Stesura Seveso 373Archivio Italiano di Urologia e Andrologia 2014; 86, 4 ORIGINAL PAPER Diagnostic ultrasound-guided excisional testicular biopsy for small (< 1 cm) incidental nodules. A single institution experience Andrea Fabiani 1, Alessandra Filosa 2, Fabrizio Fioretti 1, Lucilla Servi 1, Mara Piergallina 1, Giovanni Ciccotti 1, Valentina Maurelli 1, Matteo Talle’ 1, Gabriele Mammana 1 1 Surgery Dpt, Section of Urology, ASUR Marche Area Vasta 3, Macerata Hospital, Macerata, Italy; 2 Section of Pathological Anatomy, Department of Clinical Pathology, Area Vasta 3, ASUR Marche, Macerata Hospital, Macerata, Italy. Introduction and objectives: The widespread use of scrotal ultrasound (SUS) has led to a marked increase in the number of inciden- tally detected testicular lesions. A small incidental nodule (STN) has defined as a non palpable (< 10 mm), asymptomatic solid lesion with normal levels of oncological testicular mark- ers. Nowadays the lack of agreement on the topic causes man- aging problems to andrologists. We present our experience consisting in 8 cases of STN discovered by SUS performed for different clinical indications. Matherial and methods: We retrieved from our ultrasono- graphic files the clinical information about 717 patients eval- uated for andrological problems. Patients with STN underwent to a complete clinical history and physical examination as well as oncological testicular markers measurement and ormonal assessment and then received a diagnostic ultrasound guided excisional biopsy (DEB). Surgical approach was performed through an inguinal incision. Using the coordinates previously obtained from preoperative SUS, STN was localized by intra- operative SUS. The lesion was enucleated and sent to the Pathology department for frozen section examination (FSE). Biopsies of affected testis (TB) were also performed. Post-exci- sion ultrasound has been used to confirm the complete removal of the nodule. Whether pathological findings were benign, testis sparing surgery (TSS) was performed. Immediate radical orchidectomy (IRO) was performed if FSE and TB findings sug- gested a malignant lesion. Results: STNs were discovered in 8 patients (1,1%). Very small lesions (< 5 mm) were detected in 50% of cases. We performed four IRO and four DEB with consequent TSS. In one case we performed a delayed radical orchidectomy (DRO). At FSE pathologist reported 3 Leydig cell tumor and 3 seminoma and an inflammatory regressive lesion in one case. FSE on TB reported intratesticular neoplasia (TIN) in three cases. In one case nodule wasn’t sent to FSE. We observed a concor- dance between FSE and definitive pathologic report in six cases (75%). Conclusions: The management of STN is still a challenge for the surgical andrologist. A correct diagnosis has a crucial role in making the best treatment and patients outcome. Ultrasound guided excisional biopsy and the close collaboration with a dedicated pathologist are very useful in reducing errors.. KEY WORDS: Scrotal ultrasound; Small testicular nodules; Seminoma; Leydig cell tumor; Intratesticular neoplasia. Submitted 3 October 2014; Accepted 31 October 2014 Summary No conflict of interest declared. INTRODUCTION The widespread use of scrotal ultrasound (SUS) has led to a marked increase in the number of incidentally detected small testicular nodules (STNs). STN is defined as a non palpable, asymptomatic solid lesion with normal levels of oncological testicular markers (1). STNs still represent an important diagnostic and therapeutic challenge for the surgical andrologist. It is difficult to decide the strategy to use with these lesions since there are no defined prog- nostic parameters. Many series in the literature revealed that the majority of non palpable intratesticular masses are malignant (2) while others suggested the benign nature of most of them (3). Nowadays the reported con- clusions are difficult to compare due to a selection bias of the population studied. However, evidence deriving from well-conducted retrospective outcome studies with con- siderable follow-up suggests that the organ-sparing approach (TSS) stands for a viable treatment modality for testicular tumors