Bilateral germ cell cancer of the testis: a report of 11 patients with a long-term follow-up A. TEKIN, Y.C. AYGUN, F.T. AKI and H. OZEN Department of Urology, School of Medicine, Hacettepe University, Ankara, Turkey Objective To describe the incidence, clinical character- istics, treatment methods and long-term follow-up of bilateral germ cell tumours of the testis (GCTT) in patients treated at one institution. Patients and methods Of 552 patients with GCTT, 11 (2%, mean age 26.9 years) developed bilateral disease; all 11 underwent radical orchidectomy. Additional treatment was planned according to the histological type and clinical stage of the tumour, and previous treatments. Intramuscular testosterone was adminis- tered periodically after total castration. The data on survival, sexual status and treatment complications were reviewed. Results Of the 11 patients, seven developed a second tumour metachronously (median interval 87 months) and four had synchronous bilateral GCTT. Cryptorchidism, infertility or atrophic testis was associated with the development of bilateral GCTT in seven of the 11 patients. All synchronous tumours and most of the sequential tumours had identical histology on both sides. Although all sequential tumours presented at an early clinical stage, three of four synchronous bilateral GCTTs presented at an advanced stage. Five patients received platinum-based chemotherapy; three patients underwent post- chemotherapy resection of the retroperitoneal residual mass. Sexual libido and potency were conserved in all patients. No signi®cant morbidity was recorded as being caused by any of these treatments. At a median follow-up of 11.6 years, all patients were alive with no evidence of cancer. Conclusions All patients with unilateral GCTT have an increased risk of developing a contralateral testicular tumour, even decades after diagnosis. Management should be adapted to each patient. As all patients in this series survived in the long-term, developing a second germ cell cancer does not necessarily predict a poor prognosis. Keywords Germ cell tumours, testis, bilateral, prognosis Introduction Germ cell tumours of the testis (GCTTs) are still the most common solid cancers in men aged 15±34 years [1]. Fortunately, more than 80% of patients are cured even if they have advanced clinical stage disease, a unique feature of this cancer. However, there is a greater risk of developing a secondary GCTT in the remaining testis. Many investigators have reported an increase in the incidence of bilateral GCTT [2,3]. Since the ®rst report by Bidard in 1853 [4], the incidence of bilateral GCTT has been reported to be 1±5.8% [5,6]. Although the second tumour is usually metachronous, synchronous tumours also occur [2,3,7,8]. Several risk factors, e.g. cryptorch- idism, a previous history of infertility, atrophic testis and carcinoma in situ (CIS) of the testis, have been associated with the increased risk of developing a secondary GCTT [7]. Herein we present the incidence of bilateral GCTT, the clinical characteristics of the patients, diagnostic procedures, treatment methods and long-term follow-up of patients from a consecutive series of GCTTs treated at one institution. Patients and methods Between 1980 and 1998, 552 patients with GCTT were treated in our department; of these, 11 (2%) developed bilateral GCTT. The diagnostic procedure included a history, physical examination, serum markers (AFP and bhCG), ultrasonographic evaluation of the testicles and abdomen, a chest X-ray and CT of the thorax, abdomen and pelvis. Clinical staging was conducted according to the Royal Marsden Hospital Staging System [9]. All patients underwent radical orchidectomy as an initial treatment and for histological diagnosis. Subsequently, the treatment strategy was determined according to the histological type and clinical stage of the cancer. Patients with clinical stage I or IIA seminoma received radio- therapy to the retroperitoneum, if not given previously. Patients who had clinical stage I seminoma as a secondary cancer after previous radiotherapy were entered into an active surveillance programme with no Accepted for publication 18 January 2000 BJU International (2000), 85, 864±868 # 2000 BJU International 864