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

PURPOSE: 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 2.26-19.39, p=0.01). On ROC analysis lesion diameter had an AUC of 0.75 (95% CI 0.63-0.86, 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

Reply by Authors

We agree that the ideal strategy in patients with an SMT would be to follow them with periodic US and perform surgery only in those who show significant growth during followup. This is our actual policy in masses less than 5 mm in diameter. In this group few patients required surgical exploration during followup. It is likely that in cases of such small lesions strict surveillance may not change the progression of germinal tumors, as reported by Bieniek et al, who noted a mean lesion diameter of 4.14 2.0 mm (reference 1 in Editorial Comment). However, sparse data are available in the literature on the natural history of larger masses when left untreated. Our study shows that even larger lesions up to 20 mm in diameter may be benign, indicating that strict surveillance might be justified even for masses larger than 5 mm. Our experience also demonstrates that with increasing lesion size the risk of cancer significantly increases 7 times per mm. This information could be used to better counsel patients about the risk of harboring TC and eventually better support a followup strategy in patients with an STM. We believe that 2 research lines which might help us in the near future are 1) study of the individual lesion growth rate, which could differentiate benign from malignant lesions, and 2) new imaging diagnostic tests such as contrast enhanced US1 or testicular magnetic resonance imaging, which might improve the diagnostic performance of scrotal U