Papel de la cirugía conservadora testicular en el manejo conservador de masas testiculares pequeñas: perspectivas oncológicas y funcionales

doi:10.1016/j.acuro.2014.02.020

Actas Urológicas Españolas

Volume 39, Issue 1, January–February 2015, Pages 57-62

https://doi.org/10.1016/j.acuro.2014.02.020 Get rights and content

Resumen

Introducción

La orquiectomía radical (OR) se considera todavía la opción estándar de atención para los tumores malignos de células germinales, que representan la gran mayoría de las masas testiculares palpables. En pacientes diagnosticados con pequeñas masas testiculares la cirugía conservadora testicular (CCT) podría ser un tratamiento alternativo a la OR. El objetivo de esta revisión actualizada es evaluar las indicaciones actuales para la CCT y debatir los resultados oncológicos y funcionales de los pacientes sometidos a cirugía conservadora testicular por pequeñas masas testiculares.

Adquisición de la evidencia

Se ha llevado a cabo una revisión no sistemática de la literatura empleando la base de datos Medline, que incluyó un protocolo de texto libre utilizando los términos «cirugía conservadora de los testículos», «cirugía conservadora testicular», «orquiectomía parcial», «tumor de testículo», «tumor del cordón sexual» y «función testicular». También se evaluaron otros estudios significativos citados en las listas de referencia de los trabajos seleccionados.

Síntesis de la evidencia

Aún no se ha registrado ningún ensayo controlado aleatorizado comparando la CCT con la OR. En aquellos pacientes con testículos contralaterales normales el uso de la CCT todavía resulta controvertido. En casos seleccionados de masas gonadales < 2 cm la CCT parece ser una opción terapéutica segura y viable. El análisis de secciones congeladas permite distinguir entre neoplasias benignas y malignas durante la CCT. Los resultados del seguimiento a medio y largo plazo no mostraron ningún riesgo significativo de recidiva local y a distancia en las principales series de la literatura.

Conclusiones

La CCT es un tratamiento efectivo para las pequeñas masas testiculares en pacientes seleccionados, limitando los sobretratamientos quirúrgicos innecesarios, sin comprometer los resultados oncológicos y funcionales. Se requieren más estudios para confirmar la seguridad oncológica.

Abstract

Introduction

Radical orchiectomy (RO) is still considered the standard of care for malignant germ cell tumors, which represent the vast majority of the palpable testicular masses. In those patients diagnosed with small testicular masses (STMs), testis-sparing surgery (TSS) could be an alternative treatment to RO. The aim of this updated review is to evaluate the current indications for TSS, and discuss the oncological and functional results of patients who had undergone organ-sparing surgery for STMs.

Evidence acquisition

A non-systematic review of the Literature using the Medline database has been performed, including a free-text protocol using the terms «testis sparing surgery», «testicular sparing surgery», «partial orchiectomy», «testis tumor», «sex cord tumor», and «testis function». Other significant studies cited in the reference lists of the selected papers were also evaluated.

Evidence synthesis

No randomized controlled trials comparing TSS with radical orchiectomy have been reported yet. In those patients with normal contra-lateral testis, the use of TSS is still controversial. In selected cases of gonadal masses < 2 cm, TSS seems to be a safe and feasible treatment option. Frozen section examination allows us to discriminate between benign and malignant neoplasms during TSS. Intermediate and long-term follow-up results showed no significant risk of local and distant recurrences in the main series reported in the literature.

Conclusions

TSS is an effective treatment for STMs in selected patients, limiting the unnecessary surgical over-treatments, without compromising the oncological and functional outcomes. Further studies are needed in order to confirm the oncological safety.

