Synchronous bilateral testicular tumors of different cell types on each side

SYNCHRONOUS BILATERAL TESTICULAR TUMORS OF DIFFERENT CELL TYPES ON EACH SIDE MASAHIRO MATSUSHIMA, M .D . KIYOSHI FUKASAWA, M .D . MASAMI KAWAHARA, M .D. MOTOMU MATSUHASHI, M .D, MASAHARU TAJIMA, M .D .

YOSHIKATSU SAWAMURA, M .D . HIROKO NONAKA, M .D. MASAFUMI SHIRAI, M .D . KO ANDO, M .D .,

From the Departments of Urology and Pathology, Toho University School of Medicine, Tokyo, Japan

ASTRACT-Bilateral and synchronous testicular tumors consisting of different cell types on each side are rare . We describe one additional case of synchronous bilateral testicular tumors comprised of different cell types on each side and review the relative literature.

Bilateral primary testicular tumor is relatively uncommon, although the number of reported cases has been gradually accumulating since 1805, when Livingstone' described the first case . However, bilateral and synchronous testicular tumors consisting of different cells types on each side are rare . We describe an additional case of synchronous bilateral testicular tumors comprised of different cell types on each side and review the relative literature . Case Report The patient, a thirty-year-old man, had been aware of swelling of the right testis since 1977, but because of the lack of pain did not have it medically examined, Although married since 1979, he had no children . Having noticed the progressive enlargement of his right testis since 1982, however, the patient visited our clinic . By palpation, we found the right testis enlarged to the size of a fist, while the left testis was the size of a small hen's egg . Ultrasonic examination revealed a mixed pattern on the right and a solid pattern on the left . At the time of admission, no abnormality was found in the hemato-clinical examination with human cho-

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rionic gonadotropin (HCC), 0-HCG subunit, or «-fetroprotein . His chest x-ray film and intravenous pyelogram were normal . We diagnosed bilateral testicular tumors and performed bilateral radical orchiectomy and inguinal and para-aortic retroperitoneal lymphadenectomy on July 2, 1982 . The right testicular mass measured 8 x 6 .5 x 2 .5 cm and weighed 218 g . Its incision surface was partially covered with cartilage-like tissue, and the central part was filled with white beancurd-like material . The left testis measured 5 .5 x 3 x 3 cm and weighed 47 g, being mostly replaced by elastic hard grayish white tumor tissue except for the normal testicular tissue remaining at the surface . The right testicle was diagnosed as cystic teratoma because cystic lesions of various sizes were covered with cornified squamous epithelium without any malignant change (Fig . 1A). The left testis, however, showed tumor cells containing hypertrophic nucleus and nucleolus and inclusion bodies, and the aggregation of those cells characteristic of seminoma (Fig . 1B) . Lymph node metastasis or spermatic cord invasion was not observed . Postoperative cobalt-60 irradiation on the left inguinoiliac and para-aortic areas below

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Section from (A) right testis showing cystic teratoma lesions of various sizes covered by cornified squamous epithelium without any malignant change. (B) Section from left testis showing seminoma cells containing hypertrophic nucleus and nucleolus and inclusion bodies, and characteristic aggregation of those cells . FIGURE 1 .

the level of the diaphragm was given up to a total of 5,200 rad . To date (15 months' postoperatively) there has been no sign of metastasis, and the patient has been regularly observed in follow-up examinations . Comment Hamilton and Girbert 2 reported 144 bilateral tumors in 7,000 subjects with testicular tumors (2%) and Collins and Pugh' and Sokal, Peckham, and Hendry' reported 25 cases of 930 (2.7 %) and 21 of 760 cases (2 .8 %), respectively. In Japan the incidence of bilateral testicular tumor ranges between 1 and 4 per cent . However, bilateral testicular tumors of different cell types on each side are less common and so far only 44 cases have been identified . Moreover, synchronous cases are extremely uncommon and, besides our patient only 6 others have been found .' 6 Although we have no clear interpreta-

