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J Ped Surg Case Reports 1 (2013) 125e128

Journal of Pediatric Surgery CASE REPORTS

journal homepage: www.jpscasereports .com

Expression analysis of the pluripotency marker UTF-1 for determiningthe applicability of testis-sparing surgery for prepubertal testis tumors

Kentaro Mizuno*, Yutaro Hayashi, Hideyuki Kamisawa, Hidenori Nishio, Yoshinobu Moritoki,Kenjiro KohriDepartment of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Aichi, Japan

a r t i c l e i n f o

Article history:Received 7 March 2013Accepted 26 April 2013

Key words:TestisPrepubertal testis tumorTestis-sparing surgery

* Corresponding author. Tel.: þ81 (0)52 853 8266;E-mail address: kmizuno@med.nagoya-cu.ac.jp (K.

2213-5766 � 2013 Elsevier Inc.http://dx.doi.org/10.1016/j.epsc.2013.04.004

Open access under CC BY

a b s t r a c t

Testis-sparing surgery (TSS) is widely performed for prepubertal testicular tumors because most of thesetumors are benign and have biological characteristics that make them amenable to local treatment. Here,we report a case of prepubertal teratoma enucleation. In order to evaluate the proliferative potential ofthe tumor and the applicability of testis-sparing surgery, we investigated the expression of UTF-1daspecific marker of pluripotency and self-renewaldusing real-time reverse transcription-polymerasechain reaction and immunohistochemistry. Because the enucleated tissue did not demonstrate theexpression of UTF-1, the applicability of TSS was verified, in the present case.

� 2013 Elsevier Inc. Open access under CC BY-NC-ND license.

Prepubertal testicular tumors have different histopathology andclinical behavior compared with adult testicular cancers [1]. Thesetumors are also relatively uncommon, with an incidence of 0.5e2per 100,000 boys. In contrast to adult testis tumors, the vastmajorityof prepubertal testis tumors contain only one histological type [2].Although their incidence varies according to the published report[3e5], teratomas are the most prevalent prepubertal testis tumor,representing 48% of these tumors in a recent multicenter report [2].Because several reports confirm the observation that most prepu-bertal testis tumors are benign [4,6], the concept of testis-sparingsurgery (TSS) is widespread and accepted for these tumors.

Here, we report a case of prepubertal teratoma treated with TSS,wherein we also investigated the expression of undifferentiatedembryonic cell transcription factor 1 (UTF-1)da specific marker ofspermatogonial stem cells [7,8]. UTF-1 expression was investigatedwithin both tumor lesions and normal tissue in order to assess themalignancy potential of the tumor and the applicability of TSS.

1. Case report

A 38-month-old boy was referred to our hospital because ofdifferences in the size of his testes. He did not show any externalgenitalia abnormalities at birth, and did not have any significantpast history. Upon physical examination, his right scrotum wasswollen and slightly indurated. There was no tenderness and the

fax: þ81 (0)52 852 3179.Mizuno).

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surface of right testis was smooth. The right testis measured23 � 17 � 17 mm, and the left testis was 17 � 12 � 12 mm. Theresults of a blood analysis failed to show any abnormalities, exceptfor slightly elevated lactate dehydrogenase levels (LDH; 260 U/mL);serum a-fetoprotein (AFP; 0.9 ng/mL) and human chorionicgonadotropin-beta (hCG-b;

Fig. 1. (A) Scrotal ultrasonography and (B) magnetic resonance imaging (T2-weighted) showing a heterogeneous mass with a hypoechoic layer and fluid accumulation (arrowheads).

K. Mizuno et al. / J Ped Surg Case Reports 1 (2013) 125e128126

recurrences over a 20-month follow-up period. The residualtesticular parenchyma was also preserved and did not show anyatrophy.

Although the etiology of testicular cancer is unknown, recentresearch has provided evidence that the spermatogenic stem cellsand their progenitors are involved in tumorigenesis [9]. Testicularcancer comprises a heterogeneous group of neoplasms classified aseither seminomas or nonseminomas, both arising from carcinomain situ (CIS). Furthermore, CIS development is attributed to abnor-malities of germline stem cells, such as gonocytes or spermatogonia[10]. Recently, we evaluated spermatogonial stem cell activity usingexpression of UTF-1da stem cell marker [11]. Thus, in order toassess the malignancy potential and subsequent applicability oftumor enucleation, UTF-1 expression was investigated using real-time reverse transcription-polymerase chain reaction (RT-PCR) andimmunohistochemistry in normal and tumor tissues of this patient.For comparison, seminoma and embryonal carcinoma tumor tissuesamples from pediatric patients were also examined.

