Stesura Seveso 397Archivio Italiano di Urologia e Andrologia 2014; 86, 4 SHORT COMMUNICATION Diagnostic-therapeutic pathway for small lesions of the testis Giulia Sbrollini 1, 2, Daniele Mazzaferro 1, Asim Ettamimi 1, Rodolfo Montironi 3, Marco Cordari 1, Guevar Maselli 1, Giacomo Tucci 1, Gaetano Donatelli 1, Francesco Pellegrinelli 1,2, Alessandro Conti 1,2, Andrea Benedetto Galosi 1 1 Division of Urology, “Augusto Murri” Hospital, ASUR Marche, Fermo, Italy; 2 Institute of Urology, 3 Institute of Pathology, Polytechnic University of the Marche Region, United Hospitals, Ancona, Italy. Objective of our study was to define a diagnostic-therapeutic pathway for proper treatment of not-palpable testicular masses, that may be benign in 38% of cases. Since the intraoperative diagnosis is difficult to reach in particular in small lesion (< 8 mm) and the risk of tissue loss in frozen sec- tion analysis occurs frequently, we propose a diagnostic flow chart for the best management of small testis lesions. This proposed protocol has to be shown in details to physicians and patients, who must understand the clinical implications and the risk to undergo a sec- ond radical surgery. KEY WORDS: Small masses; Testis neoplasms; Partial orchiectomy; Ultrasound; Pathology. Submitted 3 October 2014; Accepted 31 October 2014 Summary No conflict of interest declared. CLINICAL PROTOCOL TO NOT-PALPABLE TESTIS LESIONS We present a diagnostic-therapeutic protocol for patients affected by not-palpable testicular masses, with maxi- mum diameter lower than 15 mm and negative testicu- lar markers. This approach follows our clinical practice. Ultrasound All men underwent scrotal ultrasound in our hospital to confirm type, dimension and localization of the lesion. Ultrasound characteristics of the lesion were then veri- fied at the confirmatory ultrasound by expert operator and last generation of ultrasound machine. If the lesion was not confirmed by confirmatory ultrasound or it is extra-testicular lesion, the patient was proposed for ultrasound follow-up. Once the small testicular mass was confirmed at our hos- pital, the therapeutic indication for all cases was testicu- lar exploration with inguinal access. This technique can be associated to intraoperative ultrasound, equipped with linear probe, in order to obtain the relative certain- ty of the size of the nodule and negative surgical margins, which of course will be subsequently verified by the pathologist. In figures, we report ultrasound images of three cases of our who underwent surgery for epider- moid cyst (Figure 2), Leydig tumor (Figure 3), and semi- noma (Figure 4). Surgery Surgical exploration, using intraoperative ultrasound was done without clamping the spermatic cord. The sur- gical technique involved the removal of the neoplastic nodule and 3 additional biopsies of the surrounding parenchyma (two distant and one next to the mass) sent for definitive histology. Smaller masses (< 8 mm) were usually sent for definitive histology, while larger masses (8-15 mm) were sent to the pathologist for intraoperative frozen sections. Pathologist confirmed size and completeness of surgical margins, by macroscopic view. If the nodule was large enough to be cut for frozen section, then a microscopic description of malignant pattern was reported. DOI: 10.4081/aiua.2014.4.397 Presented at 19th National Congress SIEUN, Fermo 2014 INTRODUCTION Incidentally discovered small testicular lesions are increasing since ultrasound use increased in particular for infertility work up. Although small lesion of the testis are benign in 38% of cases (1, 2), there is no agreement on criteria for testis- sparing surgery. Guidelines give indication for testis-sparing surgery only in selected cases (bilateral testicular tumor or monorchid patient) (3). However, testis-sparing surgery has been performed also in patients with contralateral normal testis with a good oncological outcome (2, 4-8). Several concerns on con- servative approach are debated: intraoperative diagnosis is not always reliable in relation to the small size of the lesion and also difficulties in pathological diagnosis relat- ed to the missing immunoistochemistry during intraop- erative analysis. The aim of this study is to establish a diagnostic-thera- peutic pathway that allows to perform an effective testis- sparing surgery for impalpable testicular masses. Archivio Italiano di Urologia e Andrologia 2014; 86, 4 G. Sbrollini, D. Mazzaferro, E. Asim, R. Montironi, M. Cordari, G. Maselli, G. Tucci, G. Donatelli, F. Pellegrinelli, A. Conti, A.B. Galosi 398 Masses