Erirish Journalof Urology(1987).

60,167-169
01987 British Journal of Urology

Bone Scintigraphy in Testicular Tumours

M. V. MERRICK

Department of Nuclear Medicine, Western General Hospital, Edinburgh

Summary-The role of bone scintigraphy was assessed by follow-up and review of 61 patients with
testicular tumours. Skeletal metastases were present in all five patients who died with seminoma
and in two of the eight whose deaths were due to teratoma. The only patient with skeletal
metastases to have a prolonged survival had a mixed teratoma/seminoma. Bone scintigraphy is
indicated in patients with recurrence after radical treatment for seminoma and may be indicated in
patients presenting with stage IV seminoma, to identify a sub-group with the worst prognosis. In
other patients it is indicated only if there is a specific clinical suspicion of bone metastases.

Testicular tumours are comparatively uncommon. prospective study. The departmental records were
There are nevertheless regional variations in prev- subsequently reviewed and notes obtained from the
alence. The age standardised rate in Scotland for referring hospital or unit. Sixty-one were identified
the period 1976 to 1980 was 4.01/100,000 (Scottish either from the departmental records or from the
Cancer Registry, 1984), in contrast to the United clinical notes as having a primary testicular
States, where the rate for 1976 to 1978 was 8.7 malignancy, 26 with seminoma, 29 with teratoma
(Porter et al., 1984). It is generally agreed that and six with mixed tumours. Dates of birth,
accurate staging is important (Heiken et al., 1984; diagnosis, imaging, death or last attendance, histol-
Montie, 1984), but neither these reviews nor the ogy, scintigraphic and radiographic findings, sub-
recent MRC multicentre study of prognostic factors sequent course, symptomatology and any other
in advanced testicular tumours (Peckham et al., relevant information were recorded. In cases where
1985) considered skeletal metastases. Indeed skel- post mortem examinations had been performed,
etal scintigraphy is not mentioned in this condition reports were obtained from the Department of
in the oncological literature, whilst scintigraphic Pathology if not filed in the notes.
series such as those of Tofe et al. (1976) and Harbert It was not policy to perform skeletal scintigraphy
(1982) and major reviews by Merrick (1975) and in all newly diagnosed cases. The decision was at
McNeil (1984) do not consider testicular tumours the discretion of the referring surgeon. The princi-
at all. pal indications were supplementary staging or
During follow-up of all patients who had under- restaging and symptoms suggestive of metastases,
gone skeletal scintigraphy in this department often with normal or equivocal radiographs. These
between 1975 and 1982, 61 patients with primary distinctions were not exclusive. There was some
malignant tumours of the testis were identified. The overlap and it was often not possible to categorise
results of bone scintigraphy and its relationship to unambiguously the reason for referral. Comparison
their subsequent course are reported. with the numbers notified to the regional Cancer
Registry over this period suggests that this series
comprised approximately one in five new cases
Patients and Methods diagnosed in the region served.
Five thousand three hundred consecutive patients Until 1977 scintigraphy (of the entire skeleton)
referred for skeletal scintigraphy between January was performed with an Ohio Nuclear series 100
1975 and December 1982 were entered into a gamma camera fitted with a whole body scanning
attachment. Subsequently a Cleon 760 multidetec-
Accepted for publication 22 September 1986 tor scanner was employed. Examinations were
167

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168 BRITISH JOURNAL OF UROLOGY

carried out 2 to 5 h after intravenous administration Table 2 Occurrence of Bone Metastases in Testicular
of 700 MBq (20 mCi) 99 “Tc MDP. Settings were Tera toma
adjusted to give a count density sufficient to
maximise the detection of both photon-rich and Stage I II III IV Unstaged
photon-deficient lesions (Merrick, 1984). Ail were Numberofpatients 7 5 3 7 7
reported or reviewed (with radiographs of all Bony metastases _ _ 1 ~
1
suspect regions) by the author. Died 1 ~- 1 4 2
For the purpose of this review studies were
classified as normal if there was no scintigraphic phy was normal in all of the surviving patients,
abnormality or if there was a definite benign none of whom had either clinical or radiographic
explanation for the scintigraphic findings (trauma, evidence of bone metastases.
osteoarthritis, etc.). They were regarded as abnor- Twenty-nine patients had testicular teratoma
mal only if there was radiographic confirmation of (Tattle 2), only one of whom (with stage IV disease)
at least one metastatic site. The remaining patients, had scintigraphic evidence of skeletal metastases
including those in whom adequate radiographs at presentation. A second (who was not staged)
were not available and those with scintigraphic developed bony metastases 5 months after a finding
abnormalities for which there was neither a benign of normal bone scintigraphy at presentation.
nor a malignant explanation, were classified as All of the others were scintigraphically normal
equivocal, even though originally reported as and none developed overt bone metastases during
“suggestive o f ” or “probable” deposits. In the follow-up. There were eight deaths in the series,
analysis these equivocal cases were included with including bothof the patients with bony metastases.
the normal. The mean survival was 1.5 years. The survivors
were followed for a mean period of 2.5 years.
Results Six patients had mixed seminoma/teratoma
(Table 3). None died during follow-up, which was
The distribution by stage of the 26 patients with not less than 30 months and up to 66 months. Two
seminoma is shown in Table I . The five who died had scintigraphic abnormalities. In one case there
during the period of follow-up, including both of was a solitary rounded region of considerably
those with stage IV, two with stage I1 and one with increased uptake in the occipital region of the skull,
stage I disease, had a mean survival of 1.5 years seen unchanged on three occasions over 2 years.
from diagnosis. The surviving patients had a mean
follow-up of 2.6 years. Four of the five who died Table 3 Occurrence of Bone Metastases in Mixed
had abnormal bone scintigrams at some point in Testicular Tumours
their illness, although the initial examination was -
normal in the patient with stage I disease and one Stage I II III IV
of those with stage 11. The former developed bone
Number of patients 5 __ 1
secondaries 18 months later, dying 14 months after -
~

-
Bony metastases I* 1
the second scintigram. The latter had a normal ~~ ~

scintigram at presentation and one showing bony * Probable false positive (see text).
metastases 9 months later. He died 1 month after
the second investigation. The fifth patient, who There was controversy about the interpretation of
presented with stage IV disease, had a normal the associated radiological abnormality, which was
scintigram only 1 month before death. Skeletal predominently lytic. The patient has been symp-
metastases were found at post mortem. Scintigra- tom-free throughout and is alive and well 7 years
later, having received no systemic therapy. In
Table 1 Occurrence of Bone Metastases in Seminoma retrospect it was probably a localised area of fibrous
dysplasia. The other had unequivocal evidence of
Stage I 11 III IV Unstaged deposits in T12 and the left innominate bone but
was well 5 years later after chemotherapy.
Number of patients 13 7 - 2 4
Bony metastases 1 2 - 2* -.

Died 1 2 ~ 2 - Discussion
* Includes one with normal scintigraphy in whom metastases Deposits were found at presentation in only two of
were confirmed at post mortem. 26 patients with seminoma, despite undoubted