Management of an accidental mass in a monorchidic patient discovered during infertility: a case report

Testicular cancer is the most frequent type of cancer in the young adult men, it is relatively rare. Infertility is an important risk factor for testicular cancer, with a doubled risk of developing cancer compared to the general population. The standard treatment for testicular cancer is the radical orchiectomy, but partial orchiectomy or testicular sparing surgery (TSS) is indicated for small masses, as many experiences, have shown that many small masses found incidentally turn out to be benign.

Case presentation

The authors report the case of a patient presented for primary infertility, a clinical examination for left-sided gynecomastia without inflammatory signs. A testicular MRI revealed a 7 mm suspicious nodule in the posterior-inferior aspect of the right testicle, with contrast enhancement in the juxta-tumoral area corresponding to a heterogeneous area on ultrasound. Due to the lesion described on MRI, monorchidism, and azoospermia, a TSS combined with testicular biopsy and testicular sperm extraction was indicated.

Clinical discussion

The reference treatment for testicular cancer is the radical orchiectomy, but in some selected situations, partial orchiectomy or TSS is indicated, as many experiences have shown that many small masses found incidentally turn out to be benign.

Conclusion

This case suggests that TSS or partial orchiectomy for small nonpalpable testicular masses in monorchidic patients can provide an excellent outcome for the patient.

Management of small testicular masses: outcomes from a single-centre specialist multidisciplinary team

OBJECTIVES

To report the management outcomes of men with ≤20-mm small testicular masses (STMs) and to identify clinical and histopathological factors associated with malignancy.

PATIENTS AND METHODS

A retrospective analysis of men managed at a single centre between January 2010 and December 2020 with a STM ≤20 mm in size was performed.

RESULTS

Overall, 307 men with a median (interquartile range [IQR]) age of 36 (30-44) years were included. Of these, 161 (52.4%), 82 (26.7%), 62 (20.2%) and 2 men (0.7%) underwent surveillance with interval ultrasonography (USS), primary excisional testicular biopsy (TBx) or primary radical orchidectomy (RO), or were discharged, respectively. The median (IQR) surveillance duration was 6 (3-18) months. The majority of men who underwent surveillance had lesions <5 mm (59.0%) and no lesion vascularity (67.1%) on USS. Thirty-three (20.5%) men undergoing surveillance had a TBx based on changes on interval USS or patient choice; seven (21.2%) were found to be malignant. The overall rate of malignancy in the surveillance cohort was 4.3%. The majority of men who underwent primary RO had lesions ≥10 mm (85.5%) and the presence of vascularity (61.7%) on USS. Nineteen men (23.2%) who underwent primary TBx (median lesion size 6 mm) had a malignancy confirmed on biopsy and underwent RO. A total of 88 men (28.7%) underwent RO, and malignancy was confirmed in 73 (83.0%) of them. The overall malignancy rate in the whole STM cohort was 23.8%. Malignant RO specimens had significantly larger lesion sizes (median [IQR] 11 [8-15] mm, vs benign: median [IQR] 8 [5-10] mm; P = 0.04).

CONCLUSIONS

Small testicular masses can be stratified and managed based on lesion size and USS features. The overall malignancy rate in men with an STM was 23.8% (4.3% in the surveillance group). Surveillance should be considered in lesions <10 mm in size, with a TBx or frozen-section examination offered prior to RO in order to preserve testicular function.

Testis sparing surgery for small testicular masses and frozen section assessment

Introduction

We present our experience with patients who had suspected testicular masses, managed by a frozen section assessment and testicular sparing surgery.

Material and methods

We performed a retrospective review of all patients over the last 5 years, who underwent a frozen section assessment and testicular sparing surgery for small testicular lesions. The frozen section assessment was compared with the final histology.

Results

Twelve patients were identified. The mean age of patients was 40 years (22–58 years). The mean lesion size was 9.8 mm (3–18 mm). Presentations varied: a testicular lump was palpable in 7 patients and 3 patients were referred due to infertility with a subsequent ultrasound, which showed incidental testicular lesions. Two patients presented with testicular pain. Tumour marker levels were within the normal limits in all patients.

The frozen section assessment correctly determined 10 out of 12 (83%) lesions, showing 1 (8%) lymphoma, 2 (17%) seminomas, 3 (25%) fibrosis, 3 (25%) low-grade Leydig cell tumours and 1 (8%) adenomatous tumour. The frozen section reported a benign epidermal cyst in 1 case, whilst the final histology showed a pre-pubertal type teratoma, a rare and low risk tumour. One patient (8%) had an indeterminate lesion, which proved to be a benign adenomatous tumour on final histology. All malignant cases were correctly identified.

There was no malignancy in 9 out of 12 (75%) patients therefore they had testicular sparing surgery. Three patients had orchidectomy, two due to a seminoma and one due to an indeterminate lesion. One patient developed a postoperative haematoma requiring antibiotics but there were no other complications.

Conclusions

Our findings demonstrate that partial orchidectomy with a frozen section assessment is useful in small testicular masses and testicular sparing surgery can be considered in order to prevent a radical orchidectomy in selected patients.

Testis-sparing surgery for the conservative management of small testicular masses: an update

BACKGROUND

Malignant germ cell tumours represent the vast majority of palpable testicular masses, and radical orchiectomy is still considered the standard-of-care. Testis-sparing surgery (TSS) could be an alternative to radical orchiectomy in patients diagnosed with small testicular masses (STMs). The aim of this article was to review the current indications and the oncological and functional outcomes of TSS when performed for STMs.

MATERIALS AND METHODS

We performed a non-systematic review of literature using the Medline database, including a free-text protocol using the terms "testis sparing surgery", "partial orchiectomy", "testis tumour" and "sex cord tumour". Only the articles reporting data on organ-sparing surgery for testicular neoplasms were evaluated.

RESULTS

No randomized controlled trials comparing TSS with radical orchiectomy have been reported. Indications for TSS are controversial, especially for patients with normal contra-lateral testis. For testicular masses of less then 2 cm, TSS seems to be the best treatment option. Frozen-section examination is an essential assessment at the time of TSS, and allows for discrimination of benign from malignant neoplasms. Intermediate- and long-term follow-up results showed no significant risk of local and distant recurrences in the main series reported in literature.

CONCLUSION

According to currently available data, TSS is a safe and effective treatment for STMs in selected patients, and bypasses surgical overtreatment, without compromising oncological and functional outcomes. Further studies are needed in order to confirm the oncological safety of this procedure.