of mean size (8-9 mm) were sent to the pathologist, who evaluated whether to perform the frozen section or to move direct- ly to the definitive exam, in order to reduce the risk of losing tissue for definitive histol- ogy and immunoistochemistry. If feasible, the intraoperative frozen section histology gives real time information about macro- scopic (localization, surgical margins, size of the lesion) and microscopic features. Such information can guide the surgical management. In case of benign or doubtful lesion there was the indication to keep on conservative man- agement. In case of malignancy at the frozen section, inguinal orchiectomy was performed. All removed testicular lesion are subjected to definitive histological examination, including immunohistochemistry of the surgical specimen, that allowed to have a definitive histologic diagnosis. Definitive paraffin-embedded tissue analysis is the main diagnostic tool for testicular cancer. If definitive histology confirmed that the mass was benign, the patient was submitted to periodic ultrasound follow up. In case of definitive malignancy inguinal orchiectomy was done. The presence of isolated intraepithelial neo- plasia (TIN) in one or more of the biopsies of the surrounding parenchyma, posed indi- cation to radiotherapy. Before undergoing this protocol, the patient has to be informed in detail about the various benefits, risks and implications: first of all the possibility of being subjected to a second surgery as soon as the urologist is in posses- sion of the definitive histological result. Our protocol has been approved by different specialists involved in the diagnosis and treatment (urologist, pathologist, radiologist and oncologist) and used in dif- ferent Departments of Urology. Figure 1 shows the flow chart of the protocol for diag- nosis, treatment and therapy of small not-palpable tes- ticular masses. Figure 1. Flow chart of diagnostic-therapeutic protocol for the management of non-palpable testicular masses. Figure 2. Testis ultrasound: hyper-echoic lesion, not palpable, inside the testis. After surgical partial orchiectomy, a dermoid cyst was described. Figure 3 Testis ultrasound: small non palpable hypo-echoic lesion inside the testis. A Leydig tumor was identified after partial resection and definitive histology. Figure 4 Testis ultrasound: small non palpable hypo-echoic lesion close to the epididymis. A seminoma was identified after partial resection and definitive histology. The histological diagnosis on frozen sections is difficult in small testicular masses and raises the risk of loss of tis- sue useful for the final histology and ancillary immuno- histochemistry. Intraoperative ultrasound allows the surgeon to orient with more confidence in the surgical practice and then to decide whether to send the specimen for intraopera- tive histological examination or for definitive examina- tion. In the masses of border-line size a key role in this deci- sion is covered by the pathologist, who must be able to evaluate the tumor volume and then to act in a way to have an definitive histologic diagnosis as accurate as possible. CONCLUSIONS Frequency of benign tumors is higher in small testicular masses. Intraoperative diagnosis of non-palpable testicular lesions with frozen sections is difficult in particular for very small lesions (< 8 mm) also for the risk of loss of tis- sue for definitive histology and ancillary immunoisto- chemistry. 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Urologia 2008; 75S12:s59-66. 399Archivio Italiano di Urologia e Andrologia 2014; 86, 4 Pathway for small testicular lesions Correspondence Giulia Sbrollini, MD, Urologist (Corresponding Author) giuliasbrollini@libero.it Alessandro Conti, MD, Urologist alessandro.conti@hotmail.com Daniele Mazzaferro, MD, Urologist mazzaferro.dr@gmail.com Ettamimi Asim, MD ettamimi.asim@tiscali.it Marco Cordari, MD, Urologist m.cordari@tin.it Guevar Maselli, MD, Urologist guevarmaselli@katamail.com Giacomo Tucci, MD, Urologis tucci.giacomo@virgilio.it Gaetano Donatelli, MD, Urologist Francesco Pellegrinelli, MD, Urologist asaga@hotmail.it Alessandro Conti, MD, Urologist alessandro.conti@hotmail.com Clinica Urologica, Azienda Ospedaliero-Universitaria Ospedali Riuniti Ancona Via Conca 71, 61100 Torrette di Ancona, Italy Rodolfo Montironi, MD, Pathologist r.montironi@univpm.it Institute of Pathology, Polytechnic University of the Marche Region, United Hospitals, Ancona, Italy Andrea Benedetto Galosi, MD, PhD galosiab@yahoo.it Division of Urology, “Augusto Murri” Hospital ASUR Marche, Fermo, Italy