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The clinical picture and management of testicular tumours
Clin. Radiol. (1973) 24, 385-391
THE
CLINICAL PICTURE TESTICULAR
AND MANAGEMENT TUMOURS*
OF
IRENE CADE
From the Department of Radiotherapy, St. Mary's Hospital, Portsmouth
The literature on testicular tumours is reviewed and a historical survey of the development of their current management is presented. A series of 93 patients treated in Portsmouth is described. It is concluded that a survival rate of over 70 % can be obtained for seminoma and 52 ~ for teratoma. Recurrences are rare after 5 years, so that 5-year survivals can be accepted as an indication of the long term results.
factor in testicular tumours, although heredity, trauma, maldescent and teratoma have been postulated as causes. In the Testicular Panel series (Collins and Pugh, 1964) a family history of testicular neoplasia was found in 5 patients, 0.5 % of the total. There seems little evidence in this or other series for a hereditary factor. A history of injury can frequently be obtained but is usually ill-defined and doubtful: it probably only serves to draw attention to a pre-existing tumour. The Testicular Panel found a history of injury, for what it is worth, in 8 % of seminomas and 11% of teratomas. A tumour may develop in a maldescended or undescended testis giving rise to a bizarre presentation and possible difficulty in diagnosis unless the significance of the empty scrotum is appreciated. In 1,115 cases, the Testicular Panel found 47 with a history of unilateral, and 11 of bilateral maldescent. 5 9 ~ of turnouts occurring in the undescended testicle were seminoma as compared with 40 % of all testicular tumours. Teratoma was of equal frequency - 31% as compared with 32 %. In 9 of their patients with unilateral undescended testes the tumour arose in the opposite, scrotal, testis, suggesting a hormonal influence rather than a local effect. Teratoma has been put forward as an aetiological factor in the development of seminoma. According to the Testicular Panel seminomata have developed in 30 % of patients with teratomas to form combined tumours. The seminoma very rarely occurs AETIOLOGY in the opposite testis, so that a local rather than There is little evidence of any known aetiological a hormonal effect must be assumed, possibly *Paper read at a Faculty Postgraduate meeting on 20th pressure of the teratomatous mass or diffusion of November, 1971. • some carcinogenic factor. 385 INCIDENCE Testicular tumours are rare i n the United Kingdom. The annual new registration of all types is about 2 to 3 per 100,000 males, that is, about 550 to 600 new cases will occur annually. In 1940 Gilbert and Hamilton estimated that testicular tumours accounted for 1.5 to 2 % of all malignant tumours in the male. More recently St. Bartholomew's Hospital, over the ten year period 1948:57, found the incidence to be 1% of male malignant disease. Racial Incidence.--Not much information is available regarding the racial incidence of testicular turnouts. Dixon and Moore in 1952 found that only 1-5% of germinal tumours of the testis occurred in non-white members of the U.S. Armed Forces, who accounted for 6 to 8.5 % of the total population at risk. Davies in 1951 found that testicular tumours were distinctly uncommon in the Johannesburg and Kampala areas though they were possibly more frequent in parts of West Africa, Age Incidence.--The peak incidence of teratoma is between 21 and 30 years: the tumour may occur in childhood. (Extremes of age in our Portsmouth series were 2 years and 48 years). Seminoma on the other hand has not been recorded in children. The maximum incidence is a decade later than teratoma and the growth may occur in the very elderly. Prossor quoted a seminoma at 80 years in the Westminister series.
386
CLINICAL
LYMPHATIC DRAINAGE Jamieson and Dobson published their classic description of the lymphatic drainage of the testis in 1910. Whilst there is some drainage to the common iliac nodes, the main drainage is direct to the para-aortic region. Here there is a vast lymphatic network with free communication between the two sides. From here the thoracic duct ascends to the left supraclavicular fossa. There is no direct drainage from the testis to the inguinal region, and, provided the tunica albuginea remains intact, spread to the scrotal tissues is unlikely. If this spread does occur, then inguinal lymph nodes are likely to be involved.
CLASSIFICATION Coats in 1895 referred to seminoma as "a proper cancer of the testis" and stated that the cancerous tissue arose from the epithelium of the seminal tubules. Confusion arose from Ewing's interpretation of the seminoma as a one-sided development of a teratoma and his concept of embryonal carcinoma. His views were opposed by Chevassu (1906), who strongly supported the theory of origin from seminiferous epithelium, and gave the tumour the name "seminome" which has since been accepted. The classification of the Armed Forces Institute of Pathology published by Dixon and Moore in 1952 was widely adopted in English speaking countries, and is still used in many centres. In 1964 Collins and Pugh published the classification agreed by the Testicular Tumour Panel and Registry. They claimed that this widened the gap between seminoma and teratoma, and simplified the nomenclature of the subgroups of teratoma. Seminoma is described as a malignant tumour considered to arise from the germinal or seminiferous epithelium of the mature or maturing testis. Teratomas are tumours of uncertain histogenesis, which arise in the testis, and display an array of tissue structures which are foreign to the normal organ. Teratomas show a greater or lesser degree of cell differentiation, and this, as well as the frequent tendency to "organoid" arrangements of ceils and tissues, is a useful means of subdividing them. The combined tumour is a malignant tumour which is a combination of seminoma and teratoma. The tumour contains distinct areas of each type of tissue.
RADIOLOGY
Seminoma and teratoma are distinguished by differences in gross and microscopic structure, in age incidence, clinical course and in response to radiotherapy. They are therefore classified under two quite distinct headings. This third and separate category of combined tumour is provided for those cases where both types of neoplasm arise in the same organ. The peak age incidence of patients with combined tumours falls between the peaks for seminoma and teratoma. Their prognosis is also intermediate, being better than in teratoma and worse than in seminoma. The Testicular Panel does not consider it established that teratomas are of "germ-cell" origin and they have rejected Ewing's theory that seminoma is a one-sided development of a teratoma. According to Willis the frequent simultaneous appearance of the two turnouts in one testis cannot be fortuitous but it does not necessarily speak for a common histogenesis. The histogenesis of seminoma is traced to the spermatic epithelium of the differentiated seminiferous tubule while that ofteratoma remains an open question. The group of rare testicular turnouts includes the following :1. The Sertoli-cell tumour which is related to the non-spermatic sustentacular cells of the tubules and which may be associated with endocrine effects. 2. The interstitial cell tumour, formed of structurally recognisable Leydig cells which may or may not be functionally active. 3. The orchioblastoma, a distinctive type of adenocarcinoma arising in the testes of infants and very young children. 4. Malignant lymphoma, embracing all histological forms of malignant lymphoid tumours. In the Testicular Panel Series 40 % of the tumours were seminomas and 32% teratomas. Combined tumours accounted for 14%. The remaining 1 4 ~ were composed of the rare varieties. Of the teratomas the most frequent were the M.T.I.A. and B, and these also accounted for the teratomatous element in most of the combined turnouts. PATHOLOGY The characteristic macroscopic and histological feature of the seminoma is its homogeneity and the uniformity of its component cells. The cells are rounded and arranged in extensive sheets or solid columns. In contrast the essential feature of the teratoma is its heterogeneity. In spite of this
THE C L I N I C A L P I C T U R E AND M A N A G E M E N T OF T E S T I C U L A R T U M O U R S TABLE 1 TESTICULAR TUMOUR PANEL CLASSIFICATION
TABLE 5 SEMINOMA CAUSEOF DEATH -- PORTSMOUTH1948--65 TOTAL NUMBER TREATED: 250 KV -- 29 (2O60 -- 24 -
Seminoma- S Teratoma - Teratoma Differentiated (T.D.) Malignant Teratoma Intermediate (M.T.I.) subdivided into :M.T.I.A. - with differentiated or organoid components M.T,I.B. - no differentiated or organoid elements apparent. Malignant Teratoma Anaplastic (M.T.A.) Malignant Teratoma Trophoblastie (M.T.T.) Combined Tumour - Seminoma and Teratoma co-existing in the same testis. Sertoli Cell Tumour Interstitial Cell Tumour Orchioblastoma Malignant lymphoma.
