Incidental testicular tumors in infertile men

Two tumor types in a unilateral testis in a patient with severe oligozoospermia and a history of cryptorchidism surgery: A case report

Testicular cancer, the most common cancer among young male adults, is associated with infertility. A 38-year-old male patient was admitted to Dokkyo Medical University Saitama Medical Center, Japan, with infertility associated with severe oligozoospermia. Scrotal ultrasonography revealed two distinct tumors in the left testis: A mass with abundant blood flow on the cranial side and a mass with poor blood flow on the caudal side. Additional analysis revealed mild elevation of intact human chorionic gonadotropin (hCG) levels (tumor marker level assessment), high testosterone and low luteinizing hormone and follicle-stimulating hormone levels (hormonal level assessment) and severe oligoasthenozoospermia (semen assessment). The preoperative diagnosis was left-sided testicular cancer and severe oligoasthenozoospermia and the patient underwent left high orchiectomy and oncological testicular sperm extraction. Based on the pathological assessment, the cranial tumor was diagnosed as a seminoma with syncytiotrophoblastic cells, whereas the caudal tumor had only scar tissue with germ cell neoplasia in situ in the adjacent parenchyma. Following surgery, intact hCG and hormone levels of the patient were normalized, and the semen parameters (semen volume, sperm density, and motility) improved dramatically. To the best of our knowledge, the present case is the first report of two types of testicular tumor in a unilateral testis in a patient with a history of cryptorchidism surgery. The present case demonstrated that scrotal ultrasonography should be performed in patients with abnormal semen results to rule out testicular tumors.

Staghorn Calculus with Adenomatoid Tumor: A Case Report

Testicular adenomatoid tumor is very rare. More understanding of the tumor and treatment is required for better outcomes. A 63-year-old man visited a urologist for staghorn calculus. During follow-up, he had recurrent left flank pain and intermittent hematuria. Computed tomography demonstrated left staghorn calculus, and then further assessment revealed left testicular swelling. Ultrasound showed epididymal mass. Percutaneous nephrolithotomy was deferred and we performed left radical orchiectomy. A pathologic examination revealed testicular adenomatoid tumor. This case highlights the importance of awareness of a very rare benign tumor in a patient with staghorn calculus.

What Is the Malignant Potential of Small (<2 cm), Nonpalpable Testicular Incidentalomas in Adults? A Systematic Review

CONTEXT

Unlike palpable lumps, a large number of nonpalpable testicular lesions found incidentally at ultrasound in asymptomatic postpuberal males are either benign tumours or non-neoplastic lesions. The prevalence of malignancy, however, is appraised based on small case series. Dedicated studies report a large number of patients, and systematic review articles are lacking.

OBJECTIVE

This systematic review is aimed to assess, from the analysis of the pooled data of the available literature, the incidence of benign tumours, malignant tumours, and non-neoplastic lesions, and to identify predictive characteristics for malignancy.

EVIDENCE ACQUISITION

A systematic review of PubMed, Scopus, Google Scholar, Turning Research Into Practice (TRIP) database, and the Cochrane Library was conducted on January 6, 2022, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Studies were retrieved reporting on adult asymptomatic men, with single, incidentally identified small testicular lesions, either fertile or infertile, with negative tumour markers and without specific risk factors for malignancy. Lesions ≤20 mm were considered small. Seventy-four studies were selected for inclusion in this analysis. Twenty-six additional publications have been retrieved by the bibliography quoted in the selected articles.

EVIDENCE SYNTHESIS

Pooled data of 1348 lesions in 1348 patients were collected. Of these lesions, 408 could be retrieved individually, 44.6% were benign, 27.2% were malignant, and 20.8% were non-neoplastic. Virtually all lesions <3 mm and 86.6% of lesions <5 mm were benign. Lesions >10 mm have a 38.14% probability of being benign. Hyperechoic lesions are likely benign. Fertility status does not affect the risk of malignancy.

CONCLUSIONS

Very small (<3 mm) and small (<5 mm) incidentally detected testicular lesions in asymptomatic postpuberal men with normal tumour markers could be frequently benign. More prospective studies are needed to better support this finding. Management strategies should be developed for these patients to reduce overtreatment.

PATIENT SUMMARY

Small testicular lesions are incidentally founded at ultrasound. It is not easy to distinguish a benign lesion from a malignant one. Results of this study are reporting a higher incidence of benign lesions with a diameter of <5 mm. More studies are needed to better understand the biology and the management strategy for small testicular lesions.