Section snippets

Introducción

El cáncer de testículo representa aproximadamente el 5% de los tumores urológicos, con una incidencia estimada de 3-10 nuevos casos por cada 100.000 varones/año en los países occidentales¹. La orquiectomía radical (OR) se considera todavía la opción estándar de atención para las masas testiculares sintomáticas, sólidas y palpables² que resultaron ser malignas en la gran mayoría de casos en el análisis histológico definitivo. No obstante, un manejo quirúrgico radical podría ser considerablemente

Conclusiones

El enfoque conservador testicular para pequeñas lesiones testiculares permite conservar tanto parénquima sano como sea posible, pero debería llevarse a cabo solo en casos seleccionados y en centros experimentados. El enfoque quirúrgico es seguro y viable y se obtienen resultados óptimos en caso de lesiones benignas. Cuando se realiza por pequeños tumores malignos de células germinales, la CCT se debería ofrecer cuidadosamente a pacientes seleccionados y la radioterapia testicular adyuvante

Conflicto de intereses

Los autores declaran que no tienen ningún conflicto de intereses.

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Cited by (24)

Testis Sparing Surgery for Benign Testicular Masses: Diagnostics and Therapeutic Approaches
2018, Journal of Urology
Citation Excerpt :
Previous studies identified tumor size as an important predictor of malignant disease since 80% of all small lesions were reported to be of benign origin.2,10,12,16–18 Nevertheless, most groups have used random cutoffs ranging from less than 2 to less than 2.5 cm to predict histology.19–23 Furthermore, in a recent study in 131 patients a lesion size of 18.5 mm was defined as most accurate to predict benign vs malignant histology with 87% sensitivity and 83% specificity.14
Small benign testicular masses are often misinterpreted as germ cell tumors and immediate inguinal orchiectomy is performed. We analyzed the diagnostic and therapeutic workup of testicular masses to improve preoperative stratification algorithms.
We performed a retrospective, single center analysis of the records of 522 patients diagnosed with primary testicular masses of unknown malignant potential.
A total of 28 patients (5%) showed a primary benign tumor after resection, including Leydig cell tumors in 9 (32%), epidermoid cysts in 9 (32%), adenomatoid tumors in 8 (29%) and Sertoli cell tumors in 2 (7%). The median volume of benign tumors was significantly less than that of malignant tumors (0.75 cm³, range 0.1 to 2.1 vs 15, range 4.5–39.9, p ≤0.001). At a cutoff of 2.8 cm³ tumor volume most accurately differentiated between benign and malignant disease, and it was a predictor of malignancy with 83% sensitivity and 89% specificity (OR 1.389, 95% CI 1.035–1.864, p = 0.029). Symptom duration in patients with benign tumors was significantly longer (365 days, range 25.5 to 365 vs 20, range 7 to 42, p ≤0.001). Also, tumor markers were unaltered in benign lesions. In patients with benign tumors significantly more fertility disorders or cryptorchidism were found (p ≤0.001) as well as a tendency toward lower testosterone (3.9 μg/l, range 0.9 to 4.9 vs 5.3, range 3.5 to 6.8, p = 0.084). Testis sparing surgery was performed in 22 of all patients (79%) with benign tumors. There was no case of relapse during followup.
Nongerm cell tumors should be considered when small testicular masses have a volume of less than 2.8 cm³ and there are hormone disorders or normal tumor markers. Immediate orchiectomy should be avoided, favoring testis sparing surgery.
Testicular tumours in children: Indications for testis-sparing surgery
2018, Anales de Pediatria
El tratamiento quirúrgico estándar del tumor testicular es la orquiectomía, sin embargo, se podría recurrir a la cirugía conservadora en casos seleccionados, basándonos en la edad del paciente, marcadores tumorales, tamaño tumoral y hallazgos histopatológicos. Nuestro objetivo es dar a conocer cuáles son las variables que tener en cuenta para indicar una cirugía conservadora como tratamiento de una masa testicular palpable y no palpable encontrada como hallazgo incidental.
