Testis-sparing Surgery for Pediatric Leydig Cell Tumors: Evidence of Favorable Outcomes Irrespective of Surgical Margins.

OBJECTIVE: To review our single institution experience, exploring the role of testis-sparing surgical resection in a cohort of children with Testicular Leydig cell tumors (LCTs). MATERIALS AND METHODS: We reviewed all consecutive children presenting with testicular tumors between 2003 and 2017 (n = 66), excluding patients with alternative pathologies (n = 57). Subsequently data were collected on age at surgery, laterality, type of surgery, operative time, presenting symptoms, serum markers, imaging findings, frozen section, final pathology, and follow-up. RESULTS: During the study period, a total of 9 (9/66; 14%) children were treated for LCT of the testis. Age at surgery was 8.4 ± 1.7 years and the majority (7/9; 77%) had unilateral disease. Most presented with a testicular mass, and 3 (33%) complained of testicular pain. None of the patients had elevated tumor markers. The primary method of management was ultrasound-guided testis-sparing surgery, with an operative time of 98.5 ± 58.7 minutes. Mean tumor size was 15 ± 10.8 mm (range 5-40 mm). In 2 of 6 patients with positive margins radical orchidectomy was performed without residual disease encountered. At a mean follow-up of 31.8 ± 26.3 months (range 2-87) none of the patients demonstrated disease recurrence. CONCLUSION: Our data suggest that LCT in children is associated with a good prognosis, and that TSS is a reasonable surgical approach without detrimental perioperative morbidity or negative long-term outcomes. Moreover, positive margins should not prompt a reflex decision for completion of orchidectomy.

[Contraception and sexuality]. / Contraception et sexualite.

PIP: Earlier age at menarche, a longer reproductive life, and fewer desired births have been factors in the increasing importance of contraception in the life of women and couples. This work assesses the optimal contraceptive methods for different physiological phases of affective and sexual life and for various sexual problems. Contraception should prevent pregnancy, not promote sexually transmitted diseases and disorders of the genital tract, and preserve future fertility. The 1st gynecological consultation, even for very young girls, has 3 main objectives: detecting anomalies of the genital tract, ensuring that no physiological problems will arise in the 1st intercourse, and providing contraception if it will be needed in the relatively near future. The physician should speak directly to the young patient instead of to her mother. Hormonal contraception is preferred for adolescents with regular sexual activity, but for the majority who have episodic and irregular sexual relations other methods may be preferable. Condoms provide some protection against sexually transmitted diseases but require cooperation from the male partner. Vaginal sponges which can be left in place for 24 hours are easier to use than other vaginal methods. The "morning after" pill is available in case of unprotected coitus. The unplanned and unstable sexuality of adolescents is increasingly followed by a period of regular and continuous premarital sexual relations requiring reliable and continuous contraception. The pill remains the best choice for its efficacy, tolerance, and safety. Various formulations are available in case of contraindications to the classic combined pill. IUDs should be formally contraindicated because of the possibility of extrauterine pregnancy or salpingitis. Mechanical methods can be used for short periods but should not replace a more effective method on a permanent basis. The IUD may be a good choice for women who have completed their families. Oral contraceptives may be continued for premenopausal women without other cardiovascular risk factors. High dose progestins derived from 17 hydroxyprogesterone are recommended in case of luteal insufficiency. Premenopausal women whose sexual relations have become less frequent may prefer IUDs, local methods, or tubal ligation. Sexual difficulties of couples should be considered in selecting a method. Frigid women do not tolerate contraception well because fear of pregnancy is their excuse for avoiding sex. IUDs may be more satisfactory than pills in such cases because they do not require daily action. Pills may be the best choice in cases of premature ejaculation or impotence.^ieng

[Difficulties in female contraception resulting from sexual and emotional problems]. / Contraceptions difficiles pour la femme parce que sa vie sexuelle et affective est difficile.

PIP: Despite a wider choice and despite the progress made in the methods available, contraception remains an insoluble problem for some women. They find it difficult or impossible to select a suitable method. Adverse reactions or failure results in unwanted pregnancies or termination. It is important to try to determine what lies behind this refusal, these fears and failures, and to help the woman to escape from the damaging situation in which she finds herself trapped. (author's modified)^ieng

[True and false regarding the risks of no contraception]. / Le vari et le faux sur les risques d'absence de contraception.

PIP: Contraception should be thought of as preventive medicine. The role of the doctor is extremely important; very often it is up to him/her whether the woman will or will not use contraception. The physician must take into consideration the feelings and wishes of the patient, her emotional stability or maturity, which is as important as her clinical health; the physician must inform before prescribing. The main risk of no contraception is, obviously, a request for induced abortion. Legalization of abortion has abolished the most serious complications. An unwanted pregnancy can have detrimental effects especially on adolescents, who are generally the least informed in matters of contraception; it is with them especially that the physician should exercise the role of educator. Many adult women do not want, or cannot, bear with the daily constraints of contraception seen as an injustice which gives the women the whole responsibility of the consequences of a sexual life. It is up to the doctor to understand these feelings and frustrations, to persuade patients to continue contraception, and to help them choose the best possible method for the particular situation.^ieng

[Advantages, inconveniences, and risks of minipills]. / Avantages, inconvenients et risques des minipilules.