Fig. 2. (A, B, and C) Operative findings of testis-sparing surgery. Tumor (arrow) was blunpreparation. The final pathological diagnosis was mature teratoma.

RNA was extracted from the frozen testicular tissue, preservedat �80 �C immediately after removal, according to the manufac-turer’s instructions [12]. Real-time RT-PCR was performed usingUTF-1- and GAPDH (glyceraldehyde-3-phosphate dehydrogenase)-specific primers, as previously described [11]. The relative expres-sion values of UTF-1 are shown in Fig. 3A. In the teratoma, UTF-1gene expression was significantly lower, compared with normaltestis and seminoma tissue (p < 0.001). In the immunohisto-chemical evaluation, UTF-1 was detectable in the germ cells ofnormal tissue, but not in tumorous tissue. However, the UTF-1protein was evident in the area of a recurrent teratoma fromanother case (Fig. 3B).

2. Discussion

In patients with prepubertal testicular tumors, TSS is widelyperformed because the majority of these tumors are unifocal andbenign [1e4]. TSS is also acceptable as it preserves residual

tly enucleated. (D) Histologic examination of the enucleated tumor in a permanent

Fig. 3. (A) Relative expression values of the UTF-1 gene. In the teratomatous area, UTF-1 gene expression was significantly lower compared to those of the normal testis andseminoma (p < 0.001). (B) Hematoxylin and eosin (HE) staining and immunohistochemistry for UTF-1 (reduced from �200).

K. Mizuno et al. / J Ped Surg Case Reports 1 (2013) 125e128 127

K. Mizuno et al. / J Ped Surg Case Reports 1 (2013) 125e128128

testicular function and prevents the need for subsequent hormonereplacement therapy. The suitability of a tumor for TSS is deter-mined during a preoperative examination, including specific echoicfindings, tumor size, and the absence of elevated serum AFP levels[1e6]. Furthermore, the accuracy of intraoperative frozen patho-logical examinations in these cases is high [13].

Taskinen et al. reported 2 patients who had recurrence due toincomplete primary resection [14], demonstrating the proliferativepotential of these tumors. Previously, a study of prepubertal testistumors and their relationship to intratubular germ cell neoplasia(ITGCN) revealed that germ cells adjacent to infantile germ celltumors are commonly proliferative [15]. ITGCN, synonymous forCIS, has been commonly accepted as a precursor for both seminomaand non-seminoma tumors in adolescents and young adults [9].In order to identify ITGCN in the absence of morphological features,immunohistochemical markers have been established [9]. Amongthem is UTF-1, a novel transcription coactivator that is mainlyexpressed in pluripotent embryonic stem cells [11]. Although UTF-1is used to assess spermatogonial stem cell activity [11], it is alsoa specific histological marker for some testicular cancers. Wanget al. reported that UTF-1 was differentially expressed in ITGCN,seminoma, and embryonal carcinoma by immunohistochemicallyevaluating specimens from 500 tumors [8]. In addition, UTF-1revealed a continuous expression pattern throughout human go-nadal development from fetus to adult, unlike other pluripotencymarkers, such as OCT-3/4 and NANOG. This characteristic may notbe related to pluripotency, but rather to a high rate of proliferationand self-renewal [7]. Thus, in the present case, spermatogonia couldbe identified in normal testis, but UTF-1 expression could not bedetected in the teratoma by either real-time RT-PCR or immuno-histochemistry; these results were consistent with previous reports[7,8]. On the other hand, in the recurrent teratoma lesion, UTF-1expression was positive, suggesting the presence of undifferenti-ated cells. In the present case, because the enucleated tissue did notdemonstrate UTF-1 expression, the applicability of TSS was verified.However, as UTF-1 is specific for undifferentiated cells withproliferative potential, UTF-1 expression is unlikely to be predictiveof malignant transformation and metastasis.

3. Conclusion

A patient with prepubertal teratoma underwent TSS. To assessthe malignant potential of the tumor and the applicability of TSS,the expression of UTF-1 was investigated within normal and tumortissue from the affected testis. Because the enucleated tissue did notdemonstrate UTF-1 expression, the applicability of TSS was verifiedin the present case. UTF-1 expression is unlikely to be a predictivefactor for malignant transformation and metastasis.