-
Under 5 years
Over 5 years
250Kv Co60 1948-59 1960-65
250Kv Co60 1948-59 1960-65
Metastases Othercauses No recurrence LosttoF.U. whileA&W
2
2
0
0
0
3
7
0
1
2
2
0
TABLE 6 TERATOMA TESTIS PORTSMOUTH 1948-65 5--YEAR SURVIVAL -
TABLE 2 TESTICULAR TUMOURS. PORTSMOUTH. 1948-65. INCIDENCE OF METASTASES AT FIRST PRESENTATION Site o f metastases Total Number
With Metastases
Lymph node
Pulmonary
Seminoma
53
7=13~
7=13~
0
Teratoma
40
17=42%
14=35~
-
All cases No metastases at first diagnosis Metastases at first diagnosis
250 Kv 1948-59
Co60 1960-65
3/15=20%
13/25--52%
2/6=33 %
11/17=65%
1/9=11%
2/8 = 2 5 %
TABLE 7 TERATOMA CAUSEOF DEATH -- PORTSMOUTH1948-65 TOTAL NUMBER TREATED 250Kv--15 COBALT 60=25 -
-
1
8--20~ Under 5 years
TABLE 3 TESTICULAR TUMOURS PORTSMOUTH 1948--65 COMPLICATIONSOF RADIOTHERAPY -
Total treated Radiation nephritis Perforated D.U. Ideopathic steatorrhoea Paraplegia
25o
1948-59
Over 5 years
250 Kv
Cobalt 60
44 2 0 1 0
49 0 1 0 0
250 Kv 1948-59
Cobalt 60 1960-65
26/29 = 90 %
17/24=71 ~o
24/27-- 89 %
14/19=74%
2/2-- 100 %
3/5 = 60
I
co6o 25o---Z1 co6--TIr
1960-65
1948-59
1960-65 / /
-
TABLE 4 SEMINOMATESTISPORTSMOUTH1948-65 5-YEAR SURVIVAL
Allcases No metastases at first diagnosis Metastases atfirst diagnosis
387
Metastases Other causes Lost to F.U.
ioo
t h e h i s t o l o g i c a l a p p e a r a n c e s c a n b e u s e d as a b a s i s f o r classification. In the Testicular Panel classification, with the exception of the trophoblastic tumour, each m a l i g n a n t t e r a t o m a is classified i n t o t h e m o s t highly differentiated category present. The "teratoma differentiated" appears to comprise o n l y fully d i f f e r e n t i a t e d tissues s u c h as c a r t i l a g e , bone, muscle or epithelium. No histologically m a l i g n a n t e l e m e n t s c a n b e f o u n d , w h i c h is t h e o n l y d i s t i n c t i o n f r o m M . T . I . A . I n s p i t e o f t h i s it is never justifiable to assume that a differentiated t u m o u r will b e h a v e as a b e n i g n one. M . T . I . is i n t e r m e d i a t e i n t y p e b e t w e e n t h e differentiated and anaplastic. It contains inc o m p l e t e l y d i f f e r e n t i a t e d tissues a n d e l e m e n t s
388
CLINICAL
having the histological characteristics of malignancy. In type A. some mature tissue or organoid structure is recognised while in type B. none can be identified. Tissues derived from any or all of the germ layers may be present. M.T.A. is characterised by sheets of pleomorphic wholly undifferentiated cells. M.T.T. shows the general type of M.T.I. or M.T.A. but is distinguished by true trophoblastic elements, namely, a syncytial cell mass, and a malignant type of cytotrophoblast, disposed in a papillary or villous manner. Even when the histological criteria are found in only a small part of the turnout the diagnosis must be made, but the criteria must be rigidly applied because of the very poor prognosis.
CLINICAL P R E S E N T A T I O N The common clinical presentation is a painless swelling of one testicle in an otherwise fit young or middle-aged man. In the Portsmouth series of 93 patients seen between 1948 and 1965, pain was present in 21% of seminomas and 35 % of teratomas. A history of trauma when present is usually vague and ill-defined but occasionally, severe trauma, with laceration of the testis, causing acute pain and swelling may be the presenting episode. The possibility of trauma complicating a preexisting tumour should be borne in mind and delay in orchidectomy avoided. Fever is occasionally present and may be a factor-leading to the misdiagnosis of epididymo-orchitis. The more anaplastic teratomas are particularly likely to present as a sudden acute painful swelling. The incidence of metastases detectable at the time of presentation is shown in Table 2. Occasionally the primary tumour may remain small and symptomless while the patient presents with symptoms due to para-aortic node involvement. 13 % of the patients with seminoma had lymph node metastases when first seen; none had blood borne dissemination. 42% of the patients with teratoma had disseminated; lymph nodes were involved in 14 and pulmonary metastases were present in 8. The incidence of metastases is higher in the more anaplastic tumours but patients with "teratoma differentiated" may present with a para-aortic node mass. Blood borne metastases are most frequent in the lungs, where they usually take the form of multiple cannon-ball type deposits. They may also occur in other viscera, skeleton or brain, and in the more highly malignant types may rapidly become widespread throughout the body. In these cases death
RADIOLOGY
may occur within months or even weeks of the onset. MANAGEMENT Hinman (1933) obtained a 6.6 % 5-year survival in testicular tumours from simple orchidectomy. He subsequently improved this to 17 % by undertaking radical orchidectomy. Randall and Bothe (1937) tried radiation alone, with a 29% 5-year survival. Further improvement in results was obtained by reversion to simple orchidectomy combined with post-operative irradiation of the abdominal nodes. Desjardins (1935) obtained 48 %, Cabot and Berkson (1939), 71% and Ahlbom (1947), 50%. None of these authors gave a clear indication of the percentage of different types of tumour. Gordon Taylor (1947) quoted a 52.5% 5-year survival for seminoma and 18% for teratoma. It soon became accepted that simple orchidectomy and radiotherapy was the optimum treatment for seminoma, but teratoma was considered radioresistant. It was felt in some centres, particularly in the United States, even in recent years, that there was a place for the radical operation in these more resistant tumours. This procedure did not regain popularity in this country, chiefly because it was felt that it was not surgically feasible to remove the vast lymphatic network which may be involved. In addition, over recent years, it has become increasingly apparent that the so-called radio-resistance of the teratomatous series is relative rather than absolute. In 1964 Prossor clearly demonstrated an improvement in results with the higher doses of irradiation possible with megavoltage radiotherapy. His 5-year survival increased from 53"7~o in cases without obvious metastases, treated with 250 Kv, to 76-1% in similar cases treated with 2MeV radiation. The latter figure approaches the results achieved in seminoma and has not been surpassed. In this country therefore the standard treatment for all types of testicular tumour is simple orchidectomy followed by megavoltage radiotherapy. Stephen (1962) stressed the dangers, not only of biopsy, but also of aspiration of any co-existing hydrocele. The tunica albuginea provides a tough resistant membrane through which spread is unlikely while it remains intact. Transgression of this membrane by an aspiration needle, or worse still by a biopsy, leads to early scrotal recurrence and fungation, with spread to inguinal and femoral nodes. He considered all testicular tumours should be regarded as semi-emergencies, and advocated
THE
CLINICAL
PICTURE
AND MANAGEMENT