of different histology and biology, both in the pediatric and adult population (4) We herein present 8 cases of small (< 10 mm) incidental intratesticular nodules discovered by SUS performed for different clinical indications. MATERIAL AND METHODS We retrieved from our ultrasonographic data base files the clinical information of 717 patients referred for an andrological evaluation at Macerata Hospital, Surgical Department, Urology Unit during a 43 months period. STNs were discovered in 8 patients (1,1%). These patients underwent a diagnostic ultrasound guided exci- sional testicular biopsy (DEB) associated to a random tes- ticular biopsies (TB). Each patient included in our study firstly underwent a complete clinical history and physical examination as well as oncological testicular markers measurement and ormonal assessment. Scrotal ultra- sonography and Doppler examination were performed with a 7.5 Mhz B-mode linear array transducer with color Doppler capability (BK Medical, Denmark). After assessing testicular diameter and volume, focal intratesticular echostructural anomalies were described (site, dimen- sions and echotexture). All our patients, informed about DOI: 10.4081/aiua.2014.4.373 Presented at 19th National Congress SIEUN, Fermo 2014 Fabiani 2_Stesura Seveso 16/01/15 11:05 Pagina 373 Archivio Italiano di Urologia e Andrologia 2014; 86, 4 A. Fabiani, A. Filosa, F. Fioretti, L. Servi, M. Piergallina, G. Ciccotti, V. Maurelli, M. Talle’, G. Mammana 374 the chance of ruling out a malignant tumor, preferred surgery despite active surveillance. Surgical approach was performed through an inguinal incision with clamping of the spermatic funiculus. The gonad was exteriorized from the same access after sectioning the gubernaculum. Using the coordinates previously obtained from preoperative ultrasonographic study, the lesion was localized by intra- operative ultrasound (7,5 Mhz B-mode linear array trans- ducer, BK Medical, Denmark) and a small caliber needle was placed adjacent to the lesion. The tunica albuginea overlying the lesion was then transversally incised and the nodule visualized by gently displacing the surrounding testicular parenchyma. The lesion was then enucleated, leaving a rim of normal appearing testicular parenchyma and sent to the patholo- gist department for frozen section examination. Intratesticular biopsies was randomly performed in num- ber of 4 specimen including perinodular testicular parenchyma and polar zone not involved by primary lesion. Biopsies was performed with the scissors through small incisions of the albuginea. Post-excision ultrasound has been used to confirm the complete removal of the nodules and the absence of intratesticular hematoma. If pathological findings were benign, the testis and wound were irrigated with sterile water, the vascular clamp on the spermatic cord was removed, and after achieving com- plete hemostasis, the tunica albuginea was closed with running 4-0 or 5-0 absorbable suture. If pathological find- ings of DEB and in TB suggested a malignant lesion, immediate radical orchidectomy (IRO) was performed. RESULTS During a 43 months period, 717 scrotal ultrasound exam- inations were performed for a variety of indications as varicocele, echo-color-Doppler for fertility study, andro- logical screening, scrotal pain or discomfort or general clinical screening. Small (< 10 mm) incidental testicular nodules were discovered in 8 patients (1,1%). Very small lesions (< 5 mm) were detected in 50% of cases. Clinical, ultrasound and pathological data are shown in Table 1. Figure 1a and 1 b show the ultrasonographic features of the small incidental testicular nodule in two different patients. Figure 2 shows the result after lesion removal at follow up control. Patient Age Nodule Nodule Ultrasonographic FSE result FSE result Final pathology Type Note diameter location indication on testicular on nodule Biopsy-nodule of (mm) and biopsy surgery testicular side 1 18 5 /left 2 36 4/left 3 42 6/right 4 23 6,5 /left 5 27 6/ right 6 40 8 /left 7 38 2,5/right 8 30 2,7/right TIN intratesticular neoplasia. RO radical orchidectomy. TSS testicular sparing surgery. IRO immediate radical