Organ-sparing approaches for testicular masses

Diagnosis and management of indeterminate testicular lesions

The sophistication and accessibility of modern-day imaging result in frequent detection of small or equivocal lesions of the testes. Traditionally, diagnosis of a testicular lesion with any possibility of malignancy would usually prompt radical orchidectomy. However, awareness is growing that a substantial proportion of these lesions might be benign and that universal application of radical orchidectomy risks frequent overtreatment. Given the potentially profound effects of radical orchidectomy on fertility, endocrine function and psychosexual well-being, particularly in scenarios of an abnormal contralateral testis or bilateral lesions, organ-preserving strategies for equivocal lesions should be considered. Image-based active surveillance can be applied for indeterminate lesions measuring ≤15 mm with a low conversion rate to surgical treatment. However, these outcomes are early and from relatively small, selected cohorts, and concerns prevail regarding the metastatic potential of even small undiagnosed germ cell tumours. No consensus exists on optimal surveillance (short interval (<3 months) ultrasonography is generally adopted); histological sampling is a widespread alternative, involving inguinal delivery of the testis and excisional biopsy of the lesion, with preoperative marking or intraoperative ultrasonographic localization when necessary. Frozen section analysis in this context demonstrates excellent diagnostic accuracy. Histological results support that approximately two-thirds of marker-negative indeterminate solitary testicular lesions measuring ≤25 mm overall are benign. In summary, modern imaging detects many small indeterminate testicular lesions, of which the majority are benign. Awareness is growing of surveillance and organ-sparing diagnostic and treatment strategies with the aim of minimizing rates of overtreatment with radical orchidectomy.

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.

Organ-Sparing Surgery for Testicular Germ Cell Tumors: A Current Perspective

Background and Objectives: We aimed to evaluate the oncological and functional outcomes of organ-sparing surgery for testicular germ cell tumors, a procedure that seeks to strike a balance between effective cancer control and organ preservation, in the treatment of testicular tumors. We aimed to discuss the surgical technique and complications, and determine the appropriate candidate selection for this approach. Material and Methods: A comprehensive literature search was conducted to identify relevant studies on organ-sparing surgery for testicular tumors. Various databases, including PubMed, Embase, and Cochrane Library, were used. Studies reporting on surgical techniques, complications, and oncologic and functional outcomes were included for analysis. Results: Current evidence suggests that organ-sparing surgery for testicular germ cell tumors can be considered a safe and efficacious alternative to radical orchiectomy. The procedure is associated with adequate oncological control, as indicated by low recurrence rates and low complication rates. Endocrine testicular function can be preserved in around 80-90% of patients and paternity can be achieved in approximately half of the patients. Candidate selection for this surgery is typically based on the following criteria: pre-surgery normal levels of testosterone and luteinizing hormone, synchronous or metachronous bilateral tumors, tumor in a solitary testis, and tumor size less than 50% of the testis. Conclusions: Organ-sparing surgery for testicular germ cell tumors offers a promising approach that balances oncological control and preservation of testicular function. Further research, including large-scale prospective studies and long-term follow-ups, is warranted to validate the effectiveness and durability of organ-sparing surgery and to identify optimal patient selection criteria.

DigiMir Test: Establishing a Novel Pipeline for MiR-371a Quantification Using Droplet Digital PCR in Liquid Biopsies From Testicular Germ Cell Tumor Patients

Testicular germ cell tumors (TGCTs) are the most common cancers in young-adult male patients aged between 15 and 39 years. Hsa-miR-371a-3p is currently the most reliable biomarker for diagnosis and monitoring of these patients non-invasively in liquid biopsies, and it is destined to be introduced in the clinic due to improved performance compared to the classical serum tumor markers available. Current studies have focused on real-time quantitative PCR (RT-qPCR) protocols for its determination; still, some challenges remain, since these protocols often require preamplification steps (costly and time-consuming), and report relative levels normalized to a housekeeping microRNA, not always performed the same way. Droplet digital PCR (ddPCR) shows the promise to overcome these challenges, skipping normalization and preamplifications, but has hardly been explored in the field of TGCTs. In this work, we provide a report of a ddPCR-based pipeline for the quantification of hsa-miR-371a-3p (the DigiMir pipeline) and compare it with two RT-qPCR protocols. A total of 107 plasma samples were investigated in the validation setting. The DigiMir pipeline detected TGCTs in a manner representative of tumor burden, with a sensitivity and specificity of 94% and 100%, respectively, outperforming the combined sensitivity of all three classical serum tumor markers (61.5%). Therefore, in this proof-of-concept investigation, we have shown that the DigiMir pipeline constitutes a new promising methodology to accurately report hsa-miR-371a-3p in the clinical setting.