simple orchidectomy through an inguinal incision, with ligation of the cord at the internal ring, with minimal delay. There was a place for hemiscrotectomy in those patients in whom aspiration or biopsy had previously been carried out. INVESTIGATION A chest X-ray is essential in all cases, and lymphography should be carried out as a routine: this may show the presence and extent of any lymph node metastases but its main value is in planning radiotherapy. A further possible use is provided by the fact that the dye persists in the nodes for a variable time. It may therefore be possible from subsequent straight films to assess response or recurrence and rate of growth. RADIOTHERAPY T E C H N I Q U E Our Portsmouth patients were treated with 250 Kv up to 1959, since when Cobalt 60 irradiation using two parallel opposed para-aortic and homolateral iliac fields has been employed. Since the advent of lymphography these fields have been planned to include all demonstrable nodes and to spare the major part of both kidneys. Check films are taken with the fields outlined with wire markers, and a simultaneous intravenous pyelogram. The dosage given to the megavoltage patients up to 1965, who are included in this analysis was 6,000r in 8 weeks central depth dose for teratoma and 4,500r central depth dose in 6 weeks for seminoma. We now feel that these doses are excessive and are currently giving 4,500r in 8 weeks for teratoma and 3,500r in 6 weeks for seminoma. The main hazards of radiotherapy for testieular tumours arise from excessive dosage to the kidneys and spinal cord. Kunkler (1952) stated that a dose of 2,300r given to the whole of both kidneys was liable to cause hypertension and renal failure. The risk of renal damage could best be minimised by ensuring that about a third of the volume of the kidneys is outside the fields, or at least is irradiated to as low a dose as is practicable. Pallis in 1961 stated that the safety limits of dose to the spinal cord should not exceed 3,300 rads for 10 cm. fields and 4,300 rads for smaller fields in 42 days. These figures are 20 ~ lower than those quoted by Boden (1948). The cord dose is now calculated in all our cases and with our current dosage is usually of the order of 3,600r in 6 weeks for seminoma and 4,600r in 8 weeks for teratoma. Complications and Side-etfects.--Side-effects during treatment have included occasional neutropenia, rarely requiring suspension of treatment,
OF T E S T I C U L A R
TUMOURS
389
and, when severe, responding to Prednisone 5 mgm. t.d.s. Nausea is usually easily controlled by Torecan or Maxolon. In an occasional patient persistent vomiting is troublesome and makes it difficult to complete treatment. Erythema of the skin is sometimes apparent towards completion of the higher doses. Late Complications.--In those patients receiving 6,000r megavoltage radiotherapy through two opposed fields subcutaneous leathering occurring a year to eighteen months later is an occasional feature. It rarely causes any symptoms. Apart from this our late complication rate has been low, and is shown in Table 3. Of the total 93 patients, two in the 250Kv series subsequently developed radiation nephritis with malignant hypertension and renal failure. The doses to the kidneys were 2,950r and 2,350r in 9 weeks for a tumour dose of 3,650r and cord dose of 4,400r. The time interval in these two patients was six years and nine years, which is of interest in view of Klunkler's statement that the latent interval is usually 6 to 12 months. None of the Cobalt patients, in whom the kidneys have been avoided, have developed this complication. Lewis (1948) quoted 3 paraplegias and 14 perforations, 8 fatal, in a series of 250 patients treated to a dose of 5,000r. We have fortunately had no instance of paraplegia to date. We have had one fatal perforated duodenal ulcer after a dose of 3,750r, but are not convinced that this was due to radiation. One patient developed idiopathic steatorrhoea 4 years after 250 Kv radiation to a dose of 3,600r, but remains alive and well 21 years later and it is doubtful whether the steatorrhoea was associated with the irradiation.
RESULTS The five year survival in the seminoma series is shown in Table 4. Table 5 shows the cause of death in these patients and illustrates the greater loss from other causes under five years in the cobalt series. No patient has died of the disease at over five years suggesting that five year figures probably indicate the long-term results. In the teratoma series there were only 40 patients, 15 treated with 250Kv and 25 with cobalt. The results are shown in Tables 6 and 7. In these there did not appear to be any artificial loading, in that all deaths were due to metastases, and no patients were lost to follow-up, up to five years. Thus the improvement from 2 0 ~ survival with 250Kv to 52 ~ of all cases with cobalt would appear to be real. 65 % of those cobalt cases who were apparently
390
CLINICAL RADIOLOGY
free from metastases a t time of treatment lived 5 years. Only one patient with a teratoma has died o f his disease after 5 years although one other has recurred at 6 years. Of the three five-year survivors o f the 250Kv series, two are alive and well at 8 and 14 years, M.T.I.B. and M.T.I.A. respectively. The third patient had a combined t u m o u r S q- M.T.I.A. He developed pulmonary metastases at 6 years for which a left p n e u m o n e c t o m y was carried out. The metastases were shown to be seminomatous 0nly. He remained clinically free o f further recurrence until his death from suicide at 8 years. N o post-mortem report is available. O f the 13 cobalt survivors, 11 are alive and well at f r o m 5 to 11 years; one died o f disseminated sclerosis at 10 years without evidence o f recurrence; one died of retro-peritoneal recurrence and vertebral metastases at 10 years. As far as can be said from this small series, in teratoma as well as seminoma, recurrence, although it has occurred in 2 o f the 40 patients, is unlikely after 5 years. MANAGEMENT OF DISSEMINATED CASES The radiosensitivity o f seminoma is so high that long term survival can still be obtained even after metastases have occurred in the para-aortic and iliac nodes. Multiple p u l m o n a r y metastases are more ominous, but m u c h can still be achieved. With teratoma the prognosis is very m u c h worsened by metastases even if only to the para-aortic nodes. Involvement of para-aortic and iliac nodes at the outset does not alter the management since these nodes are treated in all cases, although fields m a y have to be modified. The treatment o f pulmonary metastases however depends on the histology and whether they are single or multiple. I n semino-
matous metastases, it is well worth while giving 2,000r to the whole chest, and with a solitary deposit raising the dose to this area by a further 1,000r. N e w t o n (1960) considered that a total dose o f 2,500r to the whole chest should not be exceeded, nor a daily dose o f 150r. With teratoma on the other hand the presence o f widespread p u l m o n a r y or other metastases indicates that the disease is uncontrollable and it is doubtful whether it is justifiable to irradiate the whole chest, particularly in the absence o f symptoms. Control is unlikely, and symptoms m a y result from the irradiation, in addition to the anxiety caused by the disclosure of the presence o f metastases. Treatment should therefore be reserved for palliation. In the presence of a solitary radioresistant metastasis, particularly after an interval since the primary treatment, there is a place for surgery such as lobectomy. Chemotherapy.--When radiotherapy has failed or is no longer feasible for widespread disease the question o f chemotherapy should be considered. We believe it is always w o r t h attempting in patients with seminoma, in w h o m long-term control m a y be achieved. With teratoma results have been very disappointing, so m u c h so that in the absence o f symptoms we do not consider the risk of sideeffects to be justified. W h e n symptoms arise an attempt at palliation m a y reasonably be made. CONCLUSION The testicular tumours provide a group of diseases o f considerable interest. They occur in y o u n g men, show a wide variability in behaviour, but adequate treatment is capable o f yielding a high percentage o f long survivors. Acknowledgement. The author is grateful to Dr. J. B. McEweu for permission to quote his patients.