Prevalence and Management of Incidental Testicular Masses-A Systematic Review

Management of incidentally diagnosed small testicular masses (STM) is controversial. Although there is the risk of malignancy, it might be realistic to safely seek preservation of testicles bearing benign masses. This study aims to systematically evaluate the evidence regarding prevalence of STMs, their benign or malignant histology and their management. We conducted a systematic literature search for studies reporting small or incidental testicular masses and their management by radical orchiectomy, testis sparing surgery (TSS) or ultrasound (US) surveillance. We initially screened 2126 abstracts and from these, 57 studies met the inclusion criteria. Testicular masses were detected in 1.74% of patients undergoing US examination. Regarding STMs removed by surgery, 41.12% were benign. Intraoperative frozen section examination (FSE) is a reliable tool to discriminate between benign and malignant testicular masses (average 93.05% accuracy), supporting TSS. Benign lesions were associated with smaller diameter (<1 cm 68.78% benign), were often hypoechoic and exhibited regular margins on US. Conclusions: Small testicular masses are often benign. Clinical and US patterns are not accurate enough for including patients in surveillance protocols and TSS paired with FSE is pivotal for precluding the removal of testicles bearing benign lesions. Future research might unveil new imaging tools or biomarkers to support clinical management.

Testicular Lesions in Infertile Men

OBJECTIVES

An increasing number of incidental testicular tumors are diagnosed in patients during infertility workup. The aim of this study was to evaluate the accuracy of frozen section examination (FSE) for the management of these tumors.

METHODS

We retrospectively studied a series of 46 testicular tumors diagnosed during exploration for infertility from 2000 to 2019 and submitted for FSE.

RESULTS

A diagnosis of malignancy was made in 23 cases on both gross examination (yellow-white or cream-colored nodules for seminomas) and FSE, then confirmed on final diagnosis in 22 of the cases. One seminoma reported on FSE was revised as being a Leydig cell tumor. The 23 other lesions were diagnosed as benign on FSE, including 11 Leydig cell tumors (yellow-brown nodules), 2 Leydig cell hyperplasias, and 10 whitish fibrous lesions. All Leydig cell lesions were confirmed except 1, which was reclassified as a Sertoli cell tumor. Of the 10 cases of fibrous lesions, 6 were associated with malignancy.

CONCLUSIONS

The high incidence of Leydig cell tumors and the accuracy of FSE for these lesions demonstrate the interest in FSE. In contrast, FSE is not reliable for fibrous lesions, and surgeons should be aware that a fibrosis result often corresponds with regressed tumors.

Correlations between Mortality-to-Incidence Ratios and Health Care Disparities in Testicular Cancer

The mortality-to-incidence ratio (MIR) is associated with the clinical outcomes of different types of cancer as well as the ranking of health care systems. However, the association between MIRs for testicular cancer and health care disparities, including differences in expenditures and health system rankings, has not yet been reported. We used the Spearman’s rank correlation coefficient (CC) to analyze the correlation between testicular cancer MIRs and both total expenditures on health/gross domestic product (e/GDP) and the World Health Organization’s (WHO) health system rankings. After screening the data for quality and missing information, 57 countries were chosen for analysis. Generally, developed countries and regions had relatively high rates of incidence/mortality, but with a favorable MIR. Among the continents, Europe had the highest incidence rates, whereas the highest MIRs were in Africa. Globally, favorable testicular cancer MIRs were observed in countries with both a high e/GDP and a good WHO ranking (R² = 0.325, p < 0.001 and CC = −0.568, p < 0.001; R² = 0.367, p < 0.001 and CC = 0.655, p < 0.001, respectively). In conclusion, the MIR for testicular cancer varies in countries and regions based on both their total health expenditure and their health care system ranking.

[Non-palpable testicular tumors in adults: A management based on imaging? Issue from the French Urologic Association Genital Cancer committee's edit]

BACKGROUND

Help in management of non-palpable testicular tumors. French Urologic Association Genital cancer committee's Edit.

OBJECTIVES

To review their characterization at imaging findings of non-palpable testicular tumors.

DOCUMENTARY SOURCES

Literature review (PubMed, Medline) of urological and radiological studies dealing with testicular tumors using keywords: non-palpable/incidental testicular tumors; color Doppler ultrasound; US elastography; magnetic resonance imaging; contrast enhanced sonography; partial surgery.

