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Case History

image A 19-year-old male presented with a 7-month history of right leg pain which was attributed to a football injury, and 4 kg weight loss prior to diagnosis. There was no significant personal or family history of cancer. His performance status was 1. Investigations revealed a localized right femoral mass invading the right hip joint in keeping with a bone sarcoma. Biopsies confirmed a high-grade osteoblastic osteosarcoma. The Sarcoma MDT recommended chemotherapy (methotrexate, doxorubicin and cisplatin) and surgery.

At his initial oncology appointment, urgent intensive multi-agent chemotherapy was outlined, given over several days, for 3 weeks out of every 5, for up to 9 months. Prechemotherapy investigations included a baseline PET-CT staging scan, GFR (glomerular filtration rate) study, virology (HIV and Hepatitis B and C), echocardiogram and audiogram. He was referred for sperm banking to preserve fertility.

The patient was unable to produce a semen sample by masturbation and was therefore given a trial of sildenafil (Viagra ®) 100 mg on an empty stomach, 1–2 hours prior to ejaculation. This was unsuccessful, so baseline FSH, LH and testosterone (taken early morning whilst fasting) and clotting were performed and he underwent electroejaculation (EEJ) under a general anaesthetic. As urgent chemotherapy was scheduled in the next 48 hours, the patient was simultaneously listed for a testicular sperm extraction (TESE) in case the EEJ was unsuccessful. An embryologist was also in theatre to examine samples and advise on the next steps.

Sperm samples from the EEJ procedure were abnormal with no viable sperm seen and so the decision was made to proceed to a surgical sperm retrieval. A bilateral TESE was performed via a 2 cm small scrotal incision. Tissue was collected, analyzed and frozen in 10 vials with a recommendation for future intracytoplasmic sperm injection (ICSI) use.

The patient had no immediate complications and was able to start his first cycle of chemotherapy without delay.

What was the goal of cancer treatment for this patient and why prioritize fertility preservation in this case?

What non-surgical options are available for patients unable to produce adequate sperm?

What are the surgical options available to patients prior to commencing oncological treatment and what is the evidence?

What can we offer to male patients who remain azoospermic following chemotherapy and have not cryopreserved sperm?

What are the options for younger patients?

What was the goal of cancer treatment for this patient and why prioritize fertility preservation in this case?

The main goal of treatment is to cure the patient with his localized disease. The current UK standard for high-grade osteoblastic osteosarcoma involves a multi-agent chemotherapy regimen of doxorubicin, cisplatin and high-dose methotrexate, with a 5-year overall survival rate around 56%.1 With this diagnosis and urgent treatment requirement, options for fertility preservation are time limited. Increasing survival rates are expected with improvements in oncological care, with approximately 60% of male patients diagnosed with an invasive cancer aged ...

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