REFERENCES AHLBOM, H. (1947). Malignant Tumours of the Testis. Treatment at Radiumhemmet, Stockholm, Acta Radiologica, Stockholm, 28, 669-680. BODEN, G. (1948). Radiation Myelitis in the Cervical Spinal Cord. British Journal of Radiology, 21, 464-469. CABOT, H. & BI~RKSON,J. (1939). Neoplasm of the Testis. New England Journal of Medicine, 220, 192-195. CHEVASSU,M. (1906). Tumeurs du Testicle. Published by G, Steinhill, Paris. p. 17. COATS, J. (1895). A Manual of Pathology. 3rd Edition, published by Longmans, Green & Co. London p. 1,047. COLLINS,D. H. & PUGH,R. C. B. (1964). The Pathology of Testieular Tum0urs. British Journal of Urology. Supplement to Vol. 36. DAVIES,J. N. P. (1959). Modern Trends in Pathology. Ed. D. H. Collins, published by Butterworth & Co. Ltd., London. p. 132.
DESJARDINS,A. U. & COUNSELLER,V. S. (1935). Results of Treatment in Tumours of the Testis. American Journal of Surgery, 27, 71-78. DIXON, F. J. & MOORE,R. A. (1952). Tumours of the Male Sex Organs. Atlas o f Tumour Pathology, VIII. 31b & 32 Published by Armed Forces Institute of Pathology. p, 48 EWtNG, J. (1942). Neoplastic Diseases. 4th Edition. Published by W. B. Saunders, Philadelphia and London. p. 854 GmB~RT, J. B. & HAMmTON,J. B. (1940). Studies in Malignant Testis Tumours, Part III. Incidence and Nature of Tumours in Ectopie Testis. S.G.O., 71, 731-743. GORDON-TAYLOR, G. & WYNDHAM, N. R. (1947). On Malignant Turnouts of the Testicle. British Journal of Surgery, 35, 6-17. HrNMAN,F. (1933). Tumours of the Testis. Surgery, Gynaeeology and Obstetrics, 56, 450-461. H~NMAN,F. & POWEL, T. O. (1938). The Management of
THE C L I N I C A L P I C T U R E AND M A N A G E M E N T OF T E S T I C U L A R TUMOURS Tumours of the Testicle.
Journal o.f American Medical
Association, 110,1, 188-190. JAMrESON, J. K. & DOaSON, J. F. (1910). The Lymphatics of the Testicle. Lancet, I, 493-495. KUNKLER, P. B., FARR, R. F. & LUXTON, R. W. (1952). The Limit of Renal Tolerance to X-rays. British Journal of Radiology, 25, 190-201. L~wIs, L. G. (1948). Radical Orchidectomy for Tumours of the Testis. Journal of American Medical Association, 137, 828-832. LEWIS, L. G. (1953). Radio-resistant Testis Turnouts. Results in 133 Cases. Five Year Follow-up. Journal of Urology, 69, 841-844.
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NEWTON, K. A. (1960). Total Thoracic Irradiation combined with Injection of Autogenous Marrow. Clinical Radiology, 11, 14-21. PALLIS, C. A-, Lores, S. & MORGAN, R. L. (1961). Radiation Myelopathy. Brain, 84, 460-479. PROSSOR, T. M. (1964). Turnouts of the Testis. Journal of the Royal College of Surgeons, Edinburgh, 9, 85-106. RANDALL, A. & BOTrrE, A. E. (1937). The Value of Preoperative Irradiation in Tumours of the Testis. Annals of Surgery, 105, 385-391. STEPHEN, R. A. (1962). The Clinical Presentation of Testicular Turnouts. British Journal of Urology, 34, 448-450.
BOOK REVIEWS Clinical Dynamic Function Studies with Radionuclides. Edited by CROLL. Published by Appleton-Century-Crofts 17 Church Street, Enfield, Middlesex. Price £8.65.
This book is the account of the contributions to a symposium aimed to bring together prominent investigators covering the recent advance in dynamic function studies, instrumentation, and radiopharmaceuticals in dynamic flow studies. The 44 contributors were from the Continent of North America and from Japan, many of t h e m outstanding figures in the establishment and development of radionuclides in medicine. The interest of the subject matter is enhanced by its topicality which has also determined the scope of the symposium and the content of the book. It is divided into seven sections. Four of these each deal with a region of the body, one with instrumentation, the sixth discusses four special topics, and the seventh merely presents a summary of the status of dynamic studies. The section on instrumentation emphasises the importance of using equipment of the best quality available. In discussing some of the applications of a computer link, it gives credence to the authors' prediction that the use of computers interfaced to static imaging devices will be the next logical development in manipulating the data available. The obvious question of justifying the need for such an expensive item is answered to some extent by some of the later papers, particularly in the section on cerebral studies. The paper on models for simulation of dynamic studies will be of considerable interest for those conducting research in this field. The extent to which the topics reflect prevailing interests is illustrated well by the renal and pulmonary sections on the one hand, and by the cardio-vascular and cerebral sections on the other. The renal section contains but one paper, a masterly review of the current situation. The pulmonary section contains two papers and some of the material barely justifies being regarded as "dynamic". However, both these papers make important points, particularly about misleading lung scans in the diagnosis of pulmonary embohis, and the way in which inhalation studies can help to improve the accuracy of interpretation. The most striking feature of the cardio-vascular section is the remarkable improvement that new techniques have brought about in the quality of
the serial images of the heart and great vessels. Although the definition does not match that of radio-opaque contrast agents, the simplicity of the method and the elegance of its application is likely to find some place in the increasing field of cardio-vascular radiology. The authors' main claim for the technique is as a screening procedure. This is a modest claim and is more than justified in their account. The cerebral section is the largest in the book mad covers many facets of the field. One of the more stimulating accounts is that of the value of perfusion and static studies in the study of various cerebral diseases. It emphasises again the amount of information that is not utilised in static studies, but which can be obtained with sophisticated equipment without any additional discomfort to the patient. In any symposium, the discussion between the participants is often stimulating, and usually helps to put the formal papers into perspctive, particularly when they concern new ideas and progress reports. It is unlikely that this symposium was an exception, and the one real disappointment is that the editors have not been able to find more space to cover the discussion that took place between the protagonists. The style of the book is remarkably constant, despite the number of contributors, and it is highly readable. The quality of the illustrations is good, though the contrast on the radiographs is generally, perhaps inevitably, less good than that on the scintigrams and scintiphotos. Anyone who is interested in dynamic studies with radionuclides will find a great deal to interest and stimulate him in this slim volume, though at £8.65 some individuals will be priced out of owning their own copy. The text summarises the status of dynamic studies by saying that they promise better and more meaningful information to the clinician. The inclusion of more clinicians among the participants might arguably have given these techniques an even firmer foundation. There is a hint in the preface that the patience of the editors was taxed and they are to be congratulated for their persistence in producing these proceedings. However, it does seem a pity, in this advanced era, that the proceedings of a symposium on developing techniques in an advancing field should take just over two years to appear in print. E. RHYS-DAVIES.