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.

Evaluation of an Algorithm for Testis-Sparing Surgery in Boys with Testicular Tumors: A Retrospective Cohort Study

Aim: This study reports surgical treatment and its outcome for boys with a testicular tumor, in order to analyze the considerations of testis-sparing surgery (TSS) and investigate whether, in retrospect, treatment was according to a recently developed algorithm. Methods: We retrospectively reviewed boys with testicular tumors who underwent surgical treatment between January 2000 and June 2020 at the Wilhelmina’s Children’s Hospital and the Princess Máxima Center for Pediatric Oncology, The Netherlands. Medical records were searched for clinical characteristics and outcome. Results: We identified 31 boys (median age = 5.5 years) with a testicular tumor, 26 germ cell tumors (GCTs), four sex cord-stromal tumors, and one gonadoblastoma. Seventeen boys (median age = 1.5 years) had malignant and 14 (median age = 3.6 years) had benign tumors. Four boys with benign GCTs were treated with TSS, 25 with radical inguinal orchiectomy (RIO), and 2 with scrotal orchiectomy. No recurrence or testicular atrophy was reported. All boys with benign testicular tumors were treated as suggested by the algorithm, except for one boy treated with RIO. Conclusion: Retrospective analysis of surgical treatment of prepubertal boys with benign testicular tumors showed that TSS appears to be safe, and should be considered based on clinicoradiological data, in line with our algorithm.

Vascularity of Intra-testicular Lesions: Inter-observer Variation in the Assessment of Non-neoplastic Versus Neoplastic Abnormalities After Vascular Enhancement With Contrast-Enhanced Ultrasound

The aim of this study is to assess the additional benefit of contrast-enhanced ultrasound (CEUS) over conventional ultrasonography (US) in identifying intra-testicular abnormalities among observers of different experiences. In this study, 91 focal testicular lesions (46 neoplastic, 45 non-neoplastic) imaged with gray-scale US/Doppler US and CEUS were classified using a 5-point scale. Three experienced and four inexperienced observers rated each lesion using gray-scale/color Doppler US alone and then with the addition of CEUS. Improved diagnostic specificity and accuracy with the addition of CEUS was observed for both experienced (specificity: 71.1% vs. 59.3%, p = 0.005; accuracy: 83.5% vs. 76.9%, p = 0.003) and inexperienced observers (specificity: 75.6% vs. 51.7%, p = 0.005; accuracy: 80.2% vs. 72.0%, p < 0.001). Significant inter-observer variability between the experienced and inexperienced observers when assessing conventional US alone was eliminated with the addition of CEUS. CEUS improves diagnostic accuracy of focal intra-testicular lesions for both experienced and inexperienced observers and reduces inter-observer variability in inexperienced operators.

Testis Sparing Surgery in Pediatric Testicular Tumors

Simple Summary

Testis sparing surgery (TSS) is a safe treatment option in selected cases of testicular tumors in adults, focusing on technical feasibility, oncologic safety, preserving of testicular function, and long-term outcome. This surgical technique is also increasingly being considered in children, as benign tumors are more common in this population. With this systematic review, we aim to evaluate outcome of TSS and to investigate under which circumstances TSS can be considered safe in boys with testicular tumors. Based on the current practice described in this systematic review, combined with the outcome of TSS, we would like to suggest an algorithm to guide clinicians in determining the appropriate surgical treatment in prepubertal patients less than 12 years of age with a testicular tumor. TSS may lead to improved testicular function and quality of life in boys with testicular tumors.

Abstract

Objective: The purpose of this review is to evaluate the outcomes of testis sparing surgery (TSS) and to investigate under which circumstances TSS can be considered a safe treatment option in pediatric patients with testicular tumors. Methods: A database search was performed in Cochrane, Pubmed, and Embase for studies that focused on TSS as treatment for testicular tumors in the pediatric population, excluding reviews and single case reports. Results: Twenty studies, describing the surgical treatment of 777 patients with testicular tumors, were included in the analysis. The majority of pediatric patients with benign germ cell tumors (GCTs) (mean age: 3.7 years) and sex cord-stromal tumors (SCSTs) (mean age: 6.6 years) were treated with TSS, 61.9% and 61.2%, respectively. No cases of testicular atrophy occurred. Four of the benign GCTs, i.e., three teratomas and one epidermoid cyst, recurred. No cases of recurrence were reported in patients with SCSTs. Of the 243 malignant GCTs (mean age: 4.2 years), only one patient had TSS (0.4%). Conclusion: TSS is a safe treatment option for prepubertal patients less than 12 years of age with benign GCTs and low grade SCSTs.

