Ci a ion: Velado-Eguskiza, A.;
Gomez-San os, L.; Badiola, I.; Sáez,
F.J.; Alonso, E. Tes icula Ge m Cell
Tumou s and P op o ein Con e ases.
Cance s 2022,14, 1633. h ps://
doi.o g/10.3390/cance s14071633
Academic Edi o :
Dominik T. Schneide
Recei ed: 27 Janua y 2022
Accep ed: 10 Ma ch 2022
Published: 23 Ma ch 2022
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cance s
Re iew
Tes icula Ge m Cell Tumou s and P op o ein Con e ases
Ai zibe Velado-Eguskiza 1, Lau a Gomez-San os 1, Ike Badiola 1,2, F ancisco JoséSáez 1
and Edu ne Alonso 3,*
1Depa men o Cell Biology and His ology, Facul y o Medicine and Nu sing,
Uni e si y o he Basque Coun y (UPV/EHU), 48940 Leioa, Spain; [email p o ec ed] (A.V.-E.);
[email p o ec ed] (L.G.-S.); ike [email p o ec ed] (I.B.); [email p o ec ed] (F.J.S.)
2Nanokide The apeu ics SL, 48940 Leioa, Spain
3Depa men o Cell Biology and His ology, Facul y o Pha macy,
Uni e si y o he Basque Coun y (UPV/EHU), 01006 Vi o ia-Gas eiz, Spain
*Co espondence: [email p o ec ed]; Tel.: +34-945-013-029
Simple Summa y:
Despi e he high su i al a e o he mos common neoplasia in young Caucasian
men: Tes icula Ge m Cell Tumo s (TGCT), he quali y o li e o hese pa ien s is impai ed by he
mul iple long- e m side e ec s o hei ea men . The s udy o molecules ha can se e bo h as
diagnos ic bioma ke s o umo de elopmen and as he apeu ic a ge s seems necessa y. P op o ein
con e ases (PC) a e a g oup o p o eases esponsible o he ma u a ion o inac i e p op o eins wi h
e y di e se unc ions, whose al e a ions in exp ession ha e been associa ed wi h a ious diseases,
such as o he ypes o cance and in lamma ion. The s udy o he immune umo mic oen i onmen
and he subs a es o PCs could con ibu e o he de elopmen o new and necessa y immuno he apies
o ea his pa hology.
Abs ac :
Tes icula Ge m Cell Tumou s (TGCT) a e widely conside ed a “cu able cance ” due o
hei excep ionally high su i al a e, e en i i is educed by many yea s a e he diagnosis due
o me as ases and elapses. The mos common he apeu ic app oach o TGCTs has no changed
in he las 50 yea s despi e i s mul iple long- e m side e ec s, and because i is he mos common
malignancy in young Caucasian men, much esea ch is needed o be e he quali y o li e o he
many su i o s. P op o ein Con e ases (PC) a e nine se ine p o eases esponsible o he ma u a ion
o inac i e p op o eins wi h many di e se unc ions. Al e a ions in hei exp ession ha e been
associa ed wi h a ious diseases, including cance and in lamma ion. Many o hei subs a es a e
adhesion molecules, me allop o eases and p oin lamma o y molecules, all o which a e in ol ed
in umou de elopmen . Inhibi ion o ce ain con e ases has also been shown o slow umou
o ma ion, demons a ing hei in ol emen in his p ocess. Conside ing he e y es ablished link
be ween PCs and in lamma ion- ela ed malignancies and he ecen s udies ca ied ou in o he
immune mic oen i onmen o TGCTs, he s udy o he in ol emen o PCs in es icula cance may
open up a enues o being bo h a bioma ke o diagnosis and a he apeu ic a ge .
Keywo ds:
es icula cance ; Tes icula Ge m Cell Tumou s (TGCT); seminoma; spe ma ogenesis;
P op o ein Con e ases (PCs)
1. In oduc ion
Tes icula Ge m Cell Tumou s (TGCTs) ha e been o his o ic ele ance o a ious
easons. Nine y pe cen o pa ien s diagnosed wi h me as a ic TGCT in 1946 died wi hin a
yea . Now, howe e , ha s a is ic has been e e sed and he as majo i y o pa ien s a e
cu ed [
1
,
2
]. As a esul , TGCT has been p oposed as a po en ial model o ind a he apy
o he es o he cance ypes [
3
]. In ac , TGCT umou s played an in aluable ole in
he es ablishmen o cance as a s em cell disease. Pe haps because o he a o emen ioned
su i al a e, no one has de eloped be e d ugs o he ea men o hese diso de s
Cance s 2022,14, 1633. h ps://doi.o g/10.3390/cance s14071633 h ps://www.mdpi.com/jou nal/cance s
Cance s 2022,14, 1633 2 o 19
since he 1970s, e en hough he mos used he apeu ic s a egies ha e ha m ul long e m
consequences [4,5].
