3 years ago

Incidentally detected testicular lesions <10 mm in diameter: can orchidectomy be avoided?

Wendy Ansell, Glenda Scandura, Jonathan Shamash, Johnson Joseph, Andrew Protheroe, Anju Sahdev, Daniel M Berney, Clare Verrill
Objective To investigate the pathology of excised testicular lesions <10 mm. Patients and methods The pathological reports of 2,681 patients from Barts Health NHS Trust and Oxford University Hospitals NHS Foundation Trust (OUHFT) were reviewed as part of a service evaluation audit from January 2003 to May 2016. Cases with a maximum diameter of <10 mm were selected. Clinical features were also accessed, where available, to look for patient demographics, pre-diagnostic levels of serum markers, ultrasonograophic (US) findings and clinical details. Results 81 cases with a tumour size <10 mm on histology were identified and of these, 16 cases (20%) had a diameter <5 mm. 56/81 cases (69%) were benign. 15 of the 16 benign cases <5 mm underwent orchidectomy; just one underwent partial-orchidectomy. Pre-operative tumour markers were available in 47/81 cases: out of the 47 cases, none of the 16 malignant tumours had raised tumour markers, while 7 of 31 remaining benign lesions had raised alpha-Fetoprotein (AFP) and Lactate Dehydrogenase (LDH). In total there were 25/81 malignant cases (31%) and they were all germ cell tumours (GCTs): 15/25 seminomas (60%) and 10/25 non-seminomas germ cell tumours (NSGCTs) (40%). Only one GCT had a diameter of <5 mm and this was a regressed tumour within an 18 mm area of granulomatous inflammation. Only one GCT relapsed: a clinical stage I, embryonal carcinoma of 6 mm in maximum diameter. The 56 ‘benign’ cases included 34 sex cord stromal tumours including 23 Leydig cell tumours (41%), eight Sertoli cell tumours (14%) and three mixed sex cord stromal tumours (5%). None showed any malignant features. The remaining 22/56 lesions (40%) were lesions of no further follow up. Benign lesions seemed to be associated with small diameter and we have found <5 mm as best cut-off to predict benign vs malignant (P = 0.002). Conclusion The majority of testicular lesions <10 mm, identified by radiology, are benign, although around one third are malignant. At <5 mm, in this study 100% of lesions were benign. Tumour markers appear unhelpful in the distinction of these small tumours. We suggest that regular ultrasound surveillance ought to be more widely used for testicular lesions of this size. Testicular tumours now have a very high cure rate and changes in size of lesions may be monitored prospectively with minimal risk of increased morbidity. Patients who undergo an orchidectomy for lesions <5 mm are “Victims of Modern Imaging Technology” (VOMIT). If surgery is undertaken in lesions 5-10 mm, patients should be counselled that two thirds of cases are benign. This article is protected by copyright. All rights reserved.

Publisher URL: http://onlinelibrary.wiley.com/resolve/doi

DOI: 10.1111/bju.14056

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