The role of partial orchidectomy in the management of small testicular tumours: Fertility and endocrine function

BACKGROUND

Radical orchidectomy in patients who are subsequently diagnosed with benign testicular tumours represents an overtreatment due to the deleterious effects on endogenous testosterone, fertility and body image. For these reasons, the option of partial orchidectomy (PO) should be considered in certain groups of patients. Patients with bilateral tumours (synchronous or metachronous) or a solitary testis where the lesion is no greater than 30% of the volume of the testis could be considered for a PO. Evidence has shown that PO is effective for small testicular masses with excellent survival and recurrence rates.

OBJECTIVES

Highlight the feasibility of maintaining post-operative fertility or normal semen parameters and endocrine function following PO.

MATERIALS AND METHODS

Data for this review were obtained through a search of the PubMed database. Papers were required to be in English and focus on adult human males.

RESULTS

Eligible and relevant papers were assessed for data regarding fertility, semen parameters and endocrine function following PO for a small testicular mass (STM).

CONCLUSION

It is possible to preserve both fertility and endocrine function after PO. Although patients may still require adjuvant radiotherapy for concomitant intratubular germ cell neoplasia (ITGCN) which results in subfertility, endocrine function is still conserved. However, it is possible to postpone radiotherapy and continue with clinical surveillance for the purposes of fertility preservation.

Partial orchiectomy: The Princess Margaret cancer centre experience

INTRODUCTION

Radical orchiectomy (RO) is the standard treatment for a testis cancer. Organ sparing surgery can be considered in the setting of a solitary functioning testis or bilateral tumors. It has also been suggested as an alternative to RO for small lesions. In this study we report our partial orchiectomy (PO) experience.

METHODS

We performed a retrospective review using our prospectively maintained database analyzing PO.

RESULTS

Between 1983 and 2018, 77 patients underwent PO. Mean age was 31.3 years (range 17-56). A lesion was palpable in 70 (90.9%) and median lesion size 14.1 mm (range 3-35 mm). Reasons for PO included ``small lesion" in 39 (50.6%); solitary functioning testis in 30 (39%); bilateral lesions in 6 (7.8%); or assumed benign lesion in 1 (1.3%). Median follow-up was 43.5 months (range 1-258). Lesion histology was benign in 25 (32.5%). A positive surgical margin was noted in 6 (7.8%) with none developing local or distant recurrence. Sixteen (20.8%) patients underwent salvage ipsilateral RO at a median of 3 months (range 0-46). Reasons for salvage RO included a radiologically detected lesion in 7, palpable lesion in 4, positive surgical margin in 3 and adverse pathology in 2 patients. Malignant histology was present in 12 (75%) of the salvage RO specimens. There were no reported Clavien-Dindo Grade 3 to 5 complications.

CONCLUSION

Organ sparing surgery is a safe and feasible approach to small testis lesions. For the third with benign disease, and even those with malignant histology, a RO can be avoided in carefully selected patients.

The survival and prognostic factors of primary testicular lymphoma: two-decade single-center experience

This study aims to investigate the effect of different local testicular treatments and validate common prognostic factors on primary testicular lymphoma (PTL) patients. We retrospectively reviewed the clinical records of 32 patients from 1993 to 2017 diagnosed with PTL and included 22 patients for analysis. The Kaplan–Meier method, Log-rank test, and multivariate Cox proportional hazard regression analysis were applied to evaluate progression-free survival (PFS), overall survival (OS), and determine prognosis predictors. The median follow-up time was 30 months. Median OS and PFS were 96 months and 49 months, respectively. In univariate analysis, advanced Ann Arbor stage (III/IV) (P < 0.001), B symptoms (P < 0.001), and extranodal involvement other than testis (P = 0.001) were significantly associated with shorter OS and PFS. In multivariate analysis, Ann Arbor stage was significantly associated with OS (OR = 11.58, P = 0.049), whereas B symptom was significantly associated with PFS (OR = 11.79, P = 0.049). In the 10 patients with the systemic usage of rituximab, bilateral intervention could improve median OS from 16 to 96 months (P = 0.032). The study provides preliminary evidence on bilateral intervention in testes in the rituximab era and validates common prognostic factors for Chinese PTL patients.