Rega dless, he e is cu en ly an ac i e push o mo e esea ch ega ding TGCTs o
minimize he ha m ul e ec his disease amily has on he li es o young men all o e
he wo ld and ha is e lec ed wi h he publica ion o se e al e iew pape s a ound ha
gene al opic [
6
,
7
]. In his e iew, we also aim o explo e he cu en s a us o TGCTs in
a molecula and clinical se ing. We p opose o app oach he p op o ein con e ase (PC)
amily as possible molecules o in e es in his disease, since bo h subjec s may be linked o
a p oin lamma o y umou mic oen i onmen (TME).
2. Tes icula Ge m-Cell Tumou s (TGCT)
Ge m Cell Tumou s (GCTs) o igina e om ge m cells, usually in he gonads ( es es
and o a ies), bu hey can also be ound elsewhe e in he cen al ne ous sys em, pel is,
ho ax, abdomen and medias inum [
8
]. TGCTs a e he second mos common o m o Ge m
Cell Tumou a e benign o a ian e a omas and accoun o mo e han 90% o neoplasms
ound in es icles [
8
,
9
]. Thei incidence has been on he ise since he 1970s, and e en
hough hey ha e an ex emely high su i al a e, i sh inks conside ably by 30 yea s a e
he diagnosis, due o me as ases and elapses (15–30% o pa ien s) [
10
–
13
]. Taking ha in o
conside a ion, i is impo an o s udy hese umou s and unde s and hei de elopmen as
well as he bes clinical pa hs o hei ea men .
The di e en ypes o TGCTs ha e usually been classi ied ollowing mo phological
c i e ia in o wo ca ego ies: seminomas and non-seminoma ous Ge m Cell Tumou s (NS-
GCTs). O hose wo, NSGCTs a e less common bu mo e agg essi e and he e ogeneous.
They a e ca ego ised in o ou his ological ypes: emb yonal ca cinoma, yolk-sac ca cinoma,
cho ioca cinoma and e a oma; mos umou s p esen mo e han one cell ca ego y, making
hem ha de o ea .
Analysing TGCT incidence by age, wo di e en spikes can be iden i ied (Figu e 1).
The i s peak is in pa ien s aged 25–29 yea s old, e en hough hese demog aphical g oups
ha e a highe incidence o o he malignancies as well. Tha i s peak is due o non-
seminomas, mainly yolk-sac umou s and e a omas. The second peak is due o seminomas
and is obse ed be ween 30 and 39 yea s o age. Fu he mo e, he e is a clea di e ence o
almos 10 yea s be ween he peak incidence o non-seminomas and seminomas [8].
Figu e 1.
G aph depic ing TGCT incidence pe 1,000,000 by age g oup and his ology using da a om
he EUROCARE s udy, published in 2017 by Annalisa T ama and F anco Be ino [8].
2.1. Tumou Classi ica ion
An ea ly p oblem in he s udy o TGCTs was he di e en e minology used o
hei classi ica ion by di e en esea ch g oups. Un il ecen ly, hei classi ica ion was
mo phology-based bu i was upda ed in 2016 by he Wo ld Heal h O ganisa ion (WHO)
o e lec he la es s udies and he epidemiological simila i ies o di e ences be ween
Cance s 2022,14, 1633 3 o 19
ce ain ypes o umou s [
14
] (Table 1). Acco ding o his nomencla u e, Tes icula Ge m
Cell Tumou s a e classi ied based on hei ela ionship wi h he ge m cell neoplasia In Si u
(GCNIS): a g oup o malignan in a ubula ge m cells wi h seminoma-like mo phology
ha appea in he spe ma ogenic niche and p ecede mos TGCTs. Then, GCTs a e classi ied
in wo main g oups: GCNIS-de i ed umou s and no GCNIS-de i ed umou s [14].
Table 1. Wo ld Heal h O ganiza ion (WHO) classi ica ion o TGCT, adap ed [14].
