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Croghan SM, Malak JW, Rohan P, Byrne C, McGrath A, Cullen IM, Davis NF. Diagnosis and management of indeterminate testicular lesions. Nat Rev Urol 2024; 21:7-21. [PMID: 37414958 DOI: 10.1038/s41585-023-00786-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 07/08/2023]
Abstract
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.
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Affiliation(s)
- Stefanie M Croghan
- Department of Surgery, Royal College of Surgeons, Dublin, Ireland.
- Department of Urology, Blackrock Clinic, Dublin, Ireland.
| | - Jamil W Malak
- Department of Surgery, Royal College of Surgeons, Dublin, Ireland
- Department of Urology, Blackrock Clinic, Dublin, Ireland
| | - Pat Rohan
- Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - Caoimhe Byrne
- Department of Radiology, Mater Hospital, Dublin, Ireland
| | - Andrew McGrath
- Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - Ivor M Cullen
- Department of Urology & Andrology, Beaumont Hospital, Dublin, Ireland
| | - Niall F Davis
- Department of Surgery, Royal College of Surgeons, Dublin, Ireland
- Department of Urology, Blackrock Clinic, Dublin, Ireland
- Department of Urology & Andrology, Beaumont Hospital, Dublin, Ireland
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2
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Pedersen MR, Møller H, Rafaelsen SR, Møller JK, Osther PJS, Vedsted P. Association between risk factors and testicular microlithiasis. Acta Radiol Open 2019; 8:2058460119870297. [PMID: 31588363 PMCID: PMC6740053 DOI: 10.1177/2058460119870297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/26/2019] [Indexed: 11/16/2022] Open
Abstract
Background Testicular microlithiasis and its clinical significance are not fully understood. Testicular microlithiasis and risk factors have been associated with testicular cancer. The role of testicular microlithiasis is investigated. Purpose To investigate the association between testicular microlithiasis and socioeconomic and other pre-diagnostic factors. Material and Methods All men who had a scrotal ultrasound examination at the Department of Radiology, Vejle Hospital, during 2001–2013 were included. They were categorized as patients with and without testicular microlithiasis and compared with pre-diagnostic data from a nationwide registry. A total of 2404 men (283 [11.8%] with testicular microlithiasis and 2121 [88.2%] without testicular microlithiasis) were included. The association between testicular microlithiasis and pre-diagnostic conditions was investigated with logistic regression. Results Overall, we found no statistically significant differences in demographics, socioeconomic characteristics, or testicular diseases in men with and without testicular microlithiasis. Men with testicular microlithiasis had more often been treated for infertility (odds ratio [OR] 2.09, 95% confidence interval [CI] 0.84–5.24) and testicular torsion (OR 1.58, 95% CI 0.34–7.36) compared to men without testicular microlithiasis. We found no association between sexually transmitted diseases and testicular microlithiasis. Conclusion Treatment for infertility and torsion was non-significantly associated with testicular microlithiasis and no other association was found. These data do not suggest early exposure is related to testicular microlithiasis.
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Affiliation(s)
- Malene Roland Pedersen
- Department of Radiology, Vejle Hospital, Vejle, Denmark.,Urological Research Centre, Department of Urology, Vejle Hospital, Vejle, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Henrik Møller
- Cancer Epidemiology and Population Health, King's College London, London, United Kingdom.,Research Unit for General Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Søren Rafael Rafaelsen
- Department of Radiology, Vejle Hospital, Vejle, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Jens Kjølseth Møller
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Department of Clinical Microbiology, Clinical Cancer Center, Vejle Hospital, Vejle, Denmark
| | - Palle Jørn Sloth Osther
- Urological Research Centre, Department of Urology, Vejle Hospital, Vejle, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Peter Vedsted
- Research Unit for General Practice, Department of Public Health, Aarhus University, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Pedersen MR, Bartlett EC, Brown C, Rafaelsen SR, Sellars ME, Sidhu PS. Is Testicular Macrocalcification a Risk for Malignancy?: Tumor Development on Ultrasonographic Follow-up of Preexisting Intratesticular Macrocalcification. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:2949-2953. [PMID: 29665033 DOI: 10.1002/jum.14657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/20/2018] [Accepted: 03/22/2018] [Indexed: 06/08/2023]
Abstract
Testicular macrocalcification is an uncommon finding when imaging the scrotum with ultrasonography (US). It is not normally a recognized risk factor for development of testicular malignancy, and patients are not usually offered follow-up US examinations or counseled for self-examination. This aspect is in distinction to patients with testicular microlithiasis (usually with an additional risk factor), who are offered follow-up on the assumption that microlithiasis is associated with malignancy. We report a series of 6 patients with predetermined testicular macrocalcification, with development of a malignancy on follow-up US. We encourage US follow-up examinations for patients with macrocalcification, potentially in a similar manner as for those with testicular microlithiasis.