orchidectomy. CT computed tomography. FSE frozen section examination Table 1. Clinical and pathological findings of 8 patients with non palpable testicular nodules less than 10 mm diagnosed by several andrological ultrasound evaluation. Figure 1a. Hypoechoic mesotesticular lesion of right testicle in a 38 years old azoospermic man. Final histological report revealed a Leydig cell tumor. Lower pole Upper pole Lower pole Mesotesticular Lower pole Mesotesticular Mesotesticular Lower pole Recent trauma Seminal infection Scrotal discomfort Bilateral gynecomastia Unilateral gynacomastia Severe oligoastenospermia Azoospermia Follow-up of cryptorchydism Normal tissue TIN TIN Normal tissue Normal tissue Normal tissue Normal tissue TIN Inflammatory and haemorragic infiltrate Seminoma Seminoma Leydig cell tumor Leydig cell tumor Seminoma Leydig cell Tumor Intratesticular Neoplasia (TIN)- hemorrhagic infiltrate TIN-Seminoma TIN-Seminoma Normal tissue Leydig cell tumor Normal tissue Leydig cell tumor Normal tissue Leydig cell tumor Normal tissue Leydig cell tumor TIN- Seminoma TSS IRO IRO TSS TSS IRO TSS IRO Patient underwent RO for seminoma 6 months later - - - - Pre surgical CT findings of retroperitoneal lymphadenopathy Non obstructive azoospermia; bilateral small testicular volume No nodule sent to FSE Fabiani 2_Stesura Seveso 16/01/15 11:05 Pagina 374 nodule to send to the pathologist for FSE. We had observed a concordance between intraoperative frozen section examination and definitive pathologic report in six cases (6/8). No complication was observed in each patient. DISCUSSION The recent marked increase in the number of incidental- ly detected and small testicular nodules is to be attribut- able to the widespread use of scrotal ultrasound. The management options of these type of lesion represent a problematic challenge for the uro-andrologist and include radical orchidectomy, immediate (IRO) or delayed (DRO), diagnostic excisional biopsy (DEB) or active sur- veillance. Although high resolution ultrasound can reli- ably detect solid intratesticular masses, benign lesions cannot be conclusively distinguished from malignant ones (5-6) The widely accepted surgical maxim that “a solid intratesticular mass, even if non palpable, must be con- sidered malignant until proven otherwise”, must be partial- ly revisited. The old dogma that equaled diagnosis of any testicular mass to immediate radical orchidectomy has been confuted by the clinical experience accumulated in the last decade.Several series are now available reporting an unremarkable follow up when, because of non palpa- ble testicular nodules, patients received either TSS or RO (4) An aggressive approach to a non palpable testicular lesion is reasonable in case of the presence of other risk factors of testicular tumor (7). It must be minimized the risk of performing a radical orchidectomy and the relat- ed patient overtreatment in the case of a benign nodule. On the other hand, in the case of a malignant nodule, the diagnostic excisional biopsy could lead to an alteration of the predictable pattern of lymphatic spread or determine a positive margin, without neglecting the possibility of unrecognizing lesions or TIN in the remaining testis. The last option management may be the active surveillance. General consensus for this approach exists only in the presence of a recent inflammation (7). The risk of an active surveillance is that the disease could progress to a higher stage in the case of a malignant lesion (8). In the management of small testicular nodules, it could be avoided these risks with use of the clinical and instru- mental information obtained during the diagnostic work-up. However the known prognostic factors are still inaccurate (7). In patients with small testicular lesions a prevalence of benign tumors has to be expected, compared to patients with palpable testicular lesions which are malignant in over 90% of cases (9). In a series of 27 patients with ultrasound detected testicular lesions Carmignani et al. (1) reported an overall 51.8% prevalence of benign dis- ease at definitive histology, with 80% of non-palpable lesions being benign. Similarly, Sheynkin