Testis-sparing Surgery: A Single Institution Experience

Histopathological Analysis in Testicular Tumors: 10 Years of Experience

Introduction. This study aims to review the morphological and immunohistochemical features of testicular tumors and compare them with prognostic parameters. Methods. Testicular tumors diagnosed between January 2011 and September 2021 were reviewed. Patient age, tumor subtype, size, spread, lateralization, number of foci, and immunohistochemical results were recorded. Results. A total of 121 tumors were detected, of which 108 (89%) were germ cell tumors (GCTs). Of the germ cell tumors, 70 (65%) were found to be pure type, and 38 (35%) were mixed germ cell tumors. The ratio of pure seminoma among GCTs was 56/108 (52%). Lymphatic/vascular invasion (LVI) was detected in 48/121 (40%), rete testis invasion in 32/121 (26%), hilar soft tissue invasion in 10/121 (8%), epididymal invasion in 5/121 (4%), and spermatic cord invasion in 5/121 (4%) patients. Lymphatic/vascular invasion was observed in 6 (22%) of 27 germ cell tumors smaller than 3 cm in size, and rete testis invasion was observed in 2 (7%), while in 40 (55%) of the 73 germ cell tumors of 3 cm and above, lymphatic/vascular invasion was seen, and 26 (36%) of them had rete testis invasion. Immunohistochemical results contributed significantly to the determination of tumor components and rates, especially in mixed germ cell tumors. Conclusion. Most of the tumors were germ cell tumors, and the majority were seminomas. Lymphatic/vascular invasion and rete testis invasion rates increase as the tumor diameter increases, which is more evident when the 3 cm cut-off value is taken into account (P < 0.005).

SAVE Testis-sparing score: a multicenter retrospective study of a novel predictive tool for quantifying testicular tumors

BACKGROUND

Testis-sparing surgery (TSS) is a safe treatment for patients with benign testicular tumors. Presently, assessments for evaluating the suitability of TSS are poorly standardized, partially because testicular anatomical elements cannot be quantitatively described.

MATERIALS AND METHODS

The authors developed a scoring method known as the SAVE testis-sparing score based on four critical and accessible anatomical features of a testicular tumor. The SAVE score ranges from 0 to 8 and is divided into four risk classes ( low , medium , high , and extremely high ) to evaluate the feasibility of TSS, wherein low-risk indicates high feasibility and vice versa. This study included 444 testicular tumor patients from eight centers. Among them, 216 patients (model group: 151 patients, validation group: 65 patients) were included in the modeling analysis, and the other 228 patients from children's centers were included in the proportion analysis. Using retrospective data, patient characteristics associated with surgical methods were identified. Furthermore, a multivariate logistic regression model was built quantify the associations between these characteristics and the surgery method. The receiver operator characteristic curve was used to evaluate the classification efficiency of SAVE.

RESULTS

The SAVE testis-sparing score includes size (tumor size as maximal diameter), available testicular tissue volume, volume ratio of the tumor to the testis, and the exophytic / endophytic properties of the tumor. The SAVE scoring system accurately classified the suitability of TSS based on the complexity of benign testicular tumors.

CONCLUSION

The SAVE score is a reproducible and robust tool for quantitatively describing the anatomical characteristics of benign testicular tumors and guide the preoperative evaluation of TSS.

Small Testicular Masses: Contemporary Diagnostic and Treatment Strategies, Future Directions, and Knowledge Gaps

The incidental discovery of small masses in the testicles of young men is becoming an increasing clinical dilemma. We are learning that the malignancy rate in masses ≤ 2 cm is much lower than traditionally thought and could be as low as 13% to 21%. The challenge remains in identifying which of these patients harbor malignant tumors that need to be treated, and benign lesions that could be safely surveilled. The aim of this narrative review is to discuss the current scientific evidence, diagnostic work-up, and treatment strategies for small testicular masses. We also discuss selection criteria, follow-up schedules and triggers for intervention for the surveillance of these small testis masses. Furthermore, we give a set of recommendations for assessing and treating these patients, based on the available literature and our experience at a dedicated testicular cancer clinic.

Testicular Neoplasms: Primary Tumour Size Is Closely Interrelated with Histology, Clinical Staging, and Tumour Marker Expression Rates-A Comprehensive Statistical Analysis

The role of primary tumour size (TS) in the clinical course of testicular tumours is incompletely understood. We retrospectively evaluated 641 consecutive patients with testicular neoplasms with regard to TS, histology, clinical stage (CS), serum tumour marker (STM) expression and patient age using descriptive statistical methods. TS ≤ 10 mm was encountered in 13.6% of cases. Median TS of 10 mm, 30 mm, 35 mm, and 53 mm were found in benign tumours, seminomas, nonseminomas, and other malignant tumours, respectively. In cases with TS ≤ 10 mm, 50.6% had benign tumours. Upon receiver operating characteristics analysis, TS of > 16 mm revealed 81.5% sensitivity and 81.0% specificity for detecting malignancy. In subcentimeter germ cell tumours (GCTs), 97.7% of cases had CS1, and CS1 frequency dropped with increasing TS. Expression rates of all STMs significantly increased with TS. MicroRNA-371a-3p (M371) serum levels had higher expression rates than classical STMs, with a rate of 44.1% in subcentimeter GCTs. In all, TS is a biologically relevant factor owing to its significant associations with CS, STM expression rates and histology. Importantly, 50% of subcentimeter testicular neoplasms are of benign nature, and M371 outperforms the classical markers even in subcentimeter tumours.

