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Surveillance Strategy for Intratesticular Cysts: Preliminary Report
0022-534 7 /90/1432-0313$02.00/0 THE JOURNAL OF UROLOGY Copyright© 1990 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 143, February Printed in U.S.A.
SURVEILLANCE STRATEGY FOR INTRATESTICULAR CYSTS: PRELIMINARY REPORT CH. KRATZIK, A. HAINZ, W. KUBER, G. DONNER, G. LUNGLMAYR, J. FRICK, H. J. SCHMOLLER AND G. AMANN From the Departments of Urology, Radiology and Pathology, University of Vienna, Medical School, Vienna, Krankenhaus Oberwart, Krankenhaus St. Polten, Krankenhaus Mistelbach/Zaya, and Landeskrankenanstalten Salzburg, Salzburg, Austria
ABSTRACT
We treated 15 patients with all sonographic criteria of a simple testicular cyst. Of the patients 6 were operated on and the diagnosis was confirmed histologically, while 9 did not undergo an operation but are under close observation (mean surveillance 11 months). All patients are without any detectable malignancy. The possibility of a surveillance strategy in simple intratesticular cysts is discussed. (J. Ural., 143: 313-315, 1990) The incidence of benign intratesticular lesions seems to be higher than previously believed. 1 Simple intraparenchymal testicular cysts are a benign condition for which, if diagnosed correctly, patients may be spared an operation. The question is if there are methods to determine preoperatively whether intratesticular lesions are benign. High resolution sonography has an important role in the diagnosis of intratesticular changes. Simple parenchymal cysts have a pathognomonic echo pattern and, therefore, they can be diagnosed accurately by preoperative ultrasound examination. 2- 5 This fact, as well as the surveillance strategies after semicastration for testicular malignancy combined with the progress in the management of testicular tumors, motivated us to try a wait and watch policy in patients with cysts. MATERIAL AND METHODS
The 15 patients with intratesticular cysts were divided into 3 groups: group 1 was composed of 3 patients treated with radical orchiectomy (the first 3 patients in the series), group 2 included 3 who underwent an organ-preserving operation and group 3 included 9 who did not undergo an operation but who were kept under close surveillance. Histological confirmation of the diagnosis was obtained in all 6 patients in groups 1 and 2 (fig. 1). The surveillance scheme in group 3 consisted of tumor markers and sonography every 4 weeks for 6 months, then every 2 months until the end of year 1, every 3 months until the end of year 2 and then at 6-month intervals. Chest x-ray and sonograms of the retroperitoneum were done in all patients at diagnosis. Ultrasound equipment used were the Squibb Medical Systems Ultramark 4, Kretz Combison 320, Siemens Sonoline SL and Squibb Medical Systems ATL/ATR 4000 S/L devices. The scan head frequency ranged from 5 to 10 MHz. RESULTS
Tumor markers, chest x-rays and sonograms of the retroperitoneum were normal throughout. The sonograms of all patients showed criteria typical of cystic lesions. There were no internal echoes and an echo enhancement behind the lesion was present consistently. In most cases a roundish appearance also was found. A lateral shadow sign was demonstrable in only the larger lesions (diameter more than 1 cm., fig. 2). The ultrasonographic report in group 1 (patients treated by orchiectomy only) mentioned an intratesticular lesion. By reviewing the sonograms retrospectively the criteria of a cyst were found in all 3 patients. In group 2 (organ-preserving operation) the preoperative ultrasound report mentioned an Accepted for publication September 15, 1989.
313
FIG. 1. L, lumen of cyst with degenerated keratin lamellae. W, fibrous cyst wall. P, testicular parenchyma. H & E, reduced from XlOO.
intratesticular cyst. All of these patients have been without any recurrent cyst and free of any malignant change. All patients in group 3 (those under surveillance) also have been free of any detectable malignancy. In none of the patients was any change in the sonographic appearance of the cystic lesion found. Patient age, surveillance interval and indications for ultrasound examination, including palpatory findings, are presented in the table. Four patients had a cyst in the right and 3 in the left testes, and 2 had multiple cysts bilaterally. DISCUSSION
Simple intraparenchymal testicular cysts are relatively rare. Nevertheless, the number of reported cases has increased during the last years. 6 Possible explanations might be that high resolution sonography is used more often and that the interest in benign intratesticular lesions has increased. Opinions on the treatment of choice for benign intratesticular lesions are divided. Some investigators postulated radical orchiectomy because benign lesions may coexist in testicles with unrecognized malignant areas and, therefore, there is no guarantee whether an intratesticular lesion is benign and can be enucleated without orchiectomy. 7 On the other hand, there are reports about organ-preserving procedures for benign disease. 6 •8 The latter approach is supported by the fact that in a followup study of benign intratesticular tumors no patient had evidence of recurrence. 9 In this context it should be mentioned that an organ-preserving operation on a small cyst can be a difficult task. If the
314
KRATZIK AND ASSOCIATES
FIG. 3. Specimen