et al. (10) reported a 75% prevalence of benign lesions among eight non-palpable testicular masses. It is noteworthy that up to 100% of non-palpa- ble testicular lesions are benign Leydig cell tumor. It has also been shown that smaller lesions (< 2 cm) are more likely to be benign (7). In our series of 8 small testicular nodules, we found 37.5% of benign tumors. At the definitive pathological 375Archivio Italiano di Urologia e Andrologia 2014; 86, 4 Diagnostic ultrasound-guided excisional testicular biopsy for small (< 1 cm) incidental nodules Figure 1b. Hypoechoic lesion of lower pole in right testicle in a 30 years old normospermic man. The ultrasonographic evaluation was performed for follow up of cryptorchidism. Figure 2a-b. Follow up of patient in figure 1a. No residual or innovative lesions was found. We have performed four (4/8) immediate radical orchidec- tomy (IRO) and four (4/8) excisional biopsy with conse- quent testis sparing procedure (TSS). In one case (1/8) we have performed a delayed radical orchidectomy (DRO). At intraoperative FSE, both Leydig cell tumor and seminoma have been diagnosed in three cases and flogosis with hem- orrhagic infiltration in one case. In this last one case, six months after TSS we have performed a RO due to the dis- covery during the follow up of a new nodular lesion revealed as seminoma. At FSE of testicular biopsies, pathologist diagnosed in three cases an intratesticular neo- plasia (TIN). In one case we were not able to identify the Fabiani 2_Stesura Seveso 16/01/15 11:05 Pagina 375 Archivio Italiano di Urologia e Andrologia 2014; 86, 4 A. Fabiani, A. Filosa, F. Fioretti, L. Servi, M. Piergallina, G. Ciccotti, V. Maurelli, M. Talle’, G. Mammana 376 report, seminoma was diagnosed in 3 cases and a defin- itive diagnosis of TIN has been made in 1 case. In case of lesions less than 5 mm (4/8), we founded a seminoma in two case (50%) and a benign Leydig cell tumor in one case (25%). Muller et al. (11) reported a series of 20 men diagnosed with a tumor mean diameter of 3.5 mm with four patients (20%) who underwent an IRO because the lesions were found to be malignant. In all case, the resected specimen revealed a multifocal TIN. According to this previous report, our limited experience did not confirm that the benign lesions are smallest than malig- nant ones. Moreover, in our small series, clinical information or imaging data was not always useful for predicting the benign or the malignant nature of testicular lesion. Two patients with gynecomastia had a definite diagnosis of Leydig cell tumor. On the other hand, although the pres- ence of retroperitoneal lymphadenopathy was consid- ered an indication to immediate radical orchidectomy, in our patient it has not been associated with a malingnant neoplasia. Moreover inflammatory and hemorrhagic infiltrate in a clinical setting of recent trauma lead us to a sparing sur- gical approach, but definitive pathological examination revealed intratesticular neoplasia (TIN) and patient underwent radical orchidectomy 6 months later for a new testicular mass (seminoma) detected after ultra- sound follow-up. Therefore, at the best of our knowledge, in small nodu- lar lesions of the testes the intra-operative ultrasound excisional biopsy is mandatory. The first description of the operative technique of ultra- sound guided testicular nodule excision was made by Stoll et al. (12) and progressively developed until 2002, when Hopps and Goldstein codified the procedure intro- ducing the use of a magnificent system, with the aim of improving the identification and complete excision of small non palpable lesions (13). Rolle et al. (14) described their experience on a series of 14 hypoechoic testicular lesions that underwent surgical exploration with the aid of the operating microscope. With a mean size of the nodules of 5.7 ± 4.6 mm, they reported the identification and the complete excision of lesions in all patients. The intraoperative frozen section examination (FSE) showed a benign lesion in 12 cases and intratesticular neoplasia (TIN) in two who under- went RO. The definitive histological analysis always confirmed the frozen section examination