Diagnostic-therapeutic pathway for small lesions of the testis

Abstract

Objective of our study was to define a diagnostic-therapeutic pathway for proper treatment of not-palpable testicular masses, that may be benign in 38% of cases. Since the intraoperative diagnosis is difficult to reach in particular in small lesion (< 8 mm) and the risk of tissue loss in frozen section analysis occurs frequently, we propose a diagnostic flow chart for the best management of small testis lesions. This proposed protocol has to be shown in details to physicians and patients, who must understand the clinical implications and the risk to undergo a second radical surgery. CLINICAL PROTOCOL TO NOT-PALPABLE TESTIS LESIONSWe present a diagnostic-therapeutic protocol for patients affected by not-palpable testicular masses, with maximum diameter lower than 15 mm and negative testicular markers. This approach follows our clinical practice. UltrasoundAll men underwent scrotal ultrasound in our hospital to confirm type, dimension and localization of the lesion. Ultrasound characteristics of the lesion were then verified at the confirmatory ultrasound by expert operator and last generation of ultrasound machine. If the lesion was not confirmed by confirmatory ultrasound or it is extra-testicular lesion, the patient was proposed for ultrasound follow-up. Once the small testicular mass was confirmed at our hospital, the therapeutic indication for all cases was testicular exploration with inguinal access. This technique can be associated to intraoperative ultrasound, equipped with linear probe, in order to obtain the relative certainty of the size of the nodule and negative surgical margins, which of course will be subsequently verified by the pathologist. In figures, we report ultrasound images of three cases of our who underwent surgery for epidermoid cyst (Figure 2), Leydig tumor (Figure 3), and seminoma (Figure 4). SurgerySurgical exploration, using intraoperative ultrasound was done without clamping the spermatic cord. The surgical technique involved the removal of the neoplastic nodule and 3 additional biopsies of the surrounding parenchyma (two distant and one next to the mass) sent for definitive histology. Smaller masses (< 8 mm) were usually sent for definitive histology, while larger masses (8-15 mm) were sent to the pathologist for intraoperative frozen sections. Pathologist confirmed size and completeness of surgical margins, by macroscopic view. If the nodule was large enough to be cut for frozen section, then a microscopic description of malignant pattern was reported.

The role of tumor size, ultrasonographic findings, and serum tumor markers in predicting the likelihood of malignant testicular histology

“…According to the general oncological rule, compared with benign tumors, malignant tumors present faster growth rate, and it is not difficult to understand the relationship between tumor diameter and tumor malignancy. To treat small testicular masses properly, Sbrollini et al 13 have defined a new diagnostic-therapeutic pathway in 2014. However, there is not a well-accepted tumor diameter criterion for judging because of the low prevalence of testicular tumors.…”

Testicular sparing surgery in small testis masses: A multinstitutional experience

“…We applied the diagnostic-therapeutic pathway described by Sbrollini et al (6) which comprises: 1) normal testicular tumor markers, 2) repeated scrotal ultrasound at the tertiary center to confirm size, localization and ultrasound characteristics, 3) surgical exploration with inguinal approach using intraoperative ultrasound, and intraoperative pathological examination. The diagnostic-therapeutic pathway recently adopted in management of small masses with testis sparing surgery is summarized in Figure 1.…”

“…For some years the testis sparing surgery is being practiced with success, with good oncologic out-comes, but there is not currently internationally agreed protocol for management and treatment of small non-palpable testicular masses. Our team published a flow chart including ultrasound diagnosis and surgical management of lesion with maximum diameter of 15 mm (6). This protocol was established with agreement of pathology, radiology, urology and oncology units.…”

The sclerosing Sertoli cell tumor of the testis is an extremely rare entity

“…Then any radical surgery (orchiectomy) should be considered after definitive histopathological examination, that is the only way for a definitive diagnosis to be made. 11 Galosi et al . were able to save testis in 40% of patients presenting with lesions smaller than 15 mm, discovering benign lesions.…”