Management of Primary Testicular Tumor

In any man with a solid testicular mass, cancer should be considered until proven otherwise. Radical inguinal orchiectomy is the treatment of choice in patients with testis mass. Placement of a testicular prosthesis is safe with a very low complication rate and should be offered to all patients undergoing radical orchiectomy. In patients with widespread or life-threatening advanced disease, delayed orchiectomy following chemotherapy is recommended. Testis-sparing surgery can be performed in highly selected patients with solitary testicle mass, bilateral testicular tumors, or strong suspicion of a benign lesion.

Testis-sparing surgery: Experience in 13 patients with oncological and functional outcomes

INTRODUCTION

We present oncological and functional outcomes of patients who underwent testis-sparing surgery (TSS).

METHODS

Overall, 13 patients were included. Mean patient age was 29.9±12.5 years. In five patients, TSS was performed for sequential bilateral testicular tumours. One patient underwent concurrent left radical orchiectomy and right TSS. In eight patients with normal contralateral testis, seven underwent left and one underwent right TSS.

RESULTS

Mean pathological tumour size was 14.6±12.5 mm. Intraoperative frozen section evaluation of the mass was performed in eight patients that revealed benign lesions. No intraoperative tumour bed biopsies were taken in this patient group. Regarding the remaining five patients, intraoperative tumour bed biopsies were taken and testicular intraepithelial neoplasia (TIN) was reported in two (40%) patients; no local testicular radiotherapy was given postoperatively. Tumour pathology was malignant in all but one lesion, including Leydig cell tumour (n=1), seminoma(n=2), embryonal carcinoma (n=1), and adenomatoid tumour (n=1). During 47.2±22.5 months of followup, local recurrence was detected in one patient who underwent radical orchiectomy. No additional local recurrence or systemic metastasis was identified in other patients with malignant lesions. For patients with malignant tumours, of the three patients with a normal preoperative testosterone levels, testosterone level was normal in one patient (with no erectile dysfunction [ED]) and was decreased in two patients (with ED) following TSS. No ED was reported in the nine patients with benign lesions.

CONCLUSIONS

In carefully selected cases, TSS appears to be a safe, feasible procedure with adequate cancer control that could preserve sexual function.

Synchronous bilateral testis cancer: clinical and oncological management

Synchronous bilateral testis cancer (SBTC) is a rare event. It represents only 0.5–1% of all new cases of testicular cancer. Patients with this disease require careful management for psychological, oncological, and medical problems.

We performed a PubMed search for all series that reported SBTC. We considered only articles in English, reporting on more than three cases. We also performed an analysis of the reported evidence regarding testosterone replacement and surgical treatment.

We found 10 studies satisfying inclusion criteria for a total of 73 patients. The majority are bilateral seminoma, which present with a low stage at diagnosis, and mixed histology tumours, both with a good overall survival. On the other hand, cases with bilateral non-seminoma histology are associated with poor prognosis and high stage at presentation.

Testis-sparing surgery should be an eligible choice in selected cases, to preserve fertility and avoid testosterone deficiency. Multiple biopsies are recommended in these patients, and in the case of intratubular germ cell neoplasia (ITGCN) presence, scrotal radiotherapy is mandatory. Subcutaneous testosterone pellets guarantee higher patient acceptance and physiological testosterone levels. Lifelong follow-up and psychological support, with special care for infertility and erectile dysfunction, must be considered in this cohort of patients.

Evaluation of the decision-making process in the conservative approach to small testicular masses

INTRODUCTION

We evaluate the clinical outcome of patients treated with conservative approach for small testicular masses (STMs). We analyzed the steps who brought to the selection of the therapeutic approach: starting from clinical presentation, through imaging and lab studies.

METHODS

We considered 18 patients who underwent an organ-sparing approach for STMs from 2005 until 2014. The selection criteria were dimension of the mass and absence of clinical, laboratory and/or radiological malignancy suspicion. Preoperative scrotal ultrasound (US) was carried out in all the patients by the same radiologist. The postoperative fertility profile was evaluated in patients younger than 40 years.

RESULTS

We performed 13 enucleations, one partial orchiectomy (PO) and four active surveillances. During surgery, a frozen section examination (FSE) was always requested and no discrepancies were noted between its results and the definitive histology. Only one seminomatous tumor was identified, while the remaining masses were four necrosis, four epidermoid cysts, three Leydig tumors, one Sertoli tumor and one chronic orchitis. After a mean follow-up of 41.6 ± 24.7 months, all the patients resulted free of disease and hypogonadism and five of them reached the fatherhood after surgery.

