Treatment

Treatment for ITGCN can significantly affect a patient's quality of life and further alter reproductive and endocrine functions. Therapeutic options for ITGCN of the contralateral testicle include orchiectomy, radiation, chemotherapy, and observation. However, before treatment for any TGCT or ITGCN is begun, sperm cryopres-ervation should be discussed with the patient. Treatment depends on a combination of factors such as age, testicular size, fertility, unilateral or bilateral cancer, and patient/physician philosophy. Orchiectomy, the most invasive treatment, is curative, but will leave the patient infertile and dependent on exogenous testosterone. Additionally, the emotional stress of castration can be difficult for any male to handle. Partial orchiec-tomy has been reported as an option for patients with a solitary testicle who develop a well-de marcated TGCT [39,40]. The goal of partial orchi-ectomy is to preserve endocrine function and fertility. However, in most cases, ITGCN is diffusely spread throughout the nontumorous portion of the testicle and can eventually develop into another TGCT. Partial orchiectomy for TGCT is currently not considered standard of care and should be performed only in highly selected situations.

ITGCN is radiosensitive and is an excellent treatment option for a positive biopsy. In the past, 20 Gy was the dose given, but up to 25% of men had compromised testosterone synthesis and needed supplementation [41]. Lower dose (14 Gy) treatments have been shown to eradicate ITGCN with preservation of Leydig cell function. Follow-up biopsy usually reveals a Sertoli cell only pattern, but Leydig cell function seems to be preserved, although some recent data suggest that with long-term follow-up, many men will ultimately require androgen replacement [42]. A positive biopsy should not automatically lead to radiating the remaining testicle, especially in patients who might already be at risk for decreased testosterone levels (atrophic testes). The German Testicular Cancer Study Group has advocated drawing pretreatment luteinizing hormone (LH) and testosterone levels in patients with atrophic testes as well as recommending observation as methods to prevent compromised endocrine function following radiation therapy [40].

Cisplatin-based chemotherapy has been shown to be effective against ITGCN but the response can be somewhat variable. While many people have no evidence of ITGCN on follow-up biopsy, the cumulative risk of developing ITGCN in 10 years is as high as 42% [43]. Cisplatin chemotherapy is not a recommended treatment for patients with contralateral ITGCN unless it will be used for treatment of the primary tumor.

Observation is the option that is recommended for men who are not considered high risk and who will be compliant with scheduled follow-up. While this entails regular physician visits and routine testicular ultrasounds, it does not place the patient at further risk from another procedure and does not change endocrine or exocrine function of the remaining testicle. Changes found on self examination or on follow-up ultrasound (mass, microcalcifications) should be biopsied.

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