A lesson in the management of testicular cancer in a patient with a solitary testis

Abstract

SummaryFive per cent of patients with germ cell tumours of the testis will develop a further tumour in the contralateral testis. Standard treatment in such cases is a second orchidectomy, resulting in infertility, hormone replacement, and psychological morbidity. In this case report we explore the role of testis conservation in these patients and also show that there is a risk of removing a potentially normal testis if a histological diagnosis is not sought prior to orchidectomy.Keywords: testicular germ cell tumours; carcinoma-insitu; orchidectomy With the current preference for orchidectomy in patients with suspicious testicular masses there is the risk of removing a potentially normal testis. Experience of a patient with a suspicious mass in a solitary testis which was subsequently found to have benign histology after testis-conserving surgery, prompted us to report the present case. Case historyA 39-year-old man presented with a 6-week history of pain in the left groin and suprapubic area with increasing tenderness in the right testis. Fourteen years earlier he had undergone a left orchidectomy and chemotherapy (four cycles of bleomycin, etoposide and cisplatin) for stage 2C teratoma. Since that time he had been well apart from azospermia which had been detected prior to starting chemotherapy.Examination on this occasion revealed a tender solitary right testis with no palpable nodule. Doppler ultrasound revealed a 4-mm lesion with normal blood flow within the right testis. Serum -human chorionic gonadotropin ( -hCG) and -fetoprotein were not raised but on the basis of the ultrasound findings it was felt that the lesion probably represented a tumour and he was advised to undergo an orchidectomy.He was concerned about having to take long-term testosterone replacement, and although he was aware that the most likely diagnosis was a second malignancy, was keen if possible to pursue testis conservation. He underwent exploration of the right testis through a groin incision. Intra-operative ultrasound using a 7.5 mH ultrasound probe was used to identify the lesion (figure 1), which was excised with a rim of surrounding normal tissue. A separate testicular biopsy was also performed. Despite the clinical prediction of a new primary malignancy, histology of the nodule revealed seminiferous tubules lined only by Sertoli cells and marked proliferation and hyperplasia of Leydig cells. The separate biopsy showed atrophic testis. DiscussionThis case highlights the problems of diagnosis of testicular masses. Ultrasound is the mainstay for imaging of the testis and has a sensitivity of 80-98%. 1One of its limitations is that non-neoplastic lesions may mimic tumours. Magnetic resonance imaging (MRI) has no proven diagnostic benefit over ultrasound, but provides better localisation when partial orchidectomy is being considered (figure 2).2 If this surgical approach is followed, then intraoperative ultrasound can be used, as in this case, to delimit the lesion and thus remove as little of the normal testis as possible.Fine needl...

Management of incidental impalpable intratesticular masses of ≤ 5 mm in diameter

“…Despite the very small tumours (mean 3.6 mm in diameter) the ratio of benign to malignant lesions in the present series (Table 1) compares well with that of previous studies including larger incidental tumours [15,17]. In a study by Horstman et al [15] including nine impalpable incidental testicular tumours, seven were found to be benign stromal tumours and two were malignant germ cell tumours; in that study the mean tumour diameter was significantly larger, at 8.8 (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15) mm. Another study by Leroy et al [17] included 15 patients, with a mean tumour diameter of 7.5 (4-16) mm; histological analysis showed malignant germ cell tumour in four, while all other lesions were benign.…”

“…epidermoid cysts) organ‐sparing surgery after frozen‐section analysis (FSA) has been widely accepted [3,4]. More recently, organ‐sparing procedures have been advocated also for treating malignant germ cell and stromal tumours in certain clinical settings [5–8]. Advanced ultrasound technology now provides images of higher resolution that allow the detection of extremely small intratesticular lesions.…”

Bilateral germ-cell tumours: 22-year experience at the Institut Gustave Roussy

“…Neoadjuvant or adjuvant chemotherapy have been used to permit conservative treatment. (Oliver et al, 1996;Sawyer et al, 1999). Testicular relapses were observed in that series of patients, but had no impact on survival.…”

Organ-sparing approaches for testicular masses

“…1,55,62,[84][85][86][87] Selection criteria in these studies included: organ-confined disease with no infiltration of the rete testis; a mass of <2 cm in order to preserve testosterone-producing parenchyma; a negative postresection biopsy of the tumor bed; and conditions of cold ischemia to preserve the function of Sertoli and leydig cells. Heidenreich et al 55 treated 73 patients with GCT with partial orchiectomy using these criteria.…”