CONCLUSIONS

The clinical and instrumental evaluation consented an accurate selection of patients eligible for the organ-preserving approach. We believe that testis-sparing surgery leads good functional and aesthetic results in patients with benign lesions; it is a safe option for STMs with a reliable pathologist performing FSE and is an important goal in young patients with fatherhood desire.

Imaging of Bilateral Synchronous Testicular Tumors of Different Histologic Types and Implications for Surgical Management

The clinical history and imaging and pathologic findings in 4 patients with bilateral synchronous testicular tumors of dissimilar histologic types were reviewed. All patients had a large scrotal mass on one side and a smaller nodule on the other one. The appearances of each pair of lesions were different enough to suggest that they could possibly be of different histologic types. The most important role of imaging, however, was its capability to guide the surgical approach to these patients: in 1 case, the smallest lesion was recognized as an epidermoid cyst; in 2 others a conservative approach was deemed possible, given the lesions' small volumes and peripheral locations.

Fertility Risk Assessment and Preservation in Male and Female Prepubertal and Adolescent Cancer Patients

Cancer represents the second cause of death in prepubertal children and adolescents, although it is currently associated with an overall survival rate of 80%–85%. The annual incidence rate is 186.6 per 1 million children and adolescents aged up to 19 years. Both disease and treatment options are associated with life-altering, long-term effects that require monitoring. Infertility is a common issue, and as such, fertility preservation represents an essential part in the management of young patients with cancer who are at risk of premature gonadal failure. This review deals with the up-to-date available data on fertility risk assessment and preservation strategies that should be addressed prior to antineoplastic therapy in this vulnerable subgroup of cancer patients.

Organ-sparing surgery for testicular tumours

PURPOSE OF REVIEW

Testicular cancer represents the majority of testicular masses, and radical orchiectomy is still considered the standard-of-care. Testis-sparing surgery (TSS) can be an alternative to radical surgery in patients with small testicular tumours, bilateral or solitary testis masses. The aim of this manuscript is to review the current indications, oncological and functional outcomes of TSS.

RECENT FINDINGS

Our review confirmed that literature lacks studies with a high level of evidence on comparing TSS with radical surgery. Indications for TSS are controversial, specifically for patients with normal contralateral testis. For nonpalpable testicular masses less than 2 cm, bilateral tumours and solitary testis mass, TSS seems to be a viable treatment option. Frozen-section examination is a critical tool for assessment at the time of TSS that allows for diagnosis of benign from malignant tumours and evaluation of margin. TSS has been shown to be associated with less fertility alterations, hormonal deficit and potential lower impact on sexual and psychosocial aspects. Intermediate to long-term follow-up results have not revealed any significant risk of local and/or distant recurrences after TSS.

SUMMARY

TSS is well tolerated and feasible for selected patients with testicular mass without compromising oncological and functional outcomes. Further studies with a higher level of evidence are needed to confirm these findings.

The role of testis-sparing surgery in children and adolescents with testicular tumors

Organ-sparing approaches have been applied to the treatment of a variety of urologic tumors in both the realms of adult and pediatric urology, with the goals of minimizing overtreatment of benign lesions, preserving function, and providing durable cure. The predominance of benign tumors in prepubertal patients and the reliability of both ultrasound and intraoperative frozen sections have resulted in a marked shift toward testis-sparing approaches over the last few decades. The role of testis sparing in the adolescent population is presently unclear, although there have been increasing reports of successful organ-sparing surgery for testis tumors in the adult literature. This review presents recent trends in testis-sparing approaches for both pediatric and adolescent patients, the operative technique, and some of the controversies related to testis-sparing surgery.

Three primary testicular tumours: Trials and tribulations of testicular preservation

Balancing recurrence risk, side effects and patient preference in the treatment of multiple metachronous testicular tumours can be challenging. We present the case of a young male patient who developed 3 different primary testicular neoplasms over an 8-year period, each associated with retroperitoneal lymphadenopathy requiring chemotherapy. The first tumour at age 19 was managed with radical orchiectomy. Four years later, a partial orchiectomy was performed to remove 2 small lesions. Another 4 years later, a complete orchiectomy was required for an additional tumour. This case highlights the caveats of testis-sparing surgery for testis cancer and the need for careful surveillance in these patients.

Focal Surgery in Testis Cancer: Current State of the Art

Radical orchiectomy is the standard treatment of testicular neoplasia causing androgen insufficiency, infertility and psychological stress. Focal surgery allows the preservation of fertility, endocrine function and integrity of the genital anatomy, with preservation of the image of the male body.