Ge m Cell Tumo s De i ed om Ge m Cell Neoplasia In Si u
Non-in asi e ge m cell neoplasia
Ge m cell neoplasia in si u (GCNIS)
Speci ic o ms o in a ubula ge m cell neoplasia
Tumo s o single his ological ype (pu e o ms)
Seminoma
Seminoma wi h scyncy io ophoblas cells
Non-seminoma ous ge m cell umo s
Emb yonal ca cinoma
Yolk sac umo , pos pube al- ype
T ophoblas ic umo s
Cho ioca cinoma
Non-cho ioca cinoma ous ophoblas ic umo s
Placen al si e ophoblas ic umo
Epi helioid ophoblas ic umo
Cys ic ophoblas ic umo
Te a oma, pos pube al- ype
Te a oma wi h soma ic- ype malignancy
Non-seminoma ous ge m cell umo s o mo e han one his ologycal ype
Mixed ge m cell umo s
Ge m cell umo s o unknown ype
Reg essed ge m cell umo s
Ge m Cell Tumo s Un ela ed o GCNIS
Spe ma ocy ic umo
Te a oma, p epube al- ype
De moid cys
Epide moid cys
Well-di e en ia ed neu oendoc ine umo (monode mal e a oma)
Mixed e a oma and yolk sac umo , p epube al- ype
Yolk sac umo , p epube al- ype
The mos closely ela ed o GCNIS would be pu e seminomas, which main ain he
same his ology. F om he e, ano he ype o classi ica ion ha is o en used in clinics
a ises, which di ides umou s in o seminoma ous o non-seminoma ous. This is espe-
cially impo an o ea men s because seminoma cells a e sensi i e o chemo he apy and
adio he apy [15–17].
The dis inc ion be ween mo phology and epidemiology-based classi ica ions is mos
no ably seen in he case o e a omas and yolk sac umou s. The e is no signi ican mo -
phological di e ence be ween he p e- and pos -pube al ypes, bu he umou s seen
in child en mo e o en lack he ma ke s associa ed wi h GCNIS ha a e p e alen in u-
mou s seen a e pube y. The e o e, al hough hey we e p e iously conside ed o be a
single diso de , we now know ha he e a e conside able epidemiological and molecula
di e ences [14].
In ac , he mos p ominen heo y on he o igin o GCNIS s a es ha he e is some
kind o umo igenic e en in u e o du ing emb yogenesis, which impai s he ma u a ion
o p imo dial s em cells in o spe ma ogonia [
18
]. Those cells a e iden i ied as GCNIS and
emain unchanged un il pube y, when al e a ions in hei molecula en i onmen lead o
malignancy. GCNIS could be conside ed as he p ecu so o mos pos -pube al TGCTs and
is usually ea ed as a s age 0 cance .
Cance s 2022,14, 1633 4 o 19
The seminoma ous/non-seminoma ous nomencla u e is s ill used oday and no -
mally di e en ia es be ween pu e seminoma (seminoma ous umou s) and e e y o he
ype o TGCT (non-seminoma ous) [
19
]. Fo he ea men o mixed umou s he non-
seminoma ous app oach has a be e p ognosis, as hese ypes o cance p esen mo e
agg essi e cha ac e is ics [19].
2.1.1. Seminoma
Seminoma is he mos common TGCT, accoun ing o 50% o all cases beyond pu-
be y [
9
]. In ac , his malignancy is ai ly uncommon du ing in ancy and in people olde
han 50 yea s, e en hough i con inues o be he mos common o m o TGCT in he la e ,
as he incidence o he es o TGCTs dec eases u he [9,20].
As is he case wi h all single cell- ype umou s, all pu e seminoma cells ha e he
same eac ion o he he apeu ic s a egies used on hem, wi h adio he apy being he mos
e ec i e. In addi ion, abou 80% o diagnoses a e made du ing s age I, so he su i al a e
o seminoma pa ien s is excep ionally high [12,21].
Howe e , i is impo an no o unde es ima e he se e i y o seminoma, especially
wi h ega d o he long- e m e ec s o he ea men s used, bo h on he physical and men al
heal h o pa ien s. The main challenge o seminoma pa ien s is no o imp o e su i al pe
se, bu o de elop sensi i e and speci ic bioma ke s o sa ely iden i y his less h ea ening
o m o cance and hus a oid he o e ea men o pa ien s, mainly wi h cispla in-based
chemo he apy [
22
]. Gi en ha seminoma pa ien s a e o en young men, he ocus o
esea ch should be on p ese ing hei quali y o li e and ep oduc i e heal h.
2.1.2. NSGCTs
Non-seminoma ous Ge m Cell Tumou s, as men ioned be o e, a e classi ied in o ou
main his ological ca ego ies: emb yonal ca cinoma, yolk-sac umou s, cho ioca cinoma,
and e a oma. Ne e heless, hese umou s do no usually appea in a pu e o m, and
mos NSGCTs a e mixed cell umou s [
23
]. As a consequence, he his ological analysis
o he p ima y umou is o g ea impo ance o de e mine which cell ypes a e p esen
and in wha p opo ion. Tha in o ma ion is impo an o he diagnosis, p ognosis and
ea men selec ion.