THE
CLINICAL PICTURE TESTICULAR
AND MANAGEMENT TUMOURS*
OF
IRENE CADE
From the Department of Radiotherapy, St. Mary's Hospital, Portsmouth
The literature on testicular tumours is reviewed and a historical survey of the development of their current management is presented. A series of 93 patients treated in Portsmouth is described. It is concluded that a survival rate of over 70 % can be obtained for seminoma and 52 ~ for teratoma. Recurrences are rare after 5 years, so that 5-year survivals can be accepted as an indication of the long term results.
factor in testicular tumours, although heredity, trauma, maldescent and teratoma have been postulated as causes. In the Testicular Panel series (Collins and Pugh, 1964) a family history of testicular neoplasia was found in 5 patients, 0.5 % of the total. There seems little evidence in this or other series for a hereditary factor. A history of injury can frequently be obtained but is usually ill-defined and doubtful: it probably only serves to draw attention to a pre-existing tumour. The Testicular Panel found a history of injury, for what it is worth, in 8 % of seminomas and 11% of teratomas. A tumour may develop in a maldescended or undescended testis giving rise to a bizarre presentation and possible difficulty in diagnosis unless the significance of the empty scrotum is appreciated. In 1,115 cases, the Testicular Panel found 47 with a history of unilateral, and 11 of bilateral maldescent. 5 9 ~ of turnouts occurring in the undescended testicle were seminoma as compared with 40 % of all testicular tumours. Teratoma was of equal frequency - 31% as compared with 32 %. In 9 of their patients with unilateral undescended testes the tumour arose in the opposite, scrotal, testis, suggesting a hormonal influence rather than a local effect. Teratoma has been put forward as an aetiological factor in the development of seminoma. According to the Testicular Panel seminomata have developed in 30 % of patients with teratomas to form combined tumours. The seminoma very rarely occurs AETIOLOGY in the opposite testis, so that a local rather than There is little evidence of any known aetiological a hormonal effect must be assumed, possibly *Paper read at a Faculty Postgraduate meeting on 20th pressure of the teratomatous mass or diffusion of November, 1971. • some carcinogenic factor. 385 INCIDENCE Testicular tumours are rare i n the United Kingdom. The annual new registration of all types is about 2 to 3 per 100,000 males, that is, about 550 to 600 new cases will occur annually. In 1940 Gilbert and Hamilton estimated that testicular tumours accounted for 1.5 to 2 % of all malignant tumours in the male. More recently St. Bartholomew's Hospital, over the ten year period 1948:57, found the incidence to be 1% of male malignant disease. Racial Incidence.--Not much information is available regarding the racial incidence of testicular turnouts. Dixon and Moore in 1952 found that only 1-5% of germinal tumours of the testis occurred in non-white members of the U.S. Armed Forces, who accounted for 6 to 8.5 % of the total population at risk. Davies in 1951 found that testicular tumours were distinctly uncommon in the Johannesburg and Kampala areas though they were possibly more frequent in parts of West Africa, Age Incidence.--The peak incidence of teratoma is between 21 and 30 years: the tumour may occur in childhood. (Extremes of age in our Portsmouth series were 2 years and 48 years). Seminoma on the other hand has not been recorded in children. The maximum incidence is a decade later than teratoma and the growth may occur in the very elderly. Prossor quoted a seminoma at 80 years in the Westminister series.
386
CLINICAL
LYMPHATIC DRAINAGE Jamieson and Dobson published their classic description of the lymphatic drainage of the testis in 1910. Whilst there is some drainage to the common iliac nodes, the main drainage is direct to the para-aortic region. Here there is a vast lymphatic network with free communication between the two sides. From here the thoracic duct ascends to the left supraclavicular fossa. There is no direct drainage from the testis to the inguinal region, and, provided the tunica albuginea remains intact, spread to the scrotal tissues is unlikely. If this spread does occur, then inguinal lymph nodes are likely to be involved.
CLASSIFICATION Coats in 1895 referred to seminoma as "a proper cancer of the testis" and stated that the cancerous tissue arose from the epithelium of the seminal tubules. Confusion arose from Ewing's interpretation of the seminoma as a one-sided development of a teratoma and his concept of embryonal carcinoma. His views were opposed by Chevassu (1906), who strongly supported the theory of origin from seminiferous epithelium, and gave the tumour the name "seminome" which has since been accepted. The classification of the Armed Forces Institute of Pathology published by Dixon and Moore in 1952 was widely adopted in English speaking countries, and is still used in many centres. In 1964 Collins and Pugh published the classification agreed by the Testicular Tumour Panel and Registry. They claimed that this widened the gap between seminoma and teratoma, and simplified the nomenclature of the subgroups of teratoma. Seminoma is described as a malignant tumour considered to arise from the germinal or seminiferous epithelium of the mature or maturing testis. Teratomas are tumours of uncertain histogenesis, which arise in the testis, and display an array of tissue structures which are foreign to the normal organ. Teratomas show a greater or lesser degree of cell differentiation, and this, as well as the frequent tendency to "organoid" arrangements of ceils and tissues, is a useful means of subdividing them. The combined tumour is a malignant tumour which is a combination of seminoma and teratoma. The tumour contains distinct areas of each type of tissue.
RADIOLOGY
Seminoma and teratoma are distinguished by differences in gross and microscopic structure, in age incidence, clinical course and in response to radiotherapy. They are therefore classified under two quite distinct headings. This third and separate category of combined tumour is provided for those cases where both types of neoplasm arise in the same organ. The peak age incidence of patients with combined tumours falls between the peaks for seminoma and teratoma. Their prognosis is also intermediate, being better than in teratoma and worse than in seminoma. The Testicular Panel does not consider it established that teratomas are of "germ-cell" origin and they have rejected Ewing's theory that seminoma is a one-sided development of a teratoma. According to Willis the frequent simultaneous appearance of the two turnouts in one testis cannot be fortuitous but it does not necessarily speak for a common histogenesis. The histogenesis of seminoma is traced to the spermatic epithelium of the differentiated seminiferous tubule while that ofteratoma remains an open question. The group of rare testicular turnouts includes the following :1. The Sertoli-cell tumour which is related to the non-spermatic sustentacular cells of the tubules and which may be associated with endocrine effects. 2. The interstitial cell tumour, formed of structurally recognisable Leydig cells which may or may not be functionally active. 3. The orchioblastoma, a distinctive type of adenocarcinoma arising in the testes of infants and very young children. 4. Malignant lymphoma, embracing all histological forms of malignant lymphoid tumours. In the Testicular Panel Series 40 % of the tumours were seminomas and 32% teratomas. Combined tumours accounted for 14%. The remaining 1 4 ~ were composed of the rare varieties. Of the teratomas the most frequent were the M.T.I.A. and B, and these also accounted for the teratomatous element in most of the combined turnouts. PATHOLOGY The characteristic macroscopic and histological feature of the seminoma is its homogeneity and the uniformity of its component cells. The cells are rounded and arranged in extensive sheets or solid columns. In contrast the essential feature of the teratoma is its heterogeneity. In spite of this
THE C L I N I C A L P I C T U R E AND M A N A G E M E N T OF T E S T I C U L A R T U M O U R S TABLE 1 TESTICULAR TUMOUR PANEL CLASSIFICATION
TABLE 5 SEMINOMA CAUSEOF DEATH -- PORTSMOUTH1948--65 TOTAL NUMBER TREATED: 250 KV -- 29 (2O60 -- 24 -
Seminoma- S Teratoma - Teratoma Differentiated (T.D.) Malignant Teratoma Intermediate (M.T.I.) subdivided into :M.T.I.A. - with differentiated or organoid components M.T,I.B. - no differentiated or organoid elements apparent. Malignant Teratoma Anaplastic (M.T.A.) Malignant Teratoma Trophoblastie (M.T.T.) Combined Tumour - Seminoma and Teratoma co-existing in the same testis. Sertoli Cell Tumour Interstitial Cell Tumour Orchioblastoma Malignant lymphoma.
