Bilateral testicular tumors are a very rare event and represent the 2.7% of all testicular masses. 15% of the bilateral testicular tumors occurs simultaneously, but in 85% of cases the second tumor appears in the remaining testicles after a variable period. Epidermoid cysts of the testis are rare and benign lesions. The incidence of bilateral cysts is around 0,5%. Granulosa cell tumor of the testis is an infrequent stromal cell tumor and is a rare pathologic finding, accounting for 1.2%-3.9% of prepuberal testicular tumors. Although radical surgery was previously considered the treatment of choice, we evaluated the role of partial orchiectomy in presence of bilateral benign lesions in terms of preservation of testicular function (1). The aim of this study was to describe our experience in testicular tumors, focusing on their diagnosis and conservative surgical treatment.
231 patients with testicular tumors whose underwent testicular surgery for testicular masses at our department from January 2010 to June 2016 were retrospectively analysed. Baseline ultrasonography (US) and an hormone panel test were performed to all patients. Contrast-enhanced ultrasound (CEUS) was performed in the patients with no clear diagnosis of malignant lesion. Semen analysis was performed before of the testicular surgery and at the 6 month follow-up. Mean values with standard deviations (±SD) were computed and reported for all items. Statistical significance was achieved if p-value was ≤0.05 (two-sides).
The patients with simultaneously occurring bilateral benign testicular tumors were 6 (2,6%). The average age is 23,8 years (range 16 – 34). Overall, 16 benign lesions are removed. 3 out of 16 patients had only 2 tumors (1 on the left testicle and 1 on the right), 2 out of 16 patients had 3 tumors (2 on the left testicle and 1 on the right) and only 1 patient had 4 tumors (2 on the left testicle and 2 on the right). The average diameter was 0,78cm (range 0,3 – 1,8cm). Preoperative average value of testosterone was 624,3±225,08 ng/dl (range 351 – 946 ng/dl). Preoperative average values of spermiogram were: global sperm cells count 45±17,34 millions (range 35 – 80 millions), sperm progressive motility 35,83±3,77% (range 29 – 40), normal forms 6±2,37% (range 3-9).
Postoperative average value of testosterone was 587,5 ± 188,16 ng/dl (range 400 – 861 ng/dl) (p=0,7648). Postoperative average values of spermiogram were: global sperm cells count 42,5 millions ± 21,14 (range 25 – 82 millions) (p=0,8273),sperm progressive motility 31,83±7,26% (range 23 – 45) (p=0,2582), normal forms 5,1±1,47% (range 3-7) (p=0,4476). No recurrences were seen at a median follow-up of 24,3 months. PGI-I (Patient Global Impression of Improvement) test average score was 2 (1 – 4).
History, physical examination and tumor markers don’t always allow to distinguish between benign and malignant lesions.
Ultrasonography has a sensitivity of 96% and a specificity of 44% for the diagnosis of the testicular masses (2).
CEUS allows seeing the distribution of the microcirculation, which is homogeneous in benign lesions and anarchic in malignant lesions. We used histograms that enable to identify the anticipation of vascularization that is typical of malignant lesions.
In our experience, no significant differences were seen for serum testosterone levels and no significant differences were seen in global sperm cells count, sperm progressive motility and normal forms after the conservative surgery.
In addiction, PGI-I score indicates an higher degree of satisfaction of the patients treated with conservative technique.
Bilateral simultaneously occurring testicular masses are extremely rare. Some of these are benign and, in this case, the radical orchiectomy can represent an overtreatment. In these patients partial orchiectomy could be an option (in particular for young patients), allowing to maximize the advantages related to the maintenance of testicular parenchyma (3). The exocrine and the endocrine function are both preserved. In addiction, we should consider the psychological and cosmetic benefits of receiving a conservative treatment.
Despite the radical orchiectomy remains the gold standard for all testicular masses, the inclusion criteria are not clear and the discussion of informed consent with the patient is mandatory. We agree with EGCCCG (European Germ Cell Cancer Consensus Group) guidelines (4) that partial orchiectomy should be proposed for simultaneously occurring bilateral benign lesions.
1-Tavolini IM, Oliva G, Nigro F, Dal Moro F, Zuliani G, Norcen M, Mazzariol C, Pagano F. Synchronous and metachronous bilateral tumors of the testis: a single institution experience of 11 cases and review of the literature. Arch Ital Urol Androl. 1999 Jun;71(3):155-64
2-Loberant N, Bhatt S, Messing E, Dogra VS. Bilateral testicular epidermoid cysts. J Clin Imaging Sci. 2011;1:4. doi: 10.4103/2156-7514.73502. Epub 2011 Jan 1.
3-Cosentino M1, Algaba F2, Saldaña L3, Bujons A4, Caffaratti J4, Garat JM4, Villavicencio H4. Juvenile granulosa cell tumor of the testis: a bilateral and synchronous case. Should testis-sparing surgery be mandatory? Urology. 2014 Sep;84(3):694-6.
4-Zuniga A, Lawrentschuk N, Jewett MA. Organ-sparing approaches for testicular masses. Nat Rev Urol. 2010 Aug;7(8):454-64.