Galosi Andrea B, Fulvi Paola, Fabiani Andrea, Servi Lucilla, Filosa Alessandra, Leone Luca, Marronaro Angelo, Caraceni Enrico, Montironi Rodolfo
Clinica Urologica, Dipartimento Scienze Cliniche e Odontostomatologiche, Università Politecnica delle Marche, AO Ospedale Riuniti, Ancona.
Arch Ital Urol Androl. 2016 Dec 30;88(4):320-324. doi: 10.4081/aiua.2016.4.320.
The incidence of benign testicular tumors is increasing in particular in small lesion incidentally found at scrotal ultrasonography. Primary aim of this study was to perform radical surgery in malignant tumor. Secondary aim was to verify the efficacy of the diagnostic-therapeutic pathway recently adopted in management of small masses with testis sparing surgery in benign lesions.
In this multicenter study, we reviewed all patients with single testis lesion less than 15 mm at ultrasound as main diameter. We applied the diagnostic-therapeutic pathway described by Sbrollini et al. (Arch Ital Urol Androl 2014; 86:397) which comprises: 1) testicular tumor markers, 2) repeated scrotal ultrasound at the tertiary center, 3) surgical exploration with inguinal approach, intraoperative ultrasound, and intraoperative pathological examination. Definitive histology was reviewed by a dedicated uro-pathologist.
Twenty-eight patients completed this clinical flowchart. The mean lesion size was 9.3 mm (range 2.5-15). Testicular tumor markers were normal except in a case. Intraoperative ultrasound was necessary in 8/28 cases. We treated 11/28 (39.3%) with immediate radical orchiectomy and 17/28 (60.7%) with testis-sparing surgery. Definitive pathological results were: malignant tumor in 6 cases (seminoma), benign tumor in 10 cases (5 Leydig tumors, 2 Sertoli tumors, 1 epidermoid cyst, 1 adenomatoid tumor, 1 angiofibroma), benign disease in 11 (8 inflammation with haemorragic infiltration, 2 tubular atrophy, 1 fibrosis), and normal parenchyma in 1 case. We observed a good concordance between frozen section examination and definitive histology. Any malignant tumor was treated conservatively. Any delayed orchiectomy was necessary based on definitive histology.
The incidence of benign lesions in 60% of small testis lesions with normal tumor markers makes orchiectomy an overtreatment. Testicular sparing surgery of single testicular nodules below 15 mm is a safe option, but requires a standardized pathway in diagnosis. Our pathway has shown good reliability and security profile to be applied in a multicenter management for small scrotal masses. Our study has shown the reliability of the diagnostic-therapeutic pathway in the management of single testicular masses. The higher incidence of benign lesions in 60% of patients makes often orchiectomy an overtreatment.
良性睾丸肿瘤的发病率正在上升，尤其是在阴囊超声偶然发现的小病灶中。本研究的主要目的是对恶性肿瘤进行根治性手术。次要目的是验证最近采用的诊断治疗途径在良性病变中保留睾丸手术治疗小肿块的疗效。
在这项多中心研究中，我们回顾了所有超声检查显示单个睾丸病灶最大直径小于15mm的患者。我们应用了Sbrollini等人（《意大利泌尿学与男科学杂志》2014年；86:397）描述的诊断治疗途径，该途径包括：1）睾丸肿瘤标志物；2）在三级中心重复进行阴囊超声检查；3）采用腹股沟入路进行手术探查、术中超声检查和术中病理检查。最终组织学检查由一位专业的泌尿病理学家进行复查。
28例患者完成了这一临床流程。病灶平均大小为9.3mm（范围2.5 - 15mm）。除1例患者外，睾丸肿瘤标志物均正常。28例中有8例需要术中超声检查。我们对11/28（39.3%）的患者立即进行了根治性睾丸切除术，对17/28（60.7%）的患者进行了保留睾丸手术。最终病理结果为：6例恶性肿瘤（精原细胞瘤），10例良性肿瘤（5例Leydig细胞瘤、2例支持细胞瘤、1例表皮样囊肿、1例腺瘤样瘤、1例血管纤维瘤），11例良性疾病（8例伴有出血浸润的炎症、2例小管萎缩、1例纤维化），1例实质正常。我们观察到冰冻切片检查与最终组织学检查之间有良好的一致性。任何恶性肿瘤均采用保守治疗。根据最终组织学检查，无需进行任何延迟睾丸切除术。
在肿瘤标志物正常的小睾丸病灶中，60%为良性病变，这使得睾丸切除术成为过度治疗。对直径小于15mm的单个睾丸结节进行保留睾丸手术是一种安全的选择，但需要标准化的诊断途径。我们的途径在多中心管理小阴囊肿块方面显示出良好的可靠性和安全性。我们的研究表明了诊断治疗途径在管理单个睾丸肿块方面的可靠性。60%的患者中良性病变发生率较高，这常常使睾丸切除术成为过度治疗。
