There is no consensus on managing STMs. Often, they are found in men investigated for common urological conditions, i.e. during infertility work-up, as an impalpable mass on color doppler ultrasound (CDU) measuring just a few to up to 2.5 cm (debatable), and associated with negative testicular markers.1 The echogenicity varies, but findings of interest are mostly hypoechoic. The risk of neoplasia is increased when the size is > 5 mm and blood flow is seen implying internal vascularity.2,3 More of these lesions than expected (varying according to size) will eventually be proven benign, especially in infertile men. The final pathology may include germ cell tumors (mostly seminomas), mixed malignant tumors, stromal tumors, various types of cysts, or inflammation types amongst others.4 Extra attention should be given to the possibility of a secondary deposit, or a burnout testicular tumor. The latter ones are of utmost importance as that diagnosis may dramatically change the clinical course.5
After metastatic disease has been excluded, radiological surveillance could be offered as first option. Although established criteria are lacking, small lesions measuring a few mm and not demonstrating internal vascularity on ultrasound may be observed with another ultrasound 3 months later.6 To our experience, decision making can be greatly enhanced by discussion in a multidisciplinary team meeting (MDT) with specialized radiologists in attendance. Stable or regressing findings may make neoplasia less likely, and radiological surveillance may be continued or eased in those cases. On the other hand, if surveillance is found not suitable, or there is progression (i.e., increase in size) then intervention must be offered. In our opinion, organ sparing surgery represents the first line therapy here, and it should not be limited to only patients with imperative indications (i.e., solitary testicle). The endocrinological, cosmetic and mental impact of an overtreatment by radical orchidectomy should be a serious consideration. Especially in men being evaluated for infertility, an organ sparing approach should be prioritized to preserve testicular tissue. Finally, a referral to a specialized centre should be considered if the clinician is not familiar with the organ sparing technique.
The technique includes the delivery of the testicle through an inguinal incision. The most demanding part of this technique is the correct identification of the tumor. Ultrasonographic guidance using a 30 G needle into the lesion is quite useful for a guided accurate excision. An operating microscope can also provide excellent direct vision of the mass.7 At this stage, intra-operative frozen section analysis (FSA) is performed. The clinician can thus be reassured that FSA correlates reliably with the final pathology.8 Surrounding tissue should also be biopsied as surrounding in situ neoplasia is common in germ cell tumors. The identification of malignancy in FSA warrants the performance of radical orchiectomy.9 If benign pathology is confirmed, the testicle can be delivered back to the scrotum. The technique can also be accompanied by microdissection of testicular tissue (mTESE) in infertile men with azoospermia accomplishing both diagnostic and therapeutic scopes.10
In conclusion, clinicians need to know their enemy, identify when to offer sparing surgery, and know how to perform it. We consider that this technique will gain ground in the years to come for the management of STMs. Optimal management subserved by the role of radiological surveillance needs to be clarified with prospective studies and optimal selection criteria yet to be confirmed.
Written by:
- Georgios Tsampoukas, MD, PhD, FEBU Consultant Urologist, Great Western Hospital NHS Trust
- Noor Buchholz, MD, Consultant Urologist, Dubai, Chairman of U-merge
References:
- Lagabrielle, S. et al. Testicular tumours discovered during infertility workup are predominantly benign and could initially be managed by sparing surgery. J. Surg. Oncol. 118, 630–635 (2018).
- Bieniek, J. M. M. et al. The prevalence and management of small testicular masses incidentally discovered on ultrasound evaluation of male infertility. Fertil. Steril. 104, e152 (2015).
- Drudi, F. M. et al. Detection of small testicular masses in monorchid patients using US, CPDUS, CEUS and US-guided biopsy. J. Ultrasound 19, 25–28 (2016).
- Song, G. et al. The role of tumor size, ultrasonographic findings, and serum tumor markers in predicting the likelihood of malignant testicular histology. Asian J. Androl. 21, 196–200 (2019).
- Mosillo, C. et al. Burned-Out Testicular Cancer: Really a Different History? Case reports in oncology vol. 10 846–850 (2017).
- Brown, D. et al. The role of radiological surveillance in the conservative management of incidental small testicular masses: A systematic review. Arab J. Urol. 19, 179–185 (2021).
- De Stefani, S. et al. Microsurgical testis-sparing surgery in small testicular masses: seven years retrospective management and results. Urology 79, 858–862 (2012).
- Tuygun, C. et al. Evaluation of frozen section results in patients who have suspected testicular masses: a preliminary report. Urol. J. 11, 1253–1257 (2014).
- Hughes, P. D. Partial orchidectomy for malignancy with consideration of carcinoma in situ. ANZ J. Surg. 76, 92–94 (2006).
- Hallak, J. et al. Organ-Sparing Microsurgical Resection of Incidental Testicular Tumors Plus Microdissection for Sperm Extraction and Cryopreservation in Azoospermic Patients: Surgical Aspects and Technical Refinements. Urology 73, 887–891 (2009).
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