Outcomes in Patients with Testicular Maldescent and Germ Cell Neoplasia: A Retrospective Assessment and Review of the Literature

Introduction Cryptorchidism is not an uncommon problem in young males, yet the ideal management of the undescended testes (UDT) is not clear-cut. Multiple issues influence the patient-physician decision process regarding treatment including fertility, hormone-production, cosmesis and the risk of testicular germ cell tumors (TGCT's). Methods A retrospective review of 2204 men presenting to Indiana University Medical Center or Baylor College of Medicine affiliated hospitals with TGCT during a 20 year period was conducted, and individuals with a history of UDT were identified. Clinical outcomes of the 94 men with UDT and TGCT who did, and did not, undergo orchidopexy were compared. Statistical analysis included chi-square, Fischer’s exact test and confidence intervals. Results Of the 94 patients identified with UDT and TGCT, 87 had a complete evaluable dataset. Fifty-two patients out of the 87 had tumors ipsilateral to the UDT (in the previously undescended testicle). Forty-nine of the 52 patients with UDT (94%) were corrected by orchidopexy at ages ranging from one to twentysix. Of the 49 orchidopexies in the ipsilateral tumor group, 48 (98%) were successful and 1 failed. Two patients had spontaneous testicular descent and 2 patients had descent with hormonal therapy. Ten patients had no treatment. The average interval from the time of UDT diagnosis and the development of GCT ipsilateral to the previously UDT was 18 years. Twenty-four patients had tumors contralateral to the UDT. 54.1%(13/24) with tumors developing in the contralateral testes had successful orchidopexy at an average age of 7 years. Of the remaining 11 of 24, four patients had contralateral orchiectomy at the time of treatment of the UDT. Exploration was conducted and no tissue identified in 3. Two patients had spontaneous descent. Two patients had no treatment. The average time interval from diagnosis of UDT to the diagnosis of GCT was 22 years. A much greater percentage of patients developed tumors in the previously undescended testicle if the orchidopexy was performed after the age of 10 years. Performing orchidopexy prior to the age of 5 years, however, did not protect the testes from the development of cancer. There is no statistical difference between the groups with ipsilateral and contralateral tumors with respect to age at tumor presentation or the time interval from orchidopexy to tumor diagnosis. Sixty-three percent of patients with tumors developing in untreated testes or testes suffering from failed orchidopexies, presented with advanced disease (B3 or C), compared with 43% of patients with treated UDT’s and 34% of patients with tumors developing in descended testes contralateral to UDT’s, an odds ratio of 2.39, but not statistically significant. The mortality for patients who had untreated or failed orchidopexies, 27%(3/11) was 4.5 times higher than those with successful orchidopexies 8% (4/52), p=0.06 at 95% confidence limit, or 3.3 times higher than for patients with normally descended testes. Conclusion Germ cell tumors occurred on average 7-10 years earlier in patients with UDT ipsilateral to the side of TGCT than in those where GCT developed in the contralateral normally descended testes. Orchidopexy did not confer protection to testes in the development of TGCTs, however, there was a nonsignificant delay in the time to onset of tumor and the percentage of the advance stage at presentation compared to untreated testes or normally descended testes. In this series, early orchidopexy was associated with 4.5 less likelihood of dying from GCT compared with non-treated testes, a difference which approached, but did not reach, statistical significance.