Estudio retrospectivo en 22 pacientes menores de 18 años, diagnosticados de tumor testicular entre 2000 y 2014. Revisamos el motivo de consulta, antecedentes, ecografía, estudio histopatológico, marcadores tumorales (BHCG, AFP), actitud terapéutica y evolución.
De los 22 pacientes (10 prepuberales), el 82% presentaron masa palpable y el 18% fueron hallazgos incidentales. Dos presentaban criptorquidia. La BHCG estaba aumentada en el 27% y la AFP en el 45%. Se realizaron 18 orquiectomías y 4 tumorectomías. La histología fue en un 72% de células germinales, 14 orquiectomías y 2 tumorectomías (2 teratomas); y en un 27% de tumores de células no germinales, en 4 orquiectomías y 2 tumorectomías (2 tumores de células de Leyding). Seis pacientes recibieron quimioterapia postoperatoria (tumores mixtos). La mediana del tamaño de la tumoración fue de un cm (0,4-1,5) en las tumorectomías y de 2,5 cm (0,5-14) en las orquiectomías. El seguimiento fue de 5 años (1-15). Un paciente falleció por enfermedad metastásica. No hubo recidiva local en la evolución de las tumorectomías.
Ponemos de manifiesto una tendencia al cambio en nuestra actitud terapéutica. Planteamos una cirugía conservadora mediante tumorectomía en los pacientes que cumplan con los criterios de benignidad de la masa testicular (pequeño tamaño y marcadores tumorales negativos).
Although standard surgical treatment of a testicular tumour is orchiectomy, use can be made of testis-sparing surgery in selected cases, based on tumour markers, tumour size, and histopathological findings. Our objective is to become acquainted with the indications of testis-sparing surgery as a treatment for the incidental finding of a palpable and non-palpable testicular mass.
A retrospective study was conducted on 22 patients younger than 18 years diagnosed with a testicular tumour between 2000 and 2014. An assessment was made of the condition, the history, ultrasound, histopathology, tumour markers (BHCG, AFP), therapeutic approach, and outcome.
Of the 22 patients (10 prepubertal age) studied, 82% had palpable mass, and 18% were incidental findings. Two had cryptorchidism. The BHCG was increased in 27% and AFP in 45% of cases. There were 18 tumorectomies and 4 orchiectomies performed. The histopathology found 72% germ cell, 14 orchiectomy, and 2 tumorectomies (2 teratomas), with 27% non-germ cell tumours in 4 orchiectomies and 2 tumorectomies (2 cells of Leydig). Six patients received post-surgical chemotherapy (mixed tumours). The median tumour size was 1 (0.4-1.5) cm in tumorectomies, and 2.5 (0.5-14) cm in orchiectomies. The mean follow-up was 5 (1-15) years. One patient died due to metastatic disease. There was no local recurrence in the follow up of the tumorectomies.
A change in the trend of our therapeutic approach is demonstrated. We propose that testis-sparing surgery is indicated in prepubertal patients who meet the benignity criteria of the testicular mass (small size and negative tumour markers).
Reliability of Frozen Section Examination in a Large Cohort of Testicular Masses: What Did We Learn?
2017, Clinical Genitourinary Cancer
Citation Excerpt :
On the contrary, the European Association of Urology consensus-based guidelines consider TSS as an alternative for “synchronous bilateral tumors, metachronous contralateral tumors, or in solitary testis and tumor volume of < 30% of testicular volume together with normal preoperative testosterone levels.”25,26 Despite the optimistic data shown from the mentioned retrospective studies, expansion of indications for TSS from treatment of benign and nontumoral masses to malignant tumors is not justified because of the lack of supportive, prospective randomized trial data, as other authors have already suggested.20,27,28 In published studies (Table 7), nontumor and benign lesions generally have been considered together.
Frozen section examination (FSE) for testicular masses is gaining popularity because of the possibility of performing testis-sparing surgery (TSS) on the basis of the FSE results. The aim of our study was to investigate the reliability of FSE in the diagnosis of testicular masses.