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Affiliation(s)
- Malene R Pedersen
- University of Southern Denmark, Institute of Regional Health Research, Odense, Denmark
- Department of Radiology, Vejle Hospital, Vejle, Denmark
| | - Emily C Bartlett
- Department of Radiology, King's College Hospital, King's College London, London, England
| | - Christian Brown
- Department of Urology, King's College Hospital, King's College London, London, England
| | - Søren R Rafaelsen
- University of Southern Denmark, Institute of Regional Health Research, Odense, Denmark
- Department of Radiology, Vejle Hospital, Vejle, Denmark
| | - Maria E Sellars
- Department of Radiology, King's College Hospital, King's College London, London, England
| | - Paul S Sidhu
- Department of Radiology, King's College Hospital, King's College London, London, England
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Balawender K, Orkisz S, Wisz P. Testicular microlithiasis: what urologists should know. A review of the current literature. Cent European J Urol 2018; 71:310-314. [PMID: 30386652 PMCID: PMC6202617 DOI: 10.5173/ceju.2018.1728] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 07/12/2018] [Accepted: 08/21/2018] [Indexed: 11/22/2022] Open
Abstract
Introduction Testicular microlithiasis is a finding incidental to the ultrasound examination of the scrotum. This article presents some new data regarding the etiopathology of testicular microliths. As there is a growing body of literature available, which associates testicular microlithiasis with a testicular germ cell tumor or male infertility, our review focuses on these relations (based on a new meta-analysis and retrospective follow-up programs). The purpose of this review is to summarize the knowledge about testicular microlithiasis and discuss the latest recommendations. Material and methods A comprehensive literature review was performed using Science Direct and Scopus with MeSH terms and keywords 'testicular microlithiasis', testicular tumor', male infertility'. Results The clinical consequences of testicular microlithiasis depend on the co-occurrence of specific risk factors. The presence of testicular microlithiasis alone in the absence of risk factors is not an indication for further investigation. Conclusions A link between testicular microlithiasis and testicular cancer as well as male infertility has been analyzed. Follow-up is only recommended where risk factors of testicular cancer other than testicular microlithiasis are present.
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Affiliation(s)
- Krzysztof Balawender
- Morphological Science Department of Human Anatomy, Medical Faculty University of Rzeszów, Poland.,Urological Department of Pope John Paul II Regional Hospital in Zamość, Poland
| | - Stanisław Orkisz
- Morphological Science Department of Human Anatomy, Medical Faculty University of Rzeszów, Poland
| | - Paweł Wisz
- Department of Physiology, Medical Faculty University of Rzeszów, Poland
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Pedersen MR, Bartlett EC, Rafaelsen SR, Osther PJ, Vedsted P, Sellars ME, Sidhu PS, Møller H. Testicular microlithiasis is associated with ethnicity and socioeconomic status. Acta Radiol Open 2017; 6:2058460117723676. [PMID: 28815058 PMCID: PMC5546649 DOI: 10.1177/2058460117723676] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 07/10/2017] [Indexed: 11/23/2022] Open
Abstract
Background There are limited studies about testicular microlithiasis (TML) and background information such as health, lifestyle, and socioeconomic status. Purpose To assess the prevalence of TML in relation to socioeconomic status and ethnicity. Material and Methods From a database of scrotal ultrasound examinations in a single institution, all men who underwent routine ultrasound examinations for a variety of symptoms from 1998 to 2015 were included. Skilled observers performed all examinations, and presence of any form of intra-testicular calcification, including TML, was recorded on the examination report and a representative image obtained and stored. A total of 1105 cases with TML were reviewed and random sample of 1105 controls from the same database was also reviewed. Demographics were recorded including ethnicity (white, black, and others) and socioeconomic groups (IMD Quintile). Results Black men had increased prevalence of TML (odds ratio [OR] = 2.17, 95% confidence interval [CI] = 1.72–2.75) compared with white men. Among the 1105 TML cases, 423 (38.3%) were white, 273 (24.7%) black, 152 (13.8%) had other ethnicities, and 257 (23.2%) had no ethnicity recorded. In the control group of 1105 men without TML, 560 (50.7%) were white, 171 (15.5%) black, 111 (10.0%) had other specified ethnicities, and 263 (23.8%) had no ethnicity recorded. Men from the most deprived socioeconomic groups had higher prevalence of TML than men in the most affluent groups, with a trend in OR from the least deprived to the most deprived group. Conclusion Pathogenesis and clinical relevance of TML is unknown but our results point towards possible ethnic and socioeconomic variation in the underlying causes of TML.
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Affiliation(s)
- Malene R Pedersen
- Department of Radiology, Clinical Cancer Centre, Vejle Hospital - Part of Lillebaelt Hospital, Vejle, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Urological Research Center, Department of Urology, Vejle Hospital - Part of Lillebaelt Hospital, Denmark
| | | | - Søren R Rafaelsen
- Department of Radiology, Clinical Cancer Centre, Vejle Hospital - Part of Lillebaelt Hospital, Vejle, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Palle J Osther
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Urological Research Center, Department of Urology, Vejle Hospital - Part of Lillebaelt Hospital, Denmark
| | - Peter Vedsted
- Research Unit for General Practice, Department of Public Health, Aarhus University, Denmark.,Department of Clinical Medicine, Aarhus University, Denmark
| | - Maria E Sellars
- Department of Radiology, King's College Hospital, London, UK
| | - Paul S Sidhu
- Department of Radiology, King's College Hospital, London, UK
| | - Henrik Møller
- Research Unit for General Practice, Department of Public Health, Aarhus University, Denmark.,Cancer Epidemiology and Population Health, King's College London, London, UK
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