RESULTS

Color Doppler is the basic exam. The size, the presence of microlithts/microlithiasis/macrocalcifications, the vascular architecture are major semiological findings to suggest the benign or the malignant nature of the lesion. Other techniques like multiparametric MRI, contrast-enhanced sonography, sonographic elastography are still in evaluation. The frequency of benign tumors such as Leydig cell tumors lead to preservation management, through improved characterization, monitoring or tumorectomy.

LIMITS

Non-randomized study - a very few prospective studies.

CONCLUSION

The era of total orchiectomy for any uncertain testicular lesion is over. We try the challenge of characterization, and define management's algorithms based on the suspected nature of the tumors.

Leydig cell tumor found incidentally during microscopic testicular sperm extraction in patient with mosaic Klinefelter syndrome: case report

OBJECTIVE

To report the finding and management of a case of Leydig cell tumor discovered during the infertility evaluation of a patient with mosaic Klinefelter syndrome.

DESIGN

Single case report.

SETTING

Academic hospital.

PATIENT(S)

Patient seeking assistance with fertility after a diagnosis of mosaic Klinefelter syndrome.

INTERVENTION(S)

The patient underwent microscopic testicular sperm extraction (mTESE) for sperm identification after the diagnosis of mosaic Klinefelter syndrome. Abnormal testicular tissue was identified during mTESE and histologically confirmed to be a Leydig cell tumor. The patient was informed of this incidental discovery and later underwent orchiectomy for conservative oncologic control.

MAIN OUTCOME MEASURE(S)

Histologic testicular assessment.

RESULT(S)

Patient was found to have no viable sperm on mTESE, but achieved oncologic control with bilateral orchiectomy.

CONCLUSION(S)

The presented case emphasizes the importance of awareness and expedient appropriate management to achieve oncologic control of a rare tumor with low malignant potential discovered during otherwise routine mTESE. In particular, it highlights the role of the infertility specialist in aiding in diagnosis and treatment of incidental and rare findings.

Les tumeurs testiculaires à cellules de Leydig: à propos de quatre cas et revue de la littérature

Introduction

Les tumeurs testiculaires à cellules de Leydig (TTCL) sont rares, elles représentent entre 1 et 3 % de l’ensemble des tumeurs testiculaires, ce sont les plus fréquentes des tumeurs des cordons sexuels et du stroma. Ces tumeurs se développent le plus fréquemment (55 %) chez les sujets jeunes de 15 à 35 ans, mais elles peuvent se voir aussi chez les enfants lors de la première décennie (20 %) et chez les hommes après 50 ans (25 %). Le mode de révélation le plus fréquent chez l’adulte est la gynécomastie, par contre chez l’enfant, c’est la pseudopuberté précoce isosexuelle. Elles posent le problème de leur diagnostic biologique devant des formes non palpables et du choix de leur traitement chirurgical en raison de la difficulté diagnostique entre les formes bénignes et malignes.

Matériel et méthodes

Nous rapportons quatre présentations différentes de cette pathologie dont les paramètres étudiés seront l’âge, le mode de révélation, le profil hormonal, le type de traitement et le mode évolutif.

Résultats

L’âge moyen de nos patients était de 37 ans et demi. Le mode de révélation était deux fois sur quatre en rapport avec une grosse bourse unilatérale, une fois pour grosse bourse bilatérale, une fois en rapport avec une gynécomastie. Dans tous les cas, la testostérone était normale ou basse et l’estradiol normal ou élevé. Les quatre patients ont subi une orchidectomie associée à une énucléation controlatérale chez un seul des patients. L’évolution était favorable pour tous nos patients, avec un recul moyen de 15 mois.

Conclusion

Le but de cette revue est de présenter, sur la base de quatre observations cliniques différentes et de l’analyse de la littérature, les différents aspects cliniques, biologiques, radiologiques pathologiques et thérapeutiques des TTCL.

Targeted testicular excision biopsy: when and how should we try to avoid radical orchidectomy?

Small, incidental testicular lesions are often benign, but in the past have usually been treated by orchidectomy. An alternative is an operative excision biopsy, with localization by ultrasound if necessary, and characterization of the lesion by frozen section analysis. The present review summarizes the indications for the procedure, lists the likely diagnoses, and describes the technique. Frozen section is accurate for distinguishing benign from malignant lesions, testicular function is usually preserved, and there is no evidence that oncological safety is impaired. Such testis-preserving surgery is a rewarding ground for collaboration between urologists, radiologists, and pathologists.