Testis-sparing Surgery in Adult Patients with Germ Cell Tumors: Systematic Search of the Literature and Focused Review

Testis-sparing surgery (TSS) is a guideline-recommended treatment option for men with synchronous or metachronous bilateral testicular germ-cell tumor (GCT) or GCT in a solitary testicle. The tumor volume should not exceed 50% of the total testicular volume and serum concentrations of both testosterone and luteinizing hormone should be within the normal ranges. After tumor enucleation, patients should undergo adjuvant radiation of the testicle in case of germ cell neoplasia in situ. The local relapse rate is approximately 4% if TSS is performed properly. Physiological serum testosterone concentrations are achieved in more than 85% of patients, and approximately 50% of men with intact spermatogenesis can achieve paternity. The risk of systemic metastases is not increased by TSS. PATIENT SUMMARY: Testis-sparing surgery is the treatment of choice for men with testicular cancer in both testes or in men who have just one testis. In more than 85% of patients this approach results in maintenance of normal testosterone levels.

Is testis sparing surgery safe in patients with incidental small testicular lesions referring to a fertility center? A retrospective analysis reporting factors correlated to malignancy and long-term oncological outcomes

PURPOSE

To define predictors of malignancy after Testis sparing surgery (TSS) in patients referring to a fertility center with incidental small testicular lesions. Sub analyses were performed to assess predictors of Leydig cell hyperplasia and Leydig cell tumor.

MATERIALS AND METHODS

We performed a retrospective analysis of a single institutional database including patients treated with TSS between 2002 and 2020. All patients who underwent TSS as a first line surgical approach for incidentally detected lesions found during fertility evaluation were included.

RESULTS

Data of 64 patients were collected. The median follow up was 58 months and no recurrences were observed. At univariable logistic regression multifocal lesions, hypervascularization, microlithiasis, age and lesion size were significantly associated with malignancy. At multivariable logistic regression lesion dimension, hypervascularization and multifocal lesions were predictors of malignancy. Lesions smaller than 5 mm proved to be benign in 96.6% of the cases (32/33). Intraoperative color of the lesion and US pattern of vascularization were predictors at multivariable logistic regression for Leydig cell hyperplasia and Leydig cell tumor.

CONCLUSION

Ultrasonographic characteristics and intraoperative appearance of the lesion can predict the malignant nature of small testicular lesions, guiding their surgical management in patients referring to a fertility center. Based on our experience, clinicians may safely perform TSS in carefully selected patients.

Outcomes of organ-sparing surgery for adult testicular tumors: A systematic review of the literature

Objective

To perform a systematic review on the effects of testicular sparing surgery (TSS) on the oncological, functional, and hormonal outcomes of adults with testicular tumors.

Methods

A literature search was performed after PROSPERO registration (CRD42020200842) and reported in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methods. We conducted a systematic search of Medline (Ovid), Embase, Cochrane CENTRAL, CINAHL, Scopus, Web of Science, ClinicalTrials.gov, and the WHO/ICTRP from inception to November 20, 2020. Manuscripts and published abstracts were included if they involved testis-sparing surgery (TSS) and contained data on any outcomes related to fertility, hormonal parameters, or oncological control, or if they evaluated surgical technique.

Results

Our initial search yielded 3,370 manuscripts, with 269 of these screened for full-text eligibility. After our exclusion criteria were applied, 32 studies were included in the final analysis. Oncological outcomes were obtained from 12 studies (average follow-up 57.8 months), functional data from 26 studies (average follow-up 49.6 months), fertility information from 10 studies (average follow-up 55.8 months), and data on nonpalpable tumors from 11 studies (average follow-up 32.1 months). Oncological control appears to be excellent in studies that reported these outcomes. Presence of germ cell neoplasia in situ was controlled with adjuvant radiation in nearly all cases. Functional outcomes are also promising, as development of primary and compensated hypogonadism was rare. Semen parameters are poor preoperatively among men with benign and malignant testis tumors, with occasional decline after TSS. Frozen section analysis at the time of surgery appears to be very reliable, and the majority of nonpalpable tumors appear to be benign.

Conclusions

TSS is a safe and efficacious technique with regards to oncological control and postoperative hormonal function based on retrospective, noncontrolled studies. TSS avoids unnecessary removal of benign testicular tissue, and should be given serious consideration in cases of nonpalpable, small tumors under 2 cm. In cases of malignancy, TSS can safely avoid anorchia in men with bilateral tumors and in men with solitary testicles. The use of the operating microscope, while theoretically promising, does not necessarily lead to better outcomes, however data are limited.

Testicular tumors in the pediatric patient

Testicular cancer is a rare malignancy that demonstrates variability in histopathologic features, treatment protocols, and outcomes based on a patient's age at presentation. In the pediatric population, puberty provides an important timestamp for evaluating and understanding the disease process. Prepubertal males, often designated as < 11 years of age, are more likely to present with benign disease. In contrast, the majority of post-pubertal testicular masses are malignant. Other factors, such as race/ethnicity, family history, and personal medical history can influence a patient's risk for malignancy as well. Serum tumor markers (STM) and histologic evaluation are key for diagnosis and for determining management. While normal STMs in a pre-pubertal patient likely qualify a patient for testis-sparing surgery, radical orchiectomy is the gold standard for post-pubertal patients, regardless of STM levels. Cross-sectional imaging is essential for staging and may be done before or after surgical intervention depending on the clinical scenario. Excellent survival outcomes are often achieved regardless of disease risk, with low-stage disease managed safely with surveillance. Surveillance usually consists of STM and imaging monitoring. If adjuvant therapy is indicated, a multi-disciplinary team approach is paramount. This approach should include following pediatric vs. adult protocols based of the patient's pubertal status in order to achieve optimal oncologic outcomes.