report. After a mean clinical and ultrasound follow-up of 15 months, they not report- ed complications. Valotto et al. (15) described a total of 25 patients with negative testicular cancer markers who underwent an inguinal surgical exploration for a testicu- lar non palpable suspected lesion of a mean diameter of 16.1 mm (range 4-89 mm) without use of magnificent systems. They identified and successfully removed all lesions. FSE revealed benign lesion in 21 cases (84%) but this find- ings was confirmed in 18/21 (84%). DRO was performed with a diagnosis of seminoma in two cases. And the pathological report was negative in one case. When FSE revealed a malignant lesion (4 cases), the definitive pathological report on radical orchidectomy specimen confirmed this findings in 75%. After a median follow up of 18 months they not reported relapse. Also in our series we used only intraoperative ultrasonography with needle lesion localization. We have not enough experience about lesion less than 5 mm in diameter (4 cases of 8) for considering microsurgery use- less in such cases. In any case a microsurgical approach to small testicular lesions can provide the opportunity to identify all lesion and remove it with appropriate margins in case of a soli- tary testis or bilateral malignancies (16). Ultrasound excisional biopsy has been very difficult for us in case of very small nodules. In particular, in one patient, we were not able to identify the lesion (diameter 2.7 mm) despitr the use of intra operatory ultrasound. Immediate radical orchidectomy was decided considering the diagnosis of TIN on testicular biopsies. Definitive histopathologic evaluation reported a small seminoma. The use of a magnificent system could have helped the dissection improving the identification, the complete nodule excision and the accuracy of the diag- nosis, especially during the intraoperative biopsy for frozen section examination. Intraoperative FSE could provide a diagnosis of nature with absolute certainty. FSE has demonstrated to be a highly reliable method to characterize testicular masses. Subik et al. reported in 36 (83.7%) of 43 cases with benign frozen section assessments, the capability to suc- cessfully avoid a radical orchidectomy (17). Therefore there is general consensus that FSE is useful for permitting testicular preservation, especially in men with small, non palpable, incidentally found masses as well as other benign lesions where a clinical diagnosis of malignancy is in doubt (17). In our series we observed a concordance between FSE and definitive pathologic report in six cases (75%). Misdiagnoses were made in absence of the dedicated pathologist. In addition to the need for magnification tools, we rec- ognize, especially in cases of very small lesion, that diag- nostic accuracy in FSE may be influenced by the expert- ise of the attending dedicated pathologist, which cannot be translated to every community hospital. CONCLUSIONS Small (< 10 mm) testicular nodules are nowadays com- monly observed due to the widespread use of scrotal ultrasound evaluation. The management of this topic is still a challenge for the surgical andrologist and the pathologist. 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Hum Pathol. 2012; 43:1514-9. 377Archivio Italiano di Urologia e Andrologia 2014; 86, 4 Diagnostic ultrasound-guided excisional testicular biopsy for small (< 1 cm) incidental nodules Correspondence Andrea Fabiani, MD (Corresponding Author) andreadoc1@libero.it Fabrizio Fioretti, MD, PhD fa.fioretti@libero.it Lucilla Servi, MD lucilla.servi@sanita.marche.it Mara Piergallina, MD mara.piergallina@tiscali.it Giovanni Ciccotti, MD giovanni.ciccotti@sanita.marche.it Valentina Maurelli, MD valentinamaurelli@hotmail.it Matteo Talle’, MD matteo.talle@gmail.com Gabriele Mammana, MD gabriele.mammana@sanita.marche.it Surgery Dpt, Head of Section of Urology ASUR Marche Area Vasta 3, Macerata Hospital, Macerata, Italy Alessandra Filosa, MD, PhD alessandrafilosa@yahoo.it Section of Pathological Anatomy, Department of Clinical Pathology, Area Vasta 3, ASUR Marche, Macerata Hospital, Macerata, Italy Fabiani 2_Stesura Seveso 16/01/15 11:05 Pagina 377