Incidental testicular cancers that subsequently developed in oligozoospermic and azoospermic patients: report of three cases

OBJECTIVE

To examine whether infertile men with poor semen count subsequently developed testicular cancers and to describe their clinical presentation.

DESIGN

We reviewed 460 male patients with abnormal semen counts between 1989 and 2004.

SETTING

University hospital.

PATIENT(S)

Infertile men who developed testicular cancers after assisted reproductive technologies (ART).

INTERVENTION(S)

Description of patient characteristics: age at infertility, presentation, semen quality, and ART.

MAIN OUTCOME MEASURE(S)

The number of patients who subsequently developed testicular cancers and the period from ART to the development of clinical testicular cancers.

RESULT(S)

Of the 460 patients, 169 patients presented with mild oligozoospermia, 117 patients with severe oligozoospermia, and 174 patients with azoospermia. The follow-up periods were as follows: 1-192 months (median, 96.5 mo) for mild oligozoospermia, 1-156 months (median, 78.5 mo) for severe oligozoospermia, and 1-197 months (median, 99 mo) for azoospermia. We subsequently found three testicular cancers that had developed among severely oligozoospermic and azoospermic patients. The period from the claim of sterility to developing testicular cancers varied from 4 to 14 years (median, 9 y).

CONCLUSION(S)

These results indicate that severe semen abnormality may be a risk factor in developing testicular cancers. Self-examination of the testes could be used as an alternative or supplement to physical examination and testicular ultrasound as part of the infertility workup, even after ART.

Organ-sparing surgery does not lead to greater antisperm antibody levels than orchidectomy

OBJECTIVE

To assess a possible development of antisperm antibodies (ASA), present in a high percentage of infertile patients, after organ-sparing surgery for small testicular tumours, to identify any additional immunogenic effect of this procedure compared with standard orchidectomy.

PATIENTS AND METHODS

Samples of sera were assessed from 54 men who had had surgery between 2000 and 2005 for testicular tumour; the men were divided into two groups, i.e. group A (23) had had organ-sparing tumour resection and group B (31) had had inguinal orchidectomy. Other possible causes of ASA besides testicular tumour were excluded in all patients. The blood samples were obtained during follow-up visits and the circulating ASA in serum determined using an enzyme-linked immunosorbent assay.

RESULTS

The mean (range) tumour diameter was statistically significantly greater (P < 0.03) in group B, at 33.6 (2-130) mm, than in group A, at 12 (2-30) mm. There were significantly more stromal tumours in group A than group B (P < 0.02). Most importantly, the mean (range) ASA levels were not statistically significantly (P > 0.3) higher in group A, at 29 (15-59) U/mL, than in group B, at 24.8 (12-39) U/mL. There was also no statistically significant correlation between ASA levels and clinical stage, length of follow-up after therapy, patient age, tumour size and type of histology.

CONCLUSION

From these data, organ-sparing surgery does not lead to greater ASA levels than orchidectomy and patients are therefore at no greater risk of developing an autoimmune infertility.

Infertility and testis cancer

Testicular cancer is the most common solid organ tumor in young men and affects men during their reproductive years. Current therapeutic regimens have significantly improved survival but often adversely impact fertility. Understanding the effects of testicular cancer, the systemic effects of neoplasia, and the effects of treatment protocols, such as radiotherapy, chemotherapy, and retroperitoneal lymph node dissection, is essential to restoring and maintaining fertility in men who have germ cell neoplasms.

[Non-germinal tumours of the testicle]

The great variety of non germinal testis tumours and their rarity explain the difficulties of a specific therapeutic management. The analysis of the most important varieties of tumours allows identifying an overall trend in both diagnosis and therapy.

Value of frozen section analysis with suspected testicular malignancy

OBJECTIVES

To determine whether frozen section analysis (FSA) assists safe conservative surgery for men presenting with suspected testicular tumors.

METHODS

We performed a retrospective review of intraoperative testicular FSA used at a single university institution during an 11-year period. The exclusion criteria included lesions of paratesticular origin, size greater than 5 cm, and the known presence of elevated tumor markers or metastatic disease.

