key: cord-0741805-h21kuwxe
authors: Almassi, Nima; Mulhall, John P.; Funt, Samuel A.; Sheinfeld, Joel
title: Case of the Month from Memorial Sloan Kettering Cancer Center, New York: Managing newly‐diagnosed metastatic testicular germ cell tumor in a COVID‐19 positive patient
date: 2020-07-01
journal: BJU Int
DOI: 10.1111/bju.15157
sha: f5c24969248c11ac80b61194a0671e2415d8f535
doc_id: 741805
cord_uid: h21kuwxe

A 17‐year‐old young man with history of a congenital solitary left testis presented to our clinic in late April 2020 with left testicular swelling and discomfort over the preceding few weeks. The patient denied unintentional weight loss or nipple tenderness but reported new, mild left‐sided back discomfort. His medical history was notable for asthma and a congenitally absent right testis for which he underwent negative surgical exploration in childhood.

Article Category: Urological Oncology

A 17-year-old young man with history of a congenital solitary left testis presented to our clinic in late April 2020 with left testicular swelling and discomfort over the preceding few weeks.

The patient denied unintentional weight loss or nipple tenderness but reported new, mild left-sided back discomfort. His medical history was notable for asthma and a congenitally absent right testis for which he underwent negative surgical exploration in childhood. Family history was negative for testicular cancer or cryptorchidism. Given the ongoing COVID-19 pandemic, which at the time of his initial presentation yielded over 2500 new cases and 300 deaths per day in New York City alone, the initial consultation was conducted by telemedicine and physical examination was not performed. A scrotal ultrasound was obtained, demonstrating a 4. Beginning in early April, our institution mandated preoperative COVID-19 screening for all patients within 48 hours of surgery, with non-emergent cases for patients testing positive deferred for 21 days from an asymptomatic positive test or resolution of symptoms. This policy was enacted to minimize risk of disease transmission to hospital and surgical personnel and to minimize the risk of perioperative morbidity, which was believed to be significantly elevated in COVID-19 positive patients based on multiple surgical series (1,2). In this case, the patient underwent preoperative

This article is protected by copyright. All rights reserved screening and although asymptomatic, tested COVID-19 positive on polymerase chain reaction of a nasopharyngeal specimen resulting in surgical cancellation.

Although asymptomatic, the patient's positive preoperative COVID-19 screening test presented a management dilemma with implications for surgical safety, systemic treatment burden, and future fertility. An early surgical series from Wuhan, China observed a high incidence of morbidity and mortality in 34 asymptomatic COVID-19 positive patients undergoing elective surgery, with 44% of patients requiring intensive care and 21% mortality at last follow-up (1). These findings have since been corroborated in an international study of 1,128 COVID-19 positive surgical patients.

Among 280 patients in this series who underwent elective surgery, 147 (53%) developed postoperative pulmonary complication and 53 (19%) died within 30 days of surgery (2) . In light of these observations, delaying all but emergent cases in COVID-19 positive patients appears prudent.

With the orchiectomy thus delayed, two management strategies were discussed with the patient and his parents (Table 1) . Strategy #1 was to defer immediate treatment and await a negative COVID-19 screening test before then proceeding with radical orchiectomy and TESE, to be followed by induction chemotherapy. Such an approach would allow surgical sperm extraction before chemotherapy. Infertility is commonly observed in testis cancer patients, with up to 35% of couples infertile at the time of testis cancer diagnosis and 50% of men demonstrating abnormal semen parameters (3). Cisplatin-based chemotherapy induces azoospermia, and although up to 50% of men can recover spermatogenesis by five years of completing chemotherapy (3), such considerations are irrelevant to a patient with a solitary testis who will undergo orchiectomy and in whom the only chance for sperm retrieval is prior to treatment. In a pathologic study of 214 patients who underwent radical orchiectomy, baseline azoospermia was not associated with lower sperm retrieval rates, with sperm identified in 58% of patients with azoospermia or cryptozoospermia (4).

An additional benefit of this management strategy was the possibility to reduce the patient's

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The patient and his parents were thoroughly counseled on the management options and the oncologic, surgical, and fertility implications of each option. The patient remained minimally symptomatic of his retroperitoneal disease, with only mild left-sided back discomfort, and elected to pursue strategy #1. Repeat COVID-19 screening was conducted two weeks later and was negative.

The patient then underwent left radical orchiectomy, ex vivo TESE, and placement of a testicular prosthesis. He received a dose of intramuscular testosterone in recovery and was discharged home, with an uncomplicated postoperative course. Pathology demonstrated mixed NSGCT with predominance of embryonal carcinoma (70%) in addition to post-pubertal teratoma, yolk sac tumor, and choriocarcinoma. Tumor was confined to the testis and without lymphovascular invasion (pT1).

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Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Fertility after chemotherapy for testicular germ cell cancers

Predictors of spermatogenesis in radical orchiectomy specimen and potential implications for patients with testicular cancer

Teratoma in the orchiectomy specimen and volume of metastasis are predictors of retroperitoneal teratoma in post-chemotherapy nonseminomatous testis cancer

Accepted Article