PIP: Minipills contain only 30-40 mgs of ethinyl estradiol, plus Norgestrel or Norethindrone acetate. Administration is the same as for other estroprogestational agents. Minipills are extremely effective and present a few advantages over traditional OC (oral contraception): the risk of thrombotic accidents is decreased, as is the risk of vascular accidents; there is no increase in weight and incidence of headache is much lower. On the other hand breakthrough bleeding is common, as is mastopathy. Patients using the minipill must be closely surveilled; contraindications for minipill use are thrombotic accidents, hyperlipidemia, familial antecedents of hypertension or of vascular affections. The minipill is especially advisable to women over 35.^ieng

[Is contraception really accessible to adolescents?].

PIP: The nature of information and accessibility of contraceptives to adolescents is examined. The absence of contraception among adolescents has led to an increase in the number of necessary artificial abortions, indicating the trend toward early sexual relations. French laws governing the use of, and accessibility to contraceptives, which have been a barrier to adolescents, are examined. 4 important basic problems are outlined: the absence of proper information and sex education, difficulty in obtaining contraceptives, the increase in the number and frequency of sexual encounters, and the irresponsibility of and fear of the dangers of using the pill. An information system for adolescents is outlined and samples of informational sources are given.^ieng

[Should hysterography always be used before IUD insertion?]. / L'hysterographie est-elle indispensable a la pose d'un D.I.U.?

PIP: Use of hysterography before IUD insertion increases the risk of infection. Unless there is reason to suspect a uterine malformation, hysterography should be avoided.^ieng

[What evidence is there to judge the effect of copper in the body?]. / De quel recul dispose-t-on pour juger du devenir du cuivre dans l'organisme--D.I.U. au cu?

PIP: Several years of experience with the copper IUD have shown no change in the rate of cupremia among women using it; the daily "leakage" of copper is minimal, much less than the alimentary intake, and occurs only locally. In the exceptional cases where pregnancies have occurred through IUD failure, no teratogenic effects have been reported.^ieng

[The new IUDs]. / Les nouveaux D.I.U.

PIP: Copper IUDs and Dalkon Shields are discussed by this panel in terms of mode of action, efficacy, expulsions, side effects, technique of insertion and insertion in specific situations, e.g., after abortion, caesarean section, oral contraception, and in nulliparas. Data were presented on Gravigarde and Byla brands of Copper 7s and on copper T-200, showing better pregnancy rates, .8 to 1.7%, and 2.4% to 6% for Dalkon Shields, than those usually reported for inert or longitudinal IUDs. A lengthy description of the technique for inserting Gravigarde (Copper-7) IUDs was concluded by summarizing its advantages, such as painless insertion, high efficacy few side effects and suitability for nulliparas, and its disadvantages such as high price, limited lifetime and poorly designed insertion device. Another discussant added that the thread is likely to retract, so it should be trimmed longer than recommended by the manufacturer. A histochemical study of 50 endometrial biopsies found all parameters normal except that the pentose phosphate shunt enzymes were less active. In the question period the speakers recommended no particular precautions for cases of medical abortion, oral contraception, nulliparas, normal caesarean sections, but in cases of septic abortion, very young nulliparas or complicated caesarean section, careful judgement in needed when inserting IUDs.^ieng

[The new IUDs]. / Les nouveaux sterilets.

PIP: This brief review mentions 3-dimensional IUDs and large surface IUDs and discusses progesterone and copper-containing IUDs. The 3-dimensional IUDs (Corolle, Basquet, and Majzlin spring) were expelled easily and were poorly tolerated. The large area Dalkon shield was difficult to insert and remove but permitted few expulsions; the failure rate of less than 1% claimed by its inventors has not been confirmed in French and British studies. IUDs with progesterone capsules or with auxiliary daily pills are on trial. Copper T and 7 shaped IUDs have proved to be more effective, seldom expelled, and rarely responsible for severe bleeding. The IUDs with 300 sq. mm copper release about 50 mcg copper /day, not enough to affect blood levels. They seem to prevent implantation by attracting leukocytes and macrophages, by modifying mucosa enzymes such as acid phosphatase, and by preventing sperm from penetrating cervical mucus.^ieng

[Information on worldwide abortion legislation]. / Informations sur la legislation mondiale de l'avortement.

PIP: Western nations are classified by degree of liberalization of abortion laws. France, Spain, Portugal, Italy, Ireland, and Albania permit abortion if it is the only means to save the mother's life. Switzerland (since 1968) and Belgium allow abortion for a proven medical indication. England (1967) and Denmark add the possibility of a malformed infant as a reason for abortion. Norway, Sweden, Russia, Yugoslavia, Poland, Hungary, Romania, and Bulgaria include the medical, eugenic, and social indications. Tables were presented showing from .5-127 abortions per 100 births, and from 1.2-257 deaths per 100,000 abortions in different countries. The variable death rates are related to the gestational age and experience of operators in a given country. In view of possibly liberalizing the law in France, the opinions of practitioners, the need for contraception, and the social injustice of illegal abortion must be considered. The author hoped that science would solve the problem by inventing a safe luteolytic drug.^ieng