Testis Sparing Surgery of Small Testicular Masses: Retrospective Analysis of a Multicenter Cohort

Abstract

We evaluated possible factors predicting testicular cancer in patients undergoing testis sparing surgery. Materials and Methods: We retrospectively analyzed the records of all patients who underwent testis sparing surgery for a small testicular mass at a total of 5 centers. All patients with 1 solitary lesion 2 cm or less on preoperative ultrasound were enrolled in the study. Testis sparing surgery consisted of tumor enucleation for frozen section examination. Immediate radical orchiectomy was performed in all cases of malignancy at frozen section examination but otherwise the testes were spared. Univariate and multivariate analysis were performed and ROC curves were produced to evaluate preoperative factors predicting testicular cancer. Results: Overall 147 patients were included in the study. No patient had elevated serum tumor markers. Overall 21 of the 147 men (14%) presented with testicular cancer. On multivariate analysis the preoperative ultrasound diameter of the lesion was a predictor of malignancy (OR 6.62, 95% CI 2.26e19.39, p[0.01). On ROC analysis lesion diameter had an AUC of 0.75 (95% CI 0.63e0.86, p[0.01) to predict testicular cancer. At the best cutoff of 0.85 the diameter of the lesion had 81% sensitivity, 58% specificity, 24% positive predictive value and 95% negative predictive value. Conclusions: Our study confirms that small testicular masses are often benign and do not always require radical orchiectomy. Preoperative ultrasound can assess lesion size and the smaller the nodule, the less likely that it is malignant. Therefore, we suggest a stepwise approach to small testicular masses, including tumorectomy, frozen section examination and radical orchiectomy or testis sparing surgery according to frozen section examination results.

Organ-Sparing Surgery in Testicular Tumor: Is This the Right Approach for Lesions ≤ 20 mm?

“…At 13.5 mm, we report a considerably higher best cutoff for lesion diameter based on our series of 99 enucleation procedures (53% sensitivity, 85% specificity, 63% PPV, 79% NPV). Moreover, we found 21.8% of all lesions with a size ≤ 10 mm (12 of 55) to be malignant, which is a considerably higher rate than the 10% reported by Gentile et al [14]. Applying the confirmed cutoff of 8.5 mm by Gentile et al [14], we obtained similar results concerning the diagnostic accuracy (75% sensitivity, 54% specificity, 44% PPV, 82% NPV).…”

“…Actually, the patients involved in this study had testicular tumors ≤ 20 mm in diameter. Gentile et al [14], who also examined patients with testicular masses less than 20 mm, found that the smaller a lesion, the less likely it was to be malignant, and reported a best cutoff of 8.5 mm [14]. At 13.5 mm, we report a considerably higher best cutoff for lesion diameter based on our series of 99 enucleation procedures (53% sensitivity, 85% specificity, 63% PPV, 79% NPV).…”

“…All testes were explored through the inguinal approach, in 9 (9.1%) of 99 cases verifiably associated with spermatic cord clamping and ischemia [7,19]. Details about the surgical technique of OSS without ischemia are described in detail in previous studies [14,16]. Briefly summarized, once the testis had been extracted from the scrotum, the tunica vaginalis was opened, and the tumor was identified by palpation and/or intraoperative ultrasonography.…”

“…Multiparametric testicular US, combining strain elastography and contrast-enhanced US, seems to be a very promising diagnostic tool in the differentiation of benign and malignant lesions with an impressive diagnostic accuracy (sensitivity and specificity of 100% and 93%, respectively) [13]. Moreover, evidence has been provided that lesion size on preoperative US might be directly associated with malignancy, meaning that smaller tumors are more often benign [14]. Nevertheless, small testicular tumors are currently not routinely managed with a view to preserving testicular parenchyma, even though OSS is an established and safe approach [7], which also has been confirmed in previous studies at our department [15,16].…”

Serum levels of microRNA-371a-3p are not elevated in testicular tumours of non-germ cell origin

“…With the evergrowing number of incidentally detected cases of small testicular neoplasms, it became clear that many of these cases are of benign nature and would, therefore, require only a conservative surgical approach or even no surgery at all (Dieckmann et al 2013;Paffenholz et al 2018). However, approximately 15-20% of all small testicular neoplasms < 1 cm still represent malignant germ cell tumours (Gentile et al 2020), and therefore the general recommendation for surveillance of small tumours has remained a matter of debate (Ates et al 2016;Kern et al 2020;Laclergerie et al 2018).…”