Simila o seminoma, 50% o NSGCTs a e ini ially diagnosed as s age I cance [
24
]. In
addi ion, i le un ea ed, a ound 30% o pa ien s will elapse due o p e iously unno iced
me as ases o he e ope i oneal lymph nodes [25].
2.2. Risk Fac o s
Gonad de elopmen al p ocesses and gene ic p edisposi ion ha e been desc ibed as
key ac o s associa ed wi h TGCT, which explains why hey a e so common amongs
younge people.
The main isk ac o iden i ied, especially in he case o seminoma, is c yp o chidism
(p oblem wi h he descen o he es es, lea ing one o bo h o hem ou side he sc o um).
The p e alence o TGCT inc eases be ween 3.7- and 7.5- old in hese pa ien s; in ac ,
be ween 5% and 10% o es icula cance pa ien s ha e a his o y o c yp o chidism [
26
,
27
].
This is p obably because he es icle is in an un a ou able molecula en i onmen o i s
de elopmen , which can lead o GCNIS [9].
O he p ominen isk ac o s include a p e ious umou in he con ala e al es icle,
especially in he p eceding 5 yea s (24.5- o 27.5- old inc ease) wi h a amily his o y o
TGCT, which has been linked o a ious candida e genes, some o which a e also ela ed o
c yp o chidism [9,28–30].
I has been obse ed ha he cells om GCNIS a e eally ha d o dis inguish om
ge m cells in in e sex gonads, which p esen a delay in hei ma u a ion. One heo y
sugges s ha hese abno mal cells become GCNIS, which would explain why be ween 25%
and 30% o people wi h gonadal dysgenesis and a Y ch omosome de elop a GCT [14,31].
Cance s 2022,14, 1633 5 o 19
Las ly, an inc eased isk o de eloping a TGCT has also been linked o abno mali ies
o he ge m cell lines ha lead o hypo e ili y and in e ili y [
32
,
33
]. Ne e heless, i is no
ye clea whe he he e is a di ec causal ela ionship o a hi d elemen ha leads o bo h
impai ed e ili y and an inc eased isk o TGCT [34].
A conside able pa o TGCTs could be due o en i onmen al ac o s. In ac , i has
been p o en ha exposu e o ce ain en i onmen al ac o s du ing oe al de elopmen o
ea ly in ancy leads o he appea ance o GCNIS om gonocy es wi h impai ed ma u a ion,
as p e iously desc ibed in people wi h in e sex cha ac e is ics [
35
,
36
]. The ela ionship
be ween impai ed gonadal de elopmen and GCNIS-media ed umo igenesis is e iden ,
as a lo o hese umou s sha e mo phological cha ac e is ics like de icien spe ma ogene-
sis, ubula sh inking, pe i ubula scle osis, imma u e Se oli cells, in e s i ial expansion,
hyalinised ubules and mic oli hiasis [37,38].
In summa y, he da a sugges ha TGCTs a e a de elopmen al ype o cance ha
adhe es o a “gene-en i onmen ” model, in which he e a e ob ious gene ic and epige-
ne ic componen s ha lead o umo igenesis unde he igh (o w ong) en i onmen al
condi ions [39].
2.3. Diagnosis, P ognosis and T ea men
When a suspicious es icula mass is disco e ed, he i s s ep is o analyse ce ain
umo al bioma ke s and ca y ou a ans-sc o al ul asonog aphy. I he imaging shows
a mass ha is suspec ed o being malignan , an inguinal o chiec omy would be ca ied
ou o u he diagnosis. I is usually ecommended no o damage he sc o um du ing
he p ocedu e, as i can lead o complica ions du ing ea men , bu ecen me a-analyses
disca d hese nega i e e ec s a leas o sho - e m su i al [40,41].
The mos common p ima y he apeu ic app oach, a adical o chiec omy, is pe o med
when he a ec ed es icle is comple ely ex ac ed [
19
]. Tha leads o he loss o he en i e
o gan, which is p oblema ic i he con ala e al es icle has al eady been emo ed o
in young pa ien s. The e o e, in ce ain cases, esea ch g oups ha e p oposed pa ial
o chiec omies o es is-spa ing su ge y (TSS) o minimise endoc ine and psychological
nega i e e ec s and p ese e e ili y [
42
]. TSS is p oposed especially in cases o suspec ed
benign umou s and in elapses when he con ala e al es icle has al eady been emo ed o
main ain endoc ine unc ion. This p ac ice has been ega ded as unnecessa y o dange ous
due o he isk o elapse compa ed o adical o chiec omy, bu a me a-analysis o mul iple
s udies has shown a elapse a e o only 7.5%, which disappea s when adju an local
adio he apy is applied (excep in adio- esis an e a omas) [41].