-
Under 5 years
Over 5 years
250Kv Co60 1948-59 1960-65
250Kv Co60 1948-59 1960-65
Metastases Othercauses No recurrence LosttoF.U. whileA&W
2
2
0
0
0
3
7
0
1
2
2
0
TABLE 6 TERATOMA TESTIS PORTSMOUTH 1948-65 5--YEAR SURVIVAL -
TABLE 2 TESTICULAR TUMOURS. PORTSMOUTH. 1948-65. INCIDENCE OF METASTASES AT FIRST PRESENTATION Site o f metastases Total Number
With Metastases
Lymph node
Pulmonary
Seminoma
53
7=13~
7=13~
0
Teratoma
40
17=42%
14=35~
-
All cases No metastases at first diagnosis Metastases at first diagnosis
250 Kv 1948-59
Co60 1960-65
3/15=20%
13/25--52%
2/6=33 %
11/17=65%
1/9=11%
2/8 = 2 5 %
TABLE 7 TERATOMA CAUSEOF DEATH -- PORTSMOUTH1948-65 TOTAL NUMBER TREATED 250Kv--15 COBALT 60=25 -
-
1
8--20~ Under 5 years
TABLE 3 TESTICULAR TUMOURS PORTSMOUTH 1948--65 COMPLICATIONSOF RADIOTHERAPY -
Total treated Radiation nephritis Perforated D.U. Ideopathic steatorrhoea Paraplegia
25o
1948-59
Over 5 years
250 Kv
Cobalt 60
44 2 0 1 0
49 0 1 0 0
250 Kv 1948-59
Cobalt 60 1960-65
26/29 = 90 %
17/24=71 ~o
24/27-- 89 %
14/19=74%
2/2-- 100 %
3/5 = 60
I
co6o 25o---Z1 co6--TIr
1960-65
1948-59
1960-65 / /
-
TABLE 4 SEMINOMATESTISPORTSMOUTH1948-65 5-YEAR SURVIVAL
Allcases No metastases at first diagnosis Metastases atfirst diagnosis
387
Metastases Other causes Lost to F.U.
ioo
t h e h i s t o l o g i c a l a p p e a r a n c e s c a n b e u s e d as a b a s i s f o r classification. In the Testicular Panel classification, with the exception of the trophoblastic tumour, each m a l i g n a n t t e r a t o m a is classified i n t o t h e m o s t highly differentiated category present. The "teratoma differentiated" appears to comprise o n l y fully d i f f e r e n t i a t e d tissues s u c h as c a r t i l a g e , bone, muscle or epithelium. No histologically m a l i g n a n t e l e m e n t s c a n b e f o u n d , w h i c h is t h e o n l y d i s t i n c t i o n f r o m M . T . I . A . I n s p i t e o f t h i s it is never justifiable to assume that a differentiated t u m o u r will b e h a v e as a b e n i g n one. M . T . I . is i n t e r m e d i a t e i n t y p e b e t w e e n t h e differentiated and anaplastic. It contains inc o m p l e t e l y d i f f e r e n t i a t e d tissues a n d e l e m e n t s
388
CLINICAL
having the histological characteristics of malignancy. In type A. some mature tissue or organoid structure is recognised while in type B. none can be identified. Tissues derived from any or all of the germ layers may be present. M.T.A. is characterised by sheets of pleomorphic wholly undifferentiated cells. M.T.T. shows the general type of M.T.I. or M.T.A. but is distinguished by true trophoblastic elements, namely, a syncytial cell mass, and a malignant type of cytotrophoblast, disposed in a papillary or villous manner. Even when the histological criteria are found in only a small part of the turnout the diagnosis must be made, but the criteria must be rigidly applied because of the very poor prognosis.
CLINICAL P R E S E N T A T I O N The common clinical presentation is a painless swelling of one testicle in an otherwise fit young or middle-aged man. In the Portsmouth series of 93 patients seen between 1948 and 1965, pain was present in 21% of seminomas and 35 % of teratomas. A history of trauma when present is usually vague and ill-defined but occasionally, severe trauma, with laceration of the testis, causing acute pain and swelling may be the presenting episode. The possibility of trauma complicating a preexisting tumour should be borne in mind and delay in orchidectomy avoided. Fever is occasionally present and may be a factor-leading to the misdiagnosis of epididymo-orchitis. The more anaplastic teratomas are particularly likely to present as a sudden acute painful swelling. The incidence of metastases detectable at the time of presentation is shown in Table 2. Occasionally the primary tumour may remain small and symptomless while the patient presents with symptoms due to para-aortic node involvement. 13 % of the patients with seminoma had lymph node metastases when first seen; none had blood borne dissemination. 42% of the patients with teratoma had disseminated; lymph nodes were involved in 14 and pulmonary metastases were present in 8. The incidence of metastases is higher in the more anaplastic tumours but patients with "teratoma differentiated" may present with a para-aortic node mass. Blood borne metastases are most frequent in the lungs, where they usually take the form of multiple cannon-ball type deposits. They may also occur in other viscera, skeleton or brain, and in the more highly malignant types may rapidly become widespread throughout the body. In these cases death
RADIOLOGY
may occur within months or even weeks of the onset. MANAGEMENT Hinman (1933) obtained a 6.6 % 5-year survival in testicular tumours from simple orchidectomy. He subsequently improved this to 17 % by undertaking radical orchidectomy. Randall and Bothe (1937) tried radiation alone, with a 29% 5-year survival. Further improvement in results was obtained by reversion to simple orchidectomy combined with post-operative irradiation of the abdominal nodes. Desjardins (1935) obtained 48 %, Cabot and Berkson (1939), 71% and Ahlbom (1947), 50%. None of these authors gave a clear indication of the percentage of different types of tumour. Gordon Taylor (1947) quoted a 52.5% 5-year survival for seminoma and 18% for teratoma. It soon became accepted that simple orchidectomy and radiotherapy was the optimum treatment for seminoma, but teratoma was considered radioresistant. It was felt in some centres, particularly in the United States, even in recent years, that there was a place for the radical operation in these more resistant tumours. This procedure did not regain popularity in this country, chiefly because it was felt that it was not surgically feasible to remove the vast lymphatic network which may be involved. In addition, over recent years, it has become increasingly apparent that the so-called radio-resistance of the teratomatous series is relative rather than absolute. In 1964 Prossor clearly demonstrated an improvement in results with the higher doses of irradiation possible with megavoltage radiotherapy. His 5-year survival increased from 53"7~o in cases without obvious metastases, treated with 250 Kv, to 76-1% in similar cases treated with 2MeV radiation. The latter figure approaches the results achieved in seminoma and has not been surpassed. In this country therefore the standard treatment for all types of testicular tumour is simple orchidectomy followed by megavoltage radiotherapy. Stephen (1962) stressed the dangers, not only of biopsy, but also of aspiration of any co-existing hydrocele. The tunica albuginea provides a tough resistant membrane through which spread is unlikely while it remains intact. Transgression of this membrane by an aspiration needle, or worse still by a biopsy, leads to early scrotal recurrence and fungation, with spread to inguinal and femoral nodes. He considered all testicular tumours should be regarded as semi-emergencies, and advocated
THE
CLINICAL
PICTURE
AND MANAGEMENT