RESULTS

Eighty men underwent FSA, facilitating the diagnosis of germ cell malignancy in 51 (54.3%) of the 94 new cases encountered during this period. Malignancy was reported by FSA in 52 patients (65.0%), but was later revised in 3 to benign Leydig cell tumor after orchiectomy. Also, 2 of 27 specimens reported as benign by FSA were revised to malignant after analysis of paraffin-embedded tissue from the biopsies. Both were seminoma and required delayed orchiectomy. FSA was reported as "suspicious" (intratubular germ cell neoplasia with necrosis) in 1 patient, in whom orchiectomy was performed and malignancy confirmed. In total, orchiectomy was avoided in 25 cases (31.3%). The positive and negative predictive value for FSA in the diagnosis of testicular malignancy was 94.2% and 92.6%, respectively. Of 13 lesions 1 cm or less, 10 (76.9%) were benign. All 26 lesions greater than 3 cm were malignant. A clear correlation between lesion size and the diagnosis of malignancy was demonstrated.

CONCLUSIONS

FSA is a valuable tool assisting testicular preservation. Lesion size correlated with incidence of malignancy; therefore, FSA may be best used for small testicular lesions suitable for excision biopsy.

INCREASED INCIDENCE OF TESTICULAR CANCER IN MEN PRESENTING WITH INFERTILITY AND ABNORMAL SEMEN ANALYSIS

PURPOSE

We determined the standardized incidence ratio of testicular cancer in infertile men presenting with an abnormal semen analysis compared to the general population.

MATERIALS AND METHODS

The charts from more than 3,800 men presenting with infertility and abnormal semen analysis during a 10-year period were retrospectively reviewed. The incidence of testicular tumors diagnosed in this group was compared to that of race and age matched controls during the same period from the general population (as reported by the Surveillance, Epidemiology and End Results [SEER] database).

RESULTS

Of 3,847 men 10 (0.3%) with infertility and abnormal semen analysis were diagnosed with testicular tumors. Mean patient age was 32.6 years (range 25 to 52) and all 10 men were diagnosed with a seminomatous germ cell tumor. Two men had a history of cryptorchidism while the remaining 8 had no identifiable risk factors for testicular cancer. The SEER database reported an incidence of 10.6 cases of testicular cancer (95% CI 10.3-10.8) per 100,000 men of similar age group and racial composition during the same period. The standardized incidence ratio of testicular cancer was 22.9 (95% CI 22.4-23.5) when comparing our infertile group to the control population. Exclusion from analysis of the 2 patients with a history of cryptorchidism decreased the standardized incidence ratio to 18.3 (95% CI 18.0-18.8).

CONCLUSIONS

Infertile men with abnormal semen analyses have a 20-fold greater incidence of testicular cancer compared to the general population. Patients and physicians should be aware that one of the causes of infertility could be cancer, particularly testicular cancer.

Microinvasive germ cell tumor of the testis

Microinvasive germ cell tumor (MGCT) consists of a limited number of malignant germ cells in the intertubular tissue of the testis. The cells have large nuclei, prominent nucleoli, abundant clear cytoplasm, and distinct cellular borders in hematoxylin and eosin staining. MGCT can be the first stage of malignancy in the development of testicular germ cell tumor (TGCT). Biopsies from men with maldescended testes have been reported to contain intratubular germ cell neoplasia, unclassified (IGCN) and MGCT in 1.8% of the examined cases (95% CI 0.5-4.6%). MGCT has also been found in testes of subfertile men and in the contralateral testis of patients with TGCT. MGCT is a frequent finding (19%) in the testicular tissue adjacent to an overt TGCT. Men with a high risk of TGCT may gain from screening for precursor lesions of TGCT with ultrasonography of the testes followed by a testicular biopsy if suspicious abnormalities are found: Treatment is high-voltage radiotherapy for intratubular germ cell neoplasia (IGCN), and orchidectomy for MGCT and germ cell tumor in situ, either intratubular seminoma or intratubular embryonal carcinoma. After local treatment, patients with precursor lesions can be followed with a surveillance program. The mRNA levels of invasion-related genes were evaluated based on a DNA microarray data set, and we found two gene abnormalities most relevant for the invasion of malignant germ cells: matrix metalloproteinase 9 (MMP9) and plasminogen activator, urokinase (PLAU) genes were up-regulated in a study comparing tissue samples of TGCT and IGCN.