Consent

Written informed consent was obtained from the patient forpublication of this case report and accompanying images. A copy of

the written consent is available for review by the Editor-in-Chief ofthis journal on request.

Sources of fundingNone.

Conflict of interestNone.

Acknowledgment

The authors thank Dr. Hideyuki Kamisawa and Dr. YoshinobuMoritoki for their assistance with immunohistochemistry and real-time RT-PCR.

References

[1] Makari JH, Ramachandra P, Ferrer Jr FA. Pediatric urologic oncology: organ-sparing surgery in kidney and testis. Urol Clin North Am 2010;37:287e98.

[2] Pohl HG, Shukla AR, Metcalf PD, Cilento BG, Retik AB, Bagli DJ, et al. Prepu-bertal testis tumors: actual prevalence rate of histological types. J Urol 2004;172:2370e2.

[3] Ross JH, Rybicki L, Kay R. Clinical behavior and a contemporary managementalgorithm for prepubertal testis tumors: a summary of the Prepubertal TestisTumor Registry. J Urol 2002;168:1675e8 [discussion 1678e9].

[4] Shukla AR, Woodard C, Carr MC, Huff DS, Canning DA, Zderic SA, et al. Expe-rience with testis sparing surgery for testicular teratoma. J Urol 2004;171:161e3.

[5] Alanee S, Shukla A. Paediatric testicular cancer: an updated review of inci-dence and conditional survival from the surveillance, epidemiology and endresults database. BJU Int 2009;104:1280e3.

[6] Metcalfe PD, Farivar-Mohseni H, Farhat W, McLorie G, Khoury A, Bägli DJ.Pediatric testicular tumors: contemporary incidence and efficacy of testicularpreserving surgery. J Urol 2003;170:2412e5 [discussion 2415e6].

[7] Kristensen DM, Nielsen JE, Skakkebaek NE, Graem N, Jacobsen GK,Rajpert-De Meyts E, et al. Presumed pluripotency markers UTF-1 and REX-1are expressed in human adult testes and germ cell neoplasms. Hum Reprod2008;23:775e82.

[8] Wang P, Li J, Allan RW, Guo CC, Peng Y, Cao D. Expression of UTF1 in primaryand metastatic testicular germ cell tumors. Am J Clin Pathol 2010;134:604e12.

[9] Rajpert-De Meyts E. Developmental model for the pathogenesis of testicularcarcinoma in situ: genetic and environmental aspects. Hum Reprod Update2006;12:303e23.

[10] Spiller CM, Feng CW, Jackson A, Gillis AJ, Rolland AD, Looijenga LH, et al.Endogenous Nodal signaling regulates germ cell potency during mammaliantestis development. Development 2012;139:4123e32.

[11] Kamisawa H, Kojima Y, Mizuno K, Imura M, Hayashi Y, Kohri K. Attenuation ofspermatogonial stem cell activity in cryptorchid testes. J Urol 2012;187:1047e52.

[12] Mizuno K, Kojima Y, Kurokawa S, Maruyama T, Sasaki S, Kohri K, et al. Iden-tification of differentially expressed genes in human cryptorchid testes usingsuppression subtractive hybridization. J Urol 2009;181:1330e7 [discussion1337].

[13] Elert A, Olbert P, Hegele A, Barth P, Hofmann R, Heidenreich A, et al. Accuracyof frozen section examination of testicular tumors of uncertain origin. Eur Urol2002;41:290e3.

[14] Taskinen S, Fagerholm R, Aronniemi J, Rintala R, Taskinen M. Testicular tumorsin children and adolescents. J Pediatr Urol 2008;4:134e7.

[15] Renedo DE, Trainer TD. Intratubular germ cell neoplasia (ITGCN) with p53 andPCNA expression and adjacent mature teratoma in an infant testis. Animmunohistochemical and morphologic study with a review of the literature.Am J Surg Pathol 1994;18:947e52.