From 1999 to 2016, 144 of 692 patients who underwent surgery in our tertiary center for testicular masses had FSE. The indications for FSE were: masses < 1 cm, nonpalpable, multiple, or with unusual presentation. Mean follow-up for patients was 25.5 months. The algorithm of surgery determined by FSE was: orchiectomy if malignant or nonconclusive pathology; TSS if benign or nontumor pathology. FSE data were analyzed retrospectively. Specificity and sensitivity of the method was calculated for benign, malignant, seminoma, and nonseminoma tumors.
Intraoperative FSE was conducted on 21% of candidates for surgery on testicular masses. The sensitivity and specificity of FSE were 93% and 98%, respectively, for malignant tumors, and 90% and 99%, respectively, for benign tumors. The κ agreement coefficient between FSE and final histopathology was statistically significant (0.76). TSS was performed in 57 (40%) patients, including 6 of 23 monorchid patients.
FSE correlates well with final histopathological diagnosis of testicular masses. Thus, it reliably identifies patients who might benefit from TSS. FSE should be considered always in small, nonpalpable, multiple, or uncommonly presenting masses in solitary testis or both testes.
The role of testis-sparing surgery in children and adolescents with testicular tumors
2016, Urologic Oncology: Seminars and Original Investigations
Citation Excerpt :
For adolescent males who are more likely to harbor malignant germ cell tumors, radical orchiectomy remains the standard of care. Organ-sparing surgery in select cases, such as for small testicular masses, bilateral tumors, or tumors occurring in a solitary testis, has been reported with greater frequency in the adult literature, though it is yet unclear whether this approach should be extrapolated to teenage boys [10–12]. Testis-sparing surgery (TSS) for prepubertal testis tumor was initially described in the early 1980s, for the management of primary testicular teratoma, an invariably benign tumor in the prepubertal patient [13].
Organ-sparing approaches have been applied to the treatment of a variety of urologic tumors in both the realms of adult and pediatric urology, with the goals of minimizing overtreatment of benign lesions, preserving function, and providing durable cure. The predominance of benign tumors in prepubertal patients and the reliability of both ultrasound and intraoperative frozen sections have resulted in a marked shift toward testis-sparing approaches over the last few decades. The role of testis sparing in the adolescent population is presently unclear, although there have been increasing reports of successful organ-sparing surgery for testis tumors in the adult literature. This review presents recent trends in testis-sparing approaches for both pediatric and adolescent patients, the operative technique, and some of the controversies related to testis-sparing surgery.
Organ-Sparing Surgery for Testicular Germ Cell Tumors: A Current Perspective
2023, Medicina (Lithuania)
Surgical management of prepubertal testicular tumors: A 30-year study in our institution
2023, International Journal of Urology

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Artículo de revisiónPapel de la cirugía conservadora testicular en el manejo conservador de masas testiculares pequeñas: perspectivas oncológicas y funcionalesRole of testis sparing surgery in the conservative management of small testicular masses: oncological and functional perspectives

Resumen

Introducción

Adquisición de la evidencia

Síntesis de la evidencia

Conclusiones

Abstract

Introduction

Evidence acquisition

Evidence synthesis

Conclusions

Section snippets

Introducción

Conclusiones

Conflicto de intereses

Ann Oncol

Eur Urol

J Urol

Eur Urol

Urology

J Urol

Eur Urol Suppl

J Urol

J Urol

J Urol

Urology

Urol Oncol

Urology

J Urol

Eur Urol

Eur Urol Suppl

Clin Genitourin Cancer

Urology

Eur Urol

J Urol

J Urol

Urology

Artículo de revisión
Papel de la cirugía conservadora testicular en el manejo conservador de masas testiculares pequeñas: perspectivas oncológicas y funcionalesRole of testis sparing surgery in the conservative management of small testicular masses: oncological and functional perspectives