simple orchidectomy through an inguinal incision, with ligation of the cord at the internal ring, with minimal delay. There was a place for hemiscrotectomy in those patients in whom aspiration or biopsy had previously been carried out. INVESTIGATION A chest X-ray is essential in all cases, and lymphography should be carried out as a routine: this may show the presence and extent of any lymph node metastases but its main value is in planning radiotherapy. A further possible use is provided by the fact that the dye persists in the nodes for a variable time. It may therefore be possible from subsequent straight films to assess response or recurrence and rate of growth. RADIOTHERAPY T E C H N I Q U E Our Portsmouth patients were treated with 250 Kv up to 1959, since when Cobalt 60 irradiation using two parallel opposed para-aortic and homolateral iliac fields has been employed. Since the advent of lymphography these fields have been planned to include all demonstrable nodes and to spare the major part of both kidneys. Check films are taken with the fields outlined with wire markers, and a simultaneous intravenous pyelogram. The dosage given to the megavoltage patients up to 1965, who are included in this analysis was 6,000r in 8 weeks central depth dose for teratoma and 4,500r central depth dose in 6 weeks for seminoma. We now feel that these doses are excessive and are currently giving 4,500r in 8 weeks for teratoma and 3,500r in 6 weeks for seminoma. The main hazards of radiotherapy for testieular tumours arise from excessive dosage to the kidneys and spinal cord. Kunkler (1952) stated that a dose of 2,300r given to the whole of both kidneys was liable to cause hypertension and renal failure. The risk of renal damage could best be minimised by ensuring that about a third of the volume of the kidneys is outside the fields, or at least is irradiated to as low a dose as is practicable. Pallis in 1961 stated that the safety limits of dose to the spinal cord should not exceed 3,300 rads for 10 cm. fields and 4,300 rads for smaller fields in 42 days. These figures are 20 ~ lower than those quoted by Boden (1948). The cord dose is now calculated in all our cases and with our current dosage is usually of the order of 3,600r in 6 weeks for seminoma and 4,600r in 8 weeks for teratoma. Complications and Side-etfects.--Side-effects during treatment have included occasional neutropenia, rarely requiring suspension of treatment,
OF T E S T I C U L A R
TUMOURS
389
and, when severe, responding to Prednisone 5 mgm. t.d.s. Nausea is usually easily controlled by Torecan or Maxolon. In an occasional patient persistent vomiting is troublesome and makes it difficult to complete treatment. Erythema of the skin is sometimes apparent towards completion of the higher doses. Late Complications.--In those patients receiving 6,000r megavoltage radiotherapy through two opposed fields subcutaneous leathering occurring a year to eighteen months later is an occasional feature. It rarely causes any symptoms. Apart from this our late complication rate has been low, and is shown in Table 3. Of the total 93 patients, two in the 250Kv series subsequently developed radiation nephritis with malignant hypertension and renal failure. The doses to the kidneys were 2,950r and 2,350r in 9 weeks for a tumour dose of 3,650r and cord dose of 4,400r. The time interval in these two patients was six years and nine years, which is of interest in view of Klunkler's statement that the latent interval is usually 6 to 12 months. None of the Cobalt patients, in whom the kidneys have been avoided, have developed this complication. Lewis (1948) quoted 3 paraplegias and 14 perforations, 8 fatal, in a series of 250 patients treated to a dose of 5,000r. We have fortunately had no instance of paraplegia to date. We have had one fatal perforated duodenal ulcer after a dose of 3,750r, but are not convinced that this was due to radiation. One patient developed idiopathic steatorrhoea 4 years after 250 Kv radiation to a dose of 3,600r, but remains alive and well 21 years later and it is doubtful whether the steatorrhoea was associated with the irradiation.
RESULTS The five year survival in the seminoma series is shown in Table 4. Table 5 shows the cause of death in these patients and illustrates the greater loss from other causes under five years in the cobalt series. No patient has died of the disease at over five years suggesting that five year figures probably indicate the long-term results. In the teratoma series there were only 40 patients, 15 treated with 250Kv and 25 with cobalt. The results are shown in Tables 6 and 7. In these there did not appear to be any artificial loading, in that all deaths were due to metastases, and no patients were lost to follow-up, up to five years. Thus the improvement from 2 0 ~ survival with 250Kv to 52 ~ of all cases with cobalt would appear to be real. 65 % of those cobalt cases who were apparently
390
CLINICAL RADIOLOGY
free from metastases a t time of treatment lived 5 years. Only one patient with a teratoma has died o f his disease after 5 years although one other has recurred at 6 years. Of the three five-year survivors o f the 250Kv series, two are alive and well at 8 and 14 years, M.T.I.B. and M.T.I.A. respectively. The third patient had a combined t u m o u r S q- M.T.I.A. He developed pulmonary metastases at 6 years for which a left p n e u m o n e c t o m y was carried out. The metastases were shown to be seminomatous 0nly. He remained clinically free o f further recurrence until his death from suicide at 8 years. N o post-mortem report is available. O f the 13 cobalt survivors, 11 are alive and well at f r o m 5 to 11 years; one died o f disseminated sclerosis at 10 years without evidence o f recurrence; one died of retro-peritoneal recurrence and vertebral metastases at 10 years. As far as can be said from this small series, in teratoma as well as seminoma, recurrence, although it has occurred in 2 o f the 40 patients, is unlikely after 5 years. MANAGEMENT OF DISSEMINATED CASES The radiosensitivity o f seminoma is so high that long term survival can still be obtained even after metastases have occurred in the para-aortic and iliac nodes. Multiple p u l m o n a r y metastases are more ominous, but m u c h can still be achieved. With teratoma the prognosis is very m u c h worsened by metastases even if only to the para-aortic nodes. Involvement of para-aortic and iliac nodes at the outset does not alter the management since these nodes are treated in all cases, although fields m a y have to be modified. The treatment o f pulmonary metastases however depends on the histology and whether they are single or multiple. I n semino-
matous metastases, it is well worth while giving 2,000r to the whole chest, and with a solitary deposit raising the dose to this area by a further 1,000r. N e w t o n (1960) considered that a total dose o f 2,500r to the whole chest should not be exceeded, nor a daily dose o f 150r. With teratoma on the other hand the presence o f widespread p u l m o n a r y or other metastases indicates that the disease is uncontrollable and it is doubtful whether it is justifiable to irradiate the whole chest, particularly in the absence o f symptoms. Control is unlikely, and symptoms m a y result from the irradiation, in addition to the anxiety caused by the disclosure of the presence o f metastases. Treatment should therefore be reserved for palliation. In the presence of a solitary radioresistant metastasis, particularly after an interval since the primary treatment, there is a place for surgery such as lobectomy. Chemotherapy.--When radiotherapy has failed or is no longer feasible for widespread disease the question o f chemotherapy should be considered. We believe it is always w o r t h attempting in patients with seminoma, in w h o m long-term control m a y be achieved. With teratoma results have been very disappointing, so m u c h so that in the absence o f symptoms we do not consider the risk of sideeffects to be justified. W h e n symptoms arise an attempt at palliation m a y reasonably be made. CONCLUSION The testicular tumours provide a group of diseases o f considerable interest. They occur in y o u n g men, show a wide variability in behaviour, but adequate treatment is capable o f yielding a high percentage o f long survivors. Acknowledgement. The author is grateful to Dr. J. B. McEweu for permission to quote his patients.