I he ini ial diagnosis was s age I cance , he same bioma ke s in es iga ed a he s a
o he diagnosis a e ollowed up un il no malisa ion. I le els do no e u n o no mal, some
kind o me as asis is con i med, and he diagnosis shi s o a la e s age. Adju an he apies
a e conside ed depending on he diagnosis and e olu ion o he se um bioma ke . All o
he in o ma ion is aken oge he , and pa ien s a e classi ied in o h ee main ca ego ies o
p ognosis: good, in e media e o poo . This classi ica ion (Table 2) was de eloped by he
In e na ional Ge m Cell Cance Collabo a i e G oup (IGCCCG) in 1997 [43].
The mos common pa hs a e o chiec omy a e he ollowing: ac i e su eillance, sys-
emic he apy and e ope i oneal lymph node dissec ion (RPLND). Sys emic he apeu ic
s a egies like chemo he apy a e usually ese ed o highe isk cases when he e is al eady
me as asis, due o he possibili y o u he complica ions o he pa ien s [
5
]. RPLND is
p e e ed as he ea men o s age I o II e a omas bu is also a oided when possible
because o i s equen damaging e ec s on he ep oduc i e heal h o he pa ien s [
44
].
Mul iple s udies ha e been ca ied ou o assess he isks associa ed wi h he di e en he -
apeu ic app oaches, and a ecen me a-analysis published in 2021 by Pie o azio e al. [
45
]
summa ises hese s udies and unde lines he impo ance o conside ing he long- e m
oxici ies when choosing he bes pa h o wa d om case o case.
Cance s 2022,14, 1633 6 o 19
Table 2.
TGCT p ognosis classi ica ion guidelines by he IGCCCG [
43
]. The IGCCCG s a i ies
s age III pa ien s acco ding o h ee g oups: good p ognosis, in e media e p ognosis, and poo
p ognosis. AFP: alpha- e op o ein, hCG: human cho ionic gonado opin, LDH: lac ic dehyd ogenase
and PFS: p og ession- ee su i al.
GOOD PROGNOSIS
Non-seminoma Seminoma
Tes is/ e ope ineal p ima y umo
And
No non-pulmona y isce al me as ases
And
Good ma ke s (all o ):
AFP< 1000 ng/mL
hCG< 5000 iu/L (1000 ng/mL)
LDH< 1.5 ×uppe limi o no mal
56% o non-seminomas
5 yea s PFS 89%
5 yea su i al 92%
Any p ima y si e
And
No non-pulmona i isce al me as ases
And
No mal AFP, any hCG and any LDH
90% o Seminomas
5 yea s PFS 82%
5 yea su i al 86%
INTERMEDIATE PROGNOSIS
Non-seminoma Seminoma
Tes is/ e ope i oneal p ima y
And
No non-pulmona y isce al me as ases
And
In e media e ma ke s (any o ):
AFP ≥1000 and ≤10,000 ng/mL
hCG ≥5000 iu/L and ≤50,000 iu/L
LDH ≥1.5 ×N and ≤10 ×N
28% o non-seminomas
5 yea s PFS 75%
5 yea su i al 80%
Any p ima y sii e
And
Non pulmona y isce al me as ases
And
No mal AFP, any hCG, any LDH
10% o seminomas
5 yea s PFS 67%
5 yea su i al 72%
POOR PROGNOSIS
Non-seminoma Seminoma
Medias inal p ima y
O
Non-pulmona y isce al me as ases
O
Poo ma ke s (any o ):
AFP > 10,000 ng/mL
hCG > 50,000 iu/L (10,000 ng/mL)
LDH > 10 ×uppe limi o no mal
16% o non-seminomas
5 yea PFS 41%
5 yea su i al 48%
No pa ien s classi ied as poo p ognosis
2.4. TGCT Molecula Ma ke s
Molecula ma ke s a e use ul o ack he p og ess o he ea men s used and dis-
inguish be ween di e en ypes o umou s du ing he diagnos ic p ocess. These can be
de ec ed h ough his ological analysis by biopsy and by biochemical es s o blood o u ine
samples. In he case o TGCT, decisions a e made based on he pa ien ’s amily his o y
and he p esence o a ew ma ke s wi h limi ed diagnos ic and p ognos ic alue which
ha e been he same o decades [
46
]. Fu he s udy o his ield could lead o a ine so ing
o pa ien s acco ding o he po en ial isks o each ea men . In addi ion, mo e p ecise
and less agg essi e ea men s han cispla in-based chemo he apy could be de eloped
Cance s 2022,14, 1633 7 o 19
because his is he ea men ha is widely used oday, whose isks and side e ec s a e
eally nega i e o he pa ien [5,22].
