Onco-testicular sperm extraction (onco-TESE) for bilateral testicular tumors: two case reports

A 38-year-old unmarried Asian-Japanese man with bilateral testicular tumors was referred to our hospital to undergo sperm preservation. His right testis was swollen to the size of a chicken’s egg; his left testis was normally sized but had a nodule. He had no particular medical history. A laboratory examination showed almost normal results (including lactate dehydrogenase [LDH] and α-fetoprotein [AFP]), with the exception of the human chorionic gonadotropin (HCG) level, which was elevated (25.8 mIU/ml). The patient’s serum testosterone level was within the normal range. An ultrasonographic examination showed a low echoic lesion on the whole right testis and partially on the left testis at the same location as the palpable nodule (Fig. 1a and b). Computed tomography (CT) showed no distant metastasis or lymph node swelling. On the basis of these findings, bilateral testicular tumors (cTxN0M0) were diagnosed, and bilateral orchiectomy was planned. In a sperm examination performed 1 day before surgery, no sperm were detected in 8.2 ml of semen. Owing to the patient’s azoospermia, we planned to perform onco-TESE from his normal left testicular tumor at the time of bilateral orchiectomy. Because the tumorous lesion was easily detected macroscopically, we could retrieve the sperm of his normal left testicular tumor soon after resection. Approximately 1000 sperm were counted and then frozen. The pathological diagnosis was seminoma (pT1N0M0). Most of the right testis was occupied by the tumor. Microscopically, the testicular parenchyma adjacent to the tumor was atrophic, with shrunken seminiferous tubules having thickened basement membranes and diminished numbers of germ cells, a so-called Sertoli cell-only appearance or completely hyalinized. Collections of hyperplastic Leydig cells were also seen. The patient’s mean Johnsen score was 1.40 (Figs. 2a and 3a). In the left testis, the parenchyma adjacent to the tumor was also atrophic and showed an almost Sertoli cell-only appearance, but it contained a few seminiferous tubules with sperm (mean Johnsen score 4.38) (Figs. 2b and 3b). The patient’s HCG level was normal after surgery, and he has received testosterone supplementation since surgery. He did not receive adjuvant chemotherapy and has had no recurrence in the 0.5 years since surgery.

A 35-year-old married Asian-Japanese man was referred to our hospital with bilateral swelling of the scrotum. He had no particular medical history. A blood analysis revealed elevated tumor marker levels (LDH 314 IU/L, HCG 27.4 mIU/ml). The patient’s AFP level and other laboratory data were within the normal limits. CT showed no distant or lymph node metastasis. On the basis of these findings, the patient was preoperatively diagnosed with a bilateral testicular tumor (cTxN0M0). One day prior to bilateral orchiectomy, a semen test was performed, but no sperm were identified (semen volume 1.8 ml). We planned to perform onco-TESE at the time of surgery because the patient wanted to preserve his sperm. Grossly, a white multinodular tumor occupied the patient’s entire left testis, whereas the tumor of the right testis left a compressed area of uninvolved parenchyma (Fig. 4). After the resection of both testes, we examined the normal part of the right testis microscopically, but no sperm were detected. The pathological diagnosis was seminoma (pT1N0M0). Microscopically, the uninvolved parenchyma of the right testis showed atrophy. In some areas without gross abnormality, tumor cells invaded between preserved seminiferous tubules. Spermatocytes were noted in preserved seminiferous tubules, but spermatogenesis was arrested. The patient’s mean Johnsen score was 2.40. The patient’s elevated LDH and HCG levels decreased to a normal level after surgery, and no adjuvant therapy was administered. He received testosterone supplementation after surgery and has shown no recurrence in the 2.5 years since surgery.