a second testicular cancer. Br. J. Urol. 1989;63:531±534. [7] Giwercman A, von Der Maase H, Berthelsen JG, Rorth M, Bertelsen A, Skakkenbaek N. Localized irradiation of testes with carcinoma in situ: effects on leydig cell function and eradication of malignant germ cells in 20 patients. Clin. Endocrinol. Metab. 1991;73:596±603. [8] Harland ST, Cook PA, Fossa SD, et al. Intratubular germ cell neoplasia of the contralateral testis in testicular cancer: de®ning a high risk group. Urology 1998;160:1353±1357. [9] Heidenreich A, Bon®g R, Derschum W, von Vietsch H, Wilbert DM. A conservative approach to bilateral testicular germ cell tumors. Urology 1995;153:10±13. [10] Heidenreich A, Holtl W, Albrecht W, Pont J, Engelmann UH. Testispreserving surgery in bilateral germ cell tumors. Br. J. Urol. 1997;79:253±257. [11] Ng RSH. The reproductive imperative: a case report highlighting the possibility of using chemotherapy to conserve the testis in patients with testis cancer. Clin. Oncol. 1997;9:334±337. [12] Richie JP. Simultaneous bilateral tumors with unorthodox management. World J. Urology 1984;2:74. [13] Rushton HG, Belman AB, Sesterhenn I, Patterson K, Mosto® FK. Testicular sparing surgery for prepubertal teratoma of testis: a clinical and pathological study. Urology 1990;144:726±730. [14] Wander EH, Fossa SD, Tretli S. Risk of a second germ cell cancer after treatment of a primary germ cell cancer in 2201 Norwegian male patients. Eur. J. Cancer 1997;33:244. [15] Weissbach L. Organ preserving surgery of malignant germ cell tumors. J. Urol. 1995;153:90±93.