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Testis-Sparing Surgery: A Single Institution Experience - Beyond the Abstract

The gold standard for testicular masses has long been radical orchiectomy. With customarily young age at diagnosis and dramatic rates of cure for testicular cancer, considerations to minimize the long-term sequelae of treatment have become increasingly important. This is reflected in options for de-escalation and risk adaptation of treatment intensity in current management guidelines.1 Just as organ-preserving approaches for other malignancies have been pursued, an interest has arisen for testis-sparing surgery (TSS).


More nonpalpable and smaller masses are being detected, which have a lower likelihood of malignancy.2 Since up to 50-80% of masses <2cm may be benign, TSS with intraoperative frozen section is a management option. In patients with benign tumors, radical orchiectomy may represent overtreatment.  In our series, echoing prior experience, frozen section examination reliably confirms benign disease allowing for completion of partial orchiectomy with a negative predictive value of 100%. 

In addition to benign masses, our series also included patients with suspicion for or history of germ cell tumor. Testis-sparing becomes especially important in the subset of men with bilateral tumors or tumors in a solitary testis who would be rendered anarchic by radical orchiectomy. However, there is oncologic concern surrounding TSS for germ cell tumors due to the risk for local recurrence, including from germ cell neoplasia in situ. Importantly, just as good outcomes have been demonstrated to salvage relapses, evidence exists about the success of salvaging local recurrence after TSS, provided good compliance with follow up is ensured.3,4 

Great strides have been made in improving survival after diagnosis and treatment for germ cell tumors. The definition of oncologic cure posited by Easson and Russell in 1963 highlighted what has come to be a shared belief of what cure means – that after treatment, a patient’s life is no different from a person who never had the disease.5 In treating testis cancer we have the luxury and the burden of considering survivorship, with side effects and late effects of treatment increasingly recognized as important. There remains little evidence on the implications of testis-sparing on long-term results, including oncologic, fertility, and hormonal. Ongoing studies and further follow up for oncologic and patient-centered outcomes are essential.

Written by: Phillip M. Pierorazio, MD, and Meredith Metcalf, MD, James Buchanan Brady Urological Institute, Johns Hopkins Medicine, Baltimore, Maryland

References:

  1. Gilligan, Timothy, Daniel W. Lin, Rahul Aggarwal, David Chism, Nicholas Cost, Ithaar H. Derweesh, Hamid Emamekhoo et al. "Testicular cancer, version 2.2020, NCCN clinical practice guidelines in oncology." Journal of the National Comprehensive Cancer Network 17, no. 12 (2019): 1529-1554.
  2. Giannarini, Gianluca, Klaus-Peter Dieckmann, Peter Albers, Axel Heidenreich, and Giorgio Pizzocaro. "Organ-sparing surgery for adult testicular tumours: a systematic review of the literature." European urology 57, no. 5 (2010): 780-790.
  3. Heidenreich, Axel, L. O. T. H. A. R. WEIßBACH, WOLFGANG HÖLTL, Peter Albers, Sabine Kliesch, KAI U. KÖHRMANN, KLAUS P. DIECKMANN FOR THE GERMAN, and TESTICULAR CANCER STUDY GROUP. "Organ sparing surgery for malignant germ cell tumor of the testis." The Journal of urology 166, no. 6 (2001): 2161-2165.
  4. Bojanic, Nebojsa, Uros Bumbasirevic, Ivan Vukovic, Gordana Bojanic, Bogomir Milojevic, Djordje Nale, Otas Durutovic et al. "Testis sparing surgery in the treatment of bilateral testicular germ cell tumors and solitary testicle tumors: a single institution experience." Journal of surgical oncology 111, no. 2 (2015): 226-230.
  5. Easson, Eric C., and Marion H. Russell. "Cure of Hodgkin's disease." British Medical Journal 1, no. 5347 (1963): 1704.
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