2.4.1. His ological Ma ke s
One o he easies o ms o umou analysis is he s udy o biopsies. In his way, a so
o snapsho is aken o a sec ion o he umou a a speci ic poin in ime. These sec ions
can be analysed using immunohis ochemical ools o look o speci ic molecules. One o
he mos sea ched molecules is he ansc ip ion ac o OCT
3
4
(also known as POU5F1 and
Oc 4), which is ega ded as one o he key egula o s o plu ipo ency and is speci ic o
p imo dial ge m cells [
47
,
48
]. I de ec ed in adul es es, i implies he p esence o GCNIS, a
seminoma o emb yonal ca cinoma [47,48].
Nine y pe cen o TGCTs ac oss all di e en ypes ha e been obse ed o p esen an
isoch omosome o 12p o i(12p) [
49
]. E en in he o he 10% o cases, he e is usually an excess
o gene ic ma e ial in he p a m o ch omosome 12, which implies a ela ionship be ween he
genes encoded he e and TGCT, bo h o gonadal and ex agonadal o igin [
50
]. Fu he mo e,
his ch omosomal anomaly is also p esen in in si u ca cinomas like GCNIS, so i seems o
be use ul as a bioma ke du ing he i s s ages o umo igenesis o e en i s cause [
51
]. In
addi ion, a highe numbe o copies o i(12p) is connec ed o mo e agg essi e umou s, so his
ma ke can p o ide in o ma ion abou bo h diagnosis and p ognosis [
52
]. Some genes p esen
in i(12p) ha ha e been obse ed o appea mu a ed in di e en GCT and linked o TGCT
de elopmen a e he oncogene KRAS and he p o ooncogenes KIT and NRA [53].
Some p oblems make he use o his ological ma ke s in cance mo e di icul . Fi s ,
he e is a need o a biopsy, which implies an in asi e p ocedu e and a leas ce ain
sho - e m isks. In addi ion, biopsies only p o ide in o ma ion om a ce ain sec ion o
he umou which, due o umou he e ogenei y, is no always ep esen a i e o he whole,
and om a p ecise momen in ime, which limi s hei p ognos ic alue. The e o e, he
limi ed bioma ke sea ch o TGCT has ecen ly ocused on molecules p esen in blood and
plasma, which is conside ed a non-in asi e liquid biopsy.
2.4.2. Blood Plasma Ma ke s
P o eins
Th ee main p o eins p esen in blood samples ha e been used o decades in he
diagnosis, p ognosis and su eillance o TGCTs:
α
- e op o ein (AFP), he
β
subuni o
human cho ionic gonado opin (
β
-hCG) and Lac a e Dehyd ogenase (LDH) [
19
]. When a
es icula umou is suspec ed, a measu emen o hese h ee molecules in he blood o he
pa ien is aken and he changes in hose le els a e moni o ed om he e y beginning o
he end o he ea men o look o possible changes [
19
]. Ne e heless, nei he o hem is
speci ic o TGCT diagnosis so hey canno be conside ed pe ec diagnos ic ools. Ele a ed
le els o
β
-hCG can also indica e a diagnosis o o he cance s such as p os a e, bladde ,
u e h a o kidney cance s [
54
]. In addi ion, only 5–40% o seminoma umou s a e posi i e
o his ma ke and i does no p o ide p ognos ic in o ma ion [55,56].
Ele a ed AFP le els a e usually linked o NSGCTs [
19
,
57
]. In ac , he de ec ion o
highe han usual AFP in a cance p e iously desc ibed as a pu e seminoma indica es
mixed cha ac e is ics o e looked un il ha poin and al e s he diagnosis and he apeu ic
app oach acco dingly [
19
]. Howe e , high le els o AFP ha e also been obse ed in
hepa ocellula ca cinomas, ci ho ic li e s and pa ien s wi h hepa i is [57].
LDH aluesa egene allyused oassess hep ognosiso dissemina ednon-seminoma ous
umou s be o e, du ing and a e ea men [
19
,
58
]. While oughly hal o all ad anced es icu-
la cance pa ien s p esen highe han a e age LDH plasma le els, his bioma ke is e en
less speci ic o es icula cance han he p e ious wo, so decisions ega ding he apeu ic
app oaches a e ne e aken based on i alone [19].