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tion of this phenomenon at present, 5 of these cases contained either bilateral or unilateral seminoma . The tumor probably has totipotentiality that covers the various histopathology of testicular tumors. Aristizabal et al .s reported that the average interval between the first and second tumors of 63 cases with metachronous bilateral testicular tumors was five years . A total of 54 per cent of the second tumors appeared within five years of the diagnosis of the first, and by ten years, 75 per cent of the second growths had been diagnosed . There is the possibility that one of the bilateral lesions may have preceded the other. In the case of unilateral tumors, it is possible that, because they are too small to notice by palpation, one of these bilaterally present tumors may be undetected . Berthelsen et al . 9 reported that carcinoma in situ of germ cells was present in the contralateral testis in 8 per cent of

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men operated on for clinically unilateral testicular germ cell tumors . Therefore, we would like to emphasize the proposal of Yoshida et aP that the term "synchronous tumors" should be changed to "simultaneously detected bilateral tumors ." Pathogenesis of the bilateral testicular tumor has not been clarified but, generally, there are two questions as to whether or not common oncogenesis is present in both testes or contralateral metastasis follows . It is believed, in general, that in bilateral tumors of testis of the so-called monodermal or tridermal types (Friedman-Moore classification), 10 the tumor formation usually appears in one testis rather than in the other, whereas in bilateral lymphomatous tumors, tumor formation appears simultaneously. In the majority of cases of bilateral tumors, it appears successively or independently . Dodson and Hooper 1l reported that half of the bilateral synchronous tumors were lymphomas . Hotchkiss and Laury 12 claimed that bilateral testicular lymphomas are not primary lesions, based on their histologic examinations, indicating an infilteration rather than invasion process associated with primary tumors . According to Aristizabal et al.,' primary lymphoma of the testis rarely exists, because the normal testis lacks lymphatic tissues . Bilateral testicular germ cell tumors of identical tissue type showed a slight predominance of asynchronous development . The tumor's metastasis to other systems has been seldom reported . The absence of lymphatic vascular connection between two testes due to the presence of scrotal septum has

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been proved .e Moreover, no case of bilateral choriocarcinoma has been reported in Japan, although it is associated with extensive distal metastasis . All these findings strongly suggest that each lesion of bilateral testicular germ cell tumors of identical tissue type is developed independently as a primary tumor . 6-11-1, Omori-Nishi Ota-ku, Tokyo 143, Japan (DR . MATSUSHIMA) References 1 . Livingstone J : A case of cancer of both testicles terminated favourably by the supervention of surgery, Edinburgh Med Surg 1 : 163 (1805) . 2 . Hamilton JB, and Girbert JB : Studies in malignant tumors of the testis ; bilateral testicular cancer. Incidence, nature and bearing upon management of patient with single testicular cancer, Cancer Res 2 : 125 (1942) . 3 . Collins DH, and Pugh RCB : CLssffication and frequency of testicular tumors, Br J Urol 36 : Suppl : 1 (1964) . 4. Sokal M, Peckham MJ, and Hendry WF : Bilateral germ cell tumors of the testis, ibid 52 : 158 (1980) . 5 . Kawabe K, et at : Synchronous germ cell tumors of the bilateral testis ; report of a case and a review of the Japanese literature, Jpn J Clin Oncol 11 : 507 (1981) . 6. Maruoka M, et at : Bilateral successive germ cell testicular tumor of different cell types, Jpn J Clin Urol 36 : 685 (1982) . 7. Yoshida M, et al: Five cases of bilateral testicular tumors ; a review of 118 cases in Japanese literature, ibid 72 : 460 (1982) . 8 . Aristizabal S, et al : Bilateral primary germ cell testicular tumors, report of four cases and review of the literature, Cancer 42 : 591 (1978) . 9 . Berthelsen JG, Skakkeback NE, Mogensen P, and Sorensen BL : Incidence of carcinoma in situ of germ cells in contralateral testis of men with testicular tumors, Br Med J 11 : 363 (1979) . 10 . Friedman NB, and Moore RA : Tumors of the testis- Milit Surg 79 : 573 (1946) . 11 . Dodson AT, and Hooper JW : Bilateral concomitant seminoma, J Urol 72 : 424 (1954) . 12 . Hotchkiss RS, and Laury RB : Concomitant bilateral malignant testicular tumors, ibid 63 : 1086 (1950) .

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