http://refhub.elsevier.com/S2213-5766(13)00044-4/sref1http://refhub.elsevier.com/S2213-5766(13)00044-4/sref1http://refhub.elsevier.com/S2213-5766(13)00044-4/sref1http://refhub.elsevier.com/S2213-5766(13)00044-4/sref1http://refhub.elsevier.com/S2213-5766(13)00044-4/sref2http://refhub.elsevier.com/S2213-5766(13)00044-4/sref2http://refhub.elsevier.com/S2213-5766(13)00044-4/sref2http://refhub.elsevier.com/S2213-5766(13)00044-4/sref2http://refhub.elsevier.com/S2213-5766(13)00044-4/sref3http://refhub.elsevier.com/S2213-5766(13)00044-4/sref3http://refhub.elsevier.com/S2213-5766(13)00044-4/sref3http://refhub.elsevier.com/S2213-5766(13)00044-4/sref3http://refhub.elsevier.com/S2213-5766(13)00044-4/sref3http://refhub.elsevier.com/S2213-5766(13)00044-4/sref4http://refhub.elsevier.com/S2213-5766(13)00044-4/sref4http://refhub.elsevier.com/S2213-5766(13)00044-4/sref4http://refhub.elsevier.com/S2213-5766(13)00044-4/sref4http://refhub.elsevier.com/S2213-5766(13)00044-4/sref5http://refhub.elsevier.com/S2213-5766(13)00044-4/sref5http://refhub.elsevier.com/S2213-5766(13)00044-4/sref5http://refhub.elsevier.com/S2213-5766(13)00044-4/sref5http://refhub.elsevier.com/S2213-5766(13)00044-4/sref6http://refhub.elsevier.com/S2213-5766(13)00044-4/sref6http://refhub.elsevier.com/S2213-5766(13)00044-4/sref6http://refhub.elsevier.com/S2213-5766(13)00044-4/sref6http://refhub.elsevier.com/S2213-5766(13)00044-4/sref6http://refhub.elsevier.com/S2213-5766(13)00044-4/sref7http://refhub.elsevier.com/S2213-5766(13)00044-4/sref7http://refhub.elsevier.com/S2213-5766(13)00044-4/sref7http://refhub.elsevier.com/S2213-5766(13)00044-4/sref7http://refhub.elsevier.com/S2213-5766(13)00044-4/sref7http://refhub.elsevier.com/S2213-5766(13)00044-4/sref8http://refhub.elsevier.com/S2213-5766(13)00044-4/sref8http://refhub.elsevier.com/S2213-5766(13)00044-4/sref8http://refhub.elsevier.com/S2213-5766(13)00044-4/sref8http://refhub.elsevier.com/S2213-5766(13)00044-4/sref9http://refhub.elsevier.com/S2213-5766(13)00044-4/sref9http://refhub.elsevier.com/S2213-5766(13)00044-4/sref9http://refhub.elsevier.com/S2213-5766(13)00044-4/sref9http://refhub.elsevier.com/S2213-5766(13)00044-4/sref10http://refhub.elsevier.com/S2213-5766(13)00044-4/sref10http://refhub.elsevier.com/S2213-5766(13)00044-4/sref10http://refhub.elsevier.com/S2213-5766(13)00044-4/sref10http://refhub.elsevier.com/S2213-5766(13)00044-4/sref11http://refhub.elsevier.com/S2213-5766(13)00044-4/sref11http://refhub.elsevier.com/S2213-5766(13)00044-4/sref11http://refhub.elsevier.com/S2213-5766(13)00044-4/sref11http://refhub.elsevier.com/S2213-5766(13)00044-4/sref12http://refhub.elsevier.com/S2213-5766(13)00044-4/sref12http://refhub.elsevier.com/S2213-5766(13)00044-4/sref12http://refhub.elsevier.com/S2213-5766(13)00044-4/sref12http://refhub.elsevier.com/S2213-5766(13)00044-4/sref12http://refhub.elsevier.com/S2213-5766(13)00044-4/sref13http://refhub.elsevier.com/S2213-5766(13)00044-4/sref13http://refhub.elsevier.com/S2213-5766(13)00044-4/sref13http://refhub.elsevier.com/S2213-5766(13)00044-4/sref13http://refhub.elsevier.com/S2213-5766(13)00044-4/sref14http://refhub.elsevier.com/S2213-5766(13)00044-4/sref14http://refhub.elsevier.com/S2213-5766(13)00044-4/sref14http://refhub.elsevier.com/S2213-5766(13)00044-4/sref15http://refhub.elsevier.com/S2213-5766(13)00044-4/sref15http://refhub.elsevier.com/S2213-5766(13)00044-4/sref15http://refhub.elsevier.com/S2213-5766(13)00044-4/sref15http://refhub.elsevier.com/S2213-5766(13)00044-4/sref15

Expression analysis of the pluripotency marker UTF-1 for determining the applicability of testis-sparing surgery for prepub ...1. Case report2. Discussion3. ConclusionConsentSources of fundingConflict of interestAcknowledgmentReferences