Cryptorchidism and Testicular Cancer: Separating Fact From Fiction
Hadley M. Wood and Jack S. Elder*
From the Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, and Vattikuti Urology Institute, Henry Ford Hospital and Children’s Hospital of Michigan, Detroit (JSE), Michigan
Abbreviations and Acronyms ASA American Society of Anesthesiologists ITGCNintratubular germ cell neoplasia UDT undescended testis
Submitted for publication July 5, 2008. * Correspondence: Vattikuti Urology Institute, Henry Ford Hospital, 2799 West Grand Blvd., K-9, Detroit, Michigan 48202 (telephone: 313-9162626; FAX: 313-916-2956; e-mail: jelder1@hfhs. org).
Purpose: We dissected prevailing assumptions about cryptorchidism and reviewed data that support andreject these assumptions. Materials and Methods: Five questions about cryptorchidism and the risk of testicular cancer were identiﬁed because of their implications in parent counseling and clinical management. Standard search techniques through MEDLINE® were used to identify all relevant English language studies of the questions being examined. Each of the 5 questions was then examined in light of theexisting data. Results: The RR of testicular cancer in a cryptorchidism case is 2.75 to 8. A RR of between 2 and 3 has been noted in patients who undergo orchiopexy by ages 10 to 12 years. Patients who undergo orchiopexy after age 12 years or no orchiopexy are 2 to 6 times as likely to have testicular cancer as those who undergo prepubertal orchiopexy. A contralateral, normally descended testisin a patient with cryptorchidism carries no increased risk of testis cancer. Persistently cryptorchid (inguinal and abdominal) testes are at higher risk for seminoma (74%), while corrected cryptorchid or scrotal testicles that undergo malignant transformation are most likely to become nonseminomatous (63%, p 0.0001), presumably because of a decreased risk of seminoma. Conclusions: Orchiectomy maybe considered in healthy patients with cryptorchidism who are between ages 12 and 50 years. Observation should be recommended in postpubertal males at signiﬁcant anesthetic risk and all males older than 50 years. While 5% to 15% of scrotal testicular remnants contain germinal tissue, only 1 case of carcinoma in situ has been reported, suggesting that the risk of malignancy in these remnants isextremely low. Key Words: testis, testicular neoplasms, cryptorchidism, abnormalities, risk CRYPTORCHIDISM, also known as UDT, is the most common congenital abnormality of the genitourinary tract. Being so, it has earned a good deal of interest by urologists in general and pediatric urologists in particular. Curiously however, cryptorchidism, its causes and its potential associated testicular cancerrisk have historically been poorly understood and documented, resulting in a number of misconceptions that have been passed
0022-5347/09/1812-0452/0 THE JOURNAL OF UROLOGY® Copyright © 2009 by AMERICAN UROLOGICAL ASSOCIATION
down through generations of urologists. A major problem with characterizing risk between cryptorchidism and testis cancer relates to diagnosing and documentingcryptorchidism. Retrospective analyses, which represent most data upon which conclusions can be drawn, may include men with retractile testes, men with a history of spontaneous descent during infancy or at puberty, men who unVol. 181, 452-461, February 2009 Printed in U.S.A. DOI:10.1016/j.juro.2008.10.074
CRYPTORCHIDISM AND TESTICULAR CANCER
derwent treatment withhormonal stimulation and men with persistent UDT after previous orchiopexy. While estimates of the incidence of cryptorchidism based on pediatrician examination and birth records are 1% to 2% at age 12 months, various groups have suggested that the rate of surgery for cryptorchidism is approximately double the estimated risk (3% to 4%), suggesting that the risk of UDT may vary during childhood...