Cance s 2022,14, 1633 8 o 19
Nucleic Acids
S udies o e he las wo decades ha e spa ked an in e es o e nucleic acid bioma ke s
in plasma and blood, speci ically mic o RNA (miRNA) and ci cula ing umou DNA
(c DNA) [
46
,
59
]. c DNA is gene ic ma e ial eleased in o he blood s eam om umou
cells h ough nec osis, apop osis o o he biological p ocesses. Recen publica ions ha e
a gued ha i s analysis would pain a pic u e o he s a us o he umou a a ce ain poin
in ime and, while o he echniques lack analy ic alue due o umou he e ogenei y, c DNA
could gi e in o ma ion abou he mo e agg essi e clones [
46
]. Mo eo e , i is qui e use ul
o iden i y pa ien s wi h TGCTs e en i he usual bioma ke le els a e no mal, ei he by
measu ing i s blood concen a ion o analysing i s me hyla ion pa e ns [
60
]. Ne e heless,
i equi es he use o e y sophis ica ed and sensi i e echnology and a highly skilled
echnical wo k o ce, which makes i di icul o use in clinical se ings.
Ano he ype o liquid biopsy would be ci cula ing umou cells (CTCs), which a e
sepa a ed om he p ima y umou du ing me as asis and en e he blood low [
46
]. A
ecen publica ion de ec ed CTCs in 18% o TGCT pa ien s and linked i o a mo e agg essi e
illness [
61
]. In gene al, he de ec ion o hese could be conside ed a sign o ac i e me as asis
and hus wo se p ognosis, bu i s wide applica ion has no been p o en ye .
Recen indings in his ield a e ela ed o se um mic oRNA o miRNA. These a e small
non-coding RNA molecules o a ound 22 nucleo ides ha in e ac wi h messenge RNA as
a kind o egula ion sys em ha akes pa in nume ous egula o y p ocesses, including
malignan ans o ma ion [
62
]. Like i(12p), miR-371a-3p appea s in ele a ed concen a ions
in 90% o TGCTs [
63
]. This las miRNA molecule is p esen in blood plasma and i s le el
a ia ions a e mo e ep esen a i e han AFP and
β
-hCG a ia ions o TGCT moni o ing.
E en hough i is no a comple ely speci ic ma ke , i s ep esen a i e alue inc eases when
combining i s analysis wi h o he miRNA molecules [
64
]. O he miRNA molecules ha e
been iden i ied as possible ma ke s wi h diagnos ic and p ognos ic alue, as well as being
use ul o moni o he e icacy o he apies in eal ime. Plasma le els o miR-371 ha e been
p o en o be linked o ac i e malignancy in NSGCT pa ien s ha ha e al eady unde gone
chemo he apy [
65
]. To maximise hei p ognos ic o diagnos ic alue, miRNA ma ke s a e
o en analysed in clus e s.
The se um bioma ke s a e mainly used in p ognosis o TGCTs, bu hey can be also
used o diagnosis. In ac , i hese molecules appea in abho en concen a ions a e an
o chiec omy, hey can indica e p e iously o e looked me as a ic si es [
66
]. Fu he mo e,
hey allow clinicians o ge in o ma ion wi hou he use o in asi e echniques, o pain a
mo ing pic u e o he de elopmen o he disease and guide possible ea men changes.
2.4.3. Recen Disco e ies and Fu u e P ospec s
Se e al a emp s ha e been made o ind possible addi ions o he classically used
ma ke p o eins, e.g., Placen al Alkaline Phospha ase (PLAP), TRA-1-60, Neu o-speci ic
Enolase (NSE), Lec in- eac i e AFP and N-glycans, bu mos o hem ha e no been as
use ul as ini ially hough , due o high alse-posi i e a es (TRA-1-60 and NSE), ele a ed
le els in smoke s (PLAP) o he inabili y o ac ually deli e in clinical se ings [46].
The e has been some p og ess ega ding his ological ma ke s, e en hough hese a e
only use ul a e o chiec omy. Some examples o ha a e he ch oma in a chi ec u al ac o s
o he HMGA amily, he ansc ip ional ep esso PATZ, he de elopmen al egula o
GPR30 and he cell cycle egula o Au o a B kinase. These ha e diagnos ic alue when
analysing he his ology o he umou s, and GPR30 and Au o a B Kinase a e cu en ly
being s udied in he hope o c ea ing no el he apeu ic app oaches [67].
Recen
in i o
s udies show ha TR4 ansc ip ion ac o o e exp ession could be
a use ul bioma ke o case o case p ognosis in pu e seminoma [
68
]. This molecule is
linked o he epi helial-mesenchymal ansi ion (EMT), which is a known s ep in me as a ic
p ocess, bu u he s udies a e needed o alida e i s use ulness
in i o
. Howe e , he
mos p omising ield o s udy in TGCT bioma ke s is s ill ha o miRNAs, and mul iple
g oups ha e ocused hei esea ch on hem.