REFERENCES AHLBOM, H. (1947). Malignant Tumours of the Testis. Treatment at Radiumhemmet, Stockholm, Acta Radiologica, Stockholm, 28, 669-680. BODEN, G. (1948). Radiation Myelitis in the Cervical Spinal Cord. British Journal of Radiology, 21, 464-469. CABOT, H. & BI~RKSON,J. (1939). Neoplasm of the Testis. New England Journal of Medicine, 220, 192-195. CHEVASSU,M. (1906). Tumeurs du Testicle. Published by G, Steinhill, Paris. p. 17. COATS, J. (1895). A Manual of Pathology. 3rd Edition, published by Longmans, Green & Co. London p. 1,047. COLLINS,D. H. & PUGH,R. C. B. (1964). The Pathology of Testieular Tum0urs. British Journal of Urology. Supplement to Vol. 36. DAVIES,J. N. P. (1959). Modern Trends in Pathology. Ed. D. H. Collins, published by Butterworth & Co. Ltd., London. p. 132.
DESJARDINS,A. U. & COUNSELLER,V. S. (1935). Results of Treatment in Tumours of the Testis. American Journal of Surgery, 27, 71-78. DIXON, F. J. & MOORE,R. A. (1952). Tumours of the Male Sex Organs. Atlas o f Tumour Pathology, VIII. 31b & 32 Published by Armed Forces Institute of Pathology. p, 48 EWtNG, J. (1942). Neoplastic Diseases. 4th Edition. Published by W. B. Saunders, Philadelphia and London. p. 854 GmB~RT, J. B. & HAMmTON,J. B. (1940). Studies in Malignant Testis Tumours, Part III. Incidence and Nature of Tumours in Ectopie Testis. S.G.O., 71, 731-743. GORDON-TAYLOR, G. & WYNDHAM, N. R. (1947). On Malignant Turnouts of the Testicle. British Journal of Surgery, 35, 6-17. HrNMAN,F. (1933). Tumours of the Testis. Surgery, Gynaeeology and Obstetrics, 56, 450-461. H~NMAN,F. & POWEL, T. O. (1938). The Management of
THE C L I N I C A L P I C T U R E AND M A N A G E M E N T OF T E S T I C U L A R TUMOURS Tumours of the Testicle.
Journal o.f American Medical
Association, 110,1, 188-190. JAMrESON, J. K. & DOaSON, J. F. (1910). The Lymphatics of the Testicle. Lancet, I, 493-495. KUNKLER, P. B., FARR, R. F. & LUXTON, R. W. (1952). The Limit of Renal Tolerance to X-rays. British Journal of Radiology, 25, 190-201. L~wIs, L. G. (1948). Radical Orchidectomy for Tumours of the Testis. Journal of American Medical Association, 137, 828-832. LEWIS, L. G. (1953). Radio-resistant Testis Turnouts. Results in 133 Cases. Five Year Follow-up. Journal of Urology, 69, 841-844.
391
NEWTON, K. A. (1960). Total Thoracic Irradiation combined with Injection of Autogenous Marrow. Clinical Radiology, 11, 14-21. PALLIS, C. A-, Lores, S. & MORGAN, R. L. (1961). Radiation Myelopathy. Brain, 84, 460-479. PROSSOR, T. M. (1964). Turnouts of the Testis. Journal of the Royal College of Surgeons, Edinburgh, 9, 85-106. RANDALL, A. & BOTrrE, A. E. (1937). The Value of Preoperative Irradiation in Tumours of the Testis. Annals of Surgery, 105, 385-391. STEPHEN, R. A. (1962). The Clinical Presentation of Testicular Turnouts. British Journal of Urology, 34, 448-450.
BOOK REVIEWS Clinical Dynamic Function Studies with Radionuclides. Edited by CROLL. Published by Appleton-Century-Crofts 17 Church Street, Enfield, Middlesex. Price £8.65.
This book is the account of the contributions to a symposium aimed to bring together prominent investigators covering the recent advance in dynamic function studies, instrumentation, and radiopharmaceuticals in dynamic flow studies. The 44 contributors were from the Continent of North America and from Japan, many of t h e m outstanding figures in the establishment and development of radionuclides in medicine. The interest of the subject matter is enhanced by its topicality which has also determined the scope of the symposium and the content of the book. It is divided into seven sections. Four of these each deal with a region of the body, one with instrumentation, the sixth discusses four special topics, and the seventh merely presents a summary of the status of dynamic studies. The section on instrumentation emphasises the importance of using equipment of the best quality available. In discussing some of the applications of a computer link, it gives credence to the authors' prediction that the use of computers interfaced to static imaging devices will be the next logical development in manipulating the data available. The obvious question of justifying the need for such an expensive item is answered to some extent by some of the later papers, particularly in the section on cerebral studies. The paper on models for simulation of dynamic studies will be of considerable interest for those conducting research in this field. The extent to which the topics reflect prevailing interests is illustrated well by the renal and pulmonary sections on the one hand, and by the cardio-vascular and cerebral sections on the other. The renal section contains but one paper, a masterly review of the current situation. The pulmonary section contains two papers and some of the material barely justifies being regarded as "dynamic". However, both these papers make important points, particularly about misleading lung scans in the diagnosis of pulmonary embohis, and the way in which inhalation studies can help to improve the accuracy of interpretation. The most striking feature of the cardio-vascular section is the remarkable improvement that new techniques have brought about in the quality of
the serial images of the heart and great vessels. Although the definition does not match that of radio-opaque contrast agents, the simplicity of the method and the elegance of its application is likely to find some place in the increasing field of cardio-vascular radiology. The authors' main claim for the technique is as a screening procedure. This is a modest claim and is more than justified in their account. The cerebral section is the largest in the book mad covers many facets of the field. One of the more stimulating accounts is that of the value of perfusion and static studies in the study of various cerebral diseases. It emphasises again the amount of information that is not utilised in static studies, but which can be obtained with sophisticated equipment without any additional discomfort to the patient. In any symposium, the discussion between the participants is often stimulating, and usually helps to put the formal papers into perspctive, particularly when they concern new ideas and progress reports. It is unlikely that this symposium was an exception, and the one real disappointment is that the editors have not been able to find more space to cover the discussion that took place between the protagonists. The style of the book is remarkably constant, despite the number of contributors, and it is highly readable. The quality of the illustrations is good, though the contrast on the radiographs is generally, perhaps inevitably, less good than that on the scintigrams and scintiphotos. Anyone who is interested in dynamic studies with radionuclides will find a great deal to interest and stimulate him in this slim volume, though at £8.65 some individuals will be priced out of owning their own copy. The text summarises the status of dynamic studies by saying that they promise better and more meaningful information to the clinician. The inclusion of more clinicians among the participants might arguably have given these techniques an even firmer foundation. There is a hint in the preface that the patience of the editors was taxed and they are to be congratulated for their persistence in producing these proceedings. However, it does seem a pity, in this advanced era, that the proceedings of a symposium on developing techniques in an advancing field should take just over two years to appear in print. E. RHYS-DAVIES.