The EAU guidelines suggest focal surgery in case of synchronous bilateral tumours, metachronous contralateral tumours, tumour in solitary testis with normal pre-operative testosterone levels, when the tumour volume is less than 30% of the testicular volume.

There are two focal surgical techniques: tumorectomy and polar resection, followed by biopsies and frozen section of the resection bed. In case of benign tumours, the treatment is often curative. In case of malignancy, carcinoma in situ is frequently found in the surrounding tissues. Adjuvant treatment with chemotherapy or radiotherapy is performed with a fair success rate.

These adjuvant treatments reduce or delete the functional benefits achieved by conservative surgery. The evidence of the literature suggests that focal surgery is a valid option for all patients with testicular tumours that are not palpable and small sized, with the advantage of avoiding unnecessary radical orchiectomy in most of cases.

Therefore, the selection criteria for focal surgery are the mass size (less than 25 mm) and a safety distance of the tumor from the rete testis, in order to preserve testicular vascularization.

A close follow-up with ultrasound, testicular markers and radiological examinations is mandatory in case of germ cell neoplasia treated conservatively in patients with indications for conservative surgery.

Testis sparing surgery in a case of small unilateral testicular cancer

A 22-year-old male presented at our institution with an incidentally ultrasound-detected testicular tumor. Magnetic resonance imaging showed a contrast-enhanced right intratesticular mass over 1 cm in size. The patient underwent testis sparing surgery. Pathologic examination revealed seminoma. A follow-up nine months later showed no residual tumor, a normal contour of the testis and no evidence of atrophy. Testis sparing surgery is an option for patients with small unilateral testicular tumors even in the presence of a healthy contralateral testis.

Organ-sparing surgery is the treatment of choice in benign testicular tumors

PURPOSE

Ablation of the testis has been the reference standard for malignant and benign testicular tumors in the past. Nowadays, an organ-sparing surgery (OSS) can be attempted in special cases. Removal of a testis for a benign lesion should be avoided. In this retrospective survey, we analyze the results and long-term follow-up of OSS in benign testicular tumors.

METHODS

Charts of all patients that underwent OSS because of a benign testicular tumor between 1999 and 2011 at our department were searched and the data from patients were collected. Before surgery, all patients underwent ultrasound (US) and complete staging. Surgery was performed under US or palpation guidance. Frozen-section examination of the tumor and tumor bed biopsies was obtained. All patients underwent postoperative follow-up. We retrospectively reviewed surgical technique, histology, epidemiology, and outcome in all patients.

RESULTS

In the study period, 40 benign testicular tumors were surgically removed in 37 consecutive patients. Definitive histology did not report of any malignant histopathologic features in all patients. All patients are free of disease after a mean follow-up of 63 months (range 10-120). During this period, two patients developed a second leydig cell tumor (LCT) on the contralateral side; another patient had a second LCT within the same testicle, but on the opposite pole. All patients underwent a subsequent organ-sparing tumor resection.

CONCLUSIONS

An overtreatment for benign testicular tumors should be avoided. Our initial results indicate that OSS in benign tumors is a safe, feasible treatment for patients.

[Carcinoma in situ of the testis: predisposition, evolution and early detection]

Carcinoma in situ (CIS), also known as intratubular germ cell neoplasia unclassified, is the common obligate precursor lesion of malignant testicular seminomatous and non-seminomatous germ cell tumors (GCT), which show a steadily increasing incidence in Europe. Although GCT is a potentially curable cancer with excellent prognosis even in patients with organ metastasis, many patients suffer from chemotherapy-associated effects and some develop a secondary (non-germ cell) malignancy. Recently, genome-wide association studies revealed genetic predispositions linked to six genes (KITL, SPRY4, BAK1, TERT, ATF7IP, DMRT1). Exposure to environmental factors was also linked to increased prevalence of testicular dysgenesis and CIS/GCT by the action of hormone disruptors on embryonal gonadal tissue during pregnancy. By unknown mechanisms these genetic and environmental factors might create a disturbed microenvironment in the fetal testis leading to survival of embryonic germ cells and subsequent malignant transformation might result in CIS. Molecular pathways involved in this process include activated cKIT pathway and LIN28 associated deregulation of miRNA targets. The challenge for the future is to identify high risk patients prior to invasive GCT, to develop non-invasive tests for detection of CIS on seminal material and elucidate the precise role of the microenvironment in CIS initiation.