Cance s 2022,14, 1633 9 o 19
The ield o s udy o TGCTs has been unde explo ed due o i s less malignan na u e.
The u he s udy o possible bioma ke s wi h diagnos ic and p ognos ic alue would
enable clinicians o be e assess he bene i s o adju an he apies agains hei d awbacks.
In ac , o e ing adju an he apies o all s age I es icula cance s would o e - ea hose
who would no de elop u he diso de s (abou 70% o hem) [
46
]. Tha o e ea men
inc eases he isk o second malignancies, oxici y and ca dio ascula disease jus in he
case o cispla in-based chemo he apy [
22
]. Be e s a i ica ion o pa ien s could lead o
a lowe need o adia ion imaging echniques, which in u n inc ease he isk o u he
malignancies [
46
]. Much emains o be s udied; conside ing he connec ion o TGCTs wi h
aul y spe ma ogenesis, i could be in e es ing o lea n mo e abou hese mechanisms and
hei molecula basis o sea ch o possible candida e molecules o he apeu ic a ge s.
2.5. Spe ma ogenesis: Key Poin s o Conside
Be o e p oceeding wi h he main opic o in e es , i is use ul o ha e a b ie eminde
abou he biogenesis o he male game e, since he e a e in e es ing aspec s o ake in o
accoun when assessing he possible molecula a ge s, bo h he apeu ic and diagnos ic,
ela ed o es icula cance .
Spe ma ogenesis akes place in he epi helium o semini e ous ubules wi h he physi-
cal suppo o Se oli cells and ho monal suppo o in e s i ial Leydig cells. Tes os e one
p oduc ion by Leydig cells kick-s a s he i s di ision o spe ma ogonial s em cells. The
i s meio ic di ision esul s in o wo seconda y spe ma ocy es and he second meio ic
di ision in o ou ound spe ma ids in e wo en by hei cy osol and cy oskele ons, because
o incomple e cy okinesis.
Fou ound haploid spe ma ids a e ans o med in ou spe ma ozoa ( he male game e)
in a p ocess called spe miogenesis. I consis s o h ee main e en s: nucleus compac ion,
ac osome o ma ion and lagella de elopmen . These e en s a e accompanied by a se e e
s uc u al es uc u ing, pa ial cy oplasm emo al and mi ochond ia eo ganisa ion. Du -
ing his p ocess, he cells mo e om he base o he lumen o he semini e ous ubule,
whe e he ma u e spe ma ids a e eleased.
Du ing spe miogenesis, he cy oskele on plays an impo an ole in he s uc u al
eo ganisa ion and biogenesis p ocesses o he ac osome, a pouch-like o ganelle whe e he
hyd oly ic enzymes necessa y o he e ilisa ion o eggs a e s o ed. I esul s om he
usion o p e-ac osomal esicles mig a ing om he ans Golgi ne wo k in he an e io
egion o he nucleus [
69
]. The cy oskele on o ms he ac osome-ac oplaxome-manche e,
a s uc u e ha is necessa y o anspo he p e-ac osomal esicles o he p oximi y o
he nuclea en elope [
70
,
71
]. I is a key s uc u e essen ial o he eo ganisa ion o he
cy oplasm, he s uc u al changes o he nucleus i sel and he elonga ion o he cell [
71
].
The e a e o he ele an cy oskele al s uc u es in spe miogenesis, like he axoneme o he
lagellum. All o hem a e c i ical o achie e he co ec ou come o elonga ed spe ma ids;
in cases o s uc u al p oblems, hese esul in spe ma ozoid mal o ma ions, also known as
e a ozoospe mia [72].
A huge pe cen age o people su e ing om TGCTs had a his o y o abno mal spe -
ma ogenesis [
73
]. This implies a leas a pa ial ela ionship be ween umo igenesis and
anomalies du ing spe ma ogenesis. P elimina y da a om ou esea ch g oup in e a ospe -
mic mice ha e shown high le els o PCSK6, an indica o o me as asis isk in a ious ypes
o cance . The e o e, he e is s ill a lo o know abou spe ma ogenesis, he molecula
pa hways ha con ibu e o i and i s ela ion o TGCT de elopmen . Conside ing he lack
o speci ic bioma ke s o seminoma, his p ocess could be a good s a ing poin o iden i y
new candida e molecules.
3. P op o eine Con e ases (PCs) as Molecula Ta ge s o Tes icula Cance
The unc ion o nume ous p o eins is egula ed by in ica e mechanisms necessa y
o he co ec unc ioning o he cell. This includes he pos - ansla ional modi ica ions o
p o eins. Wi h he disco e y o p oinsulin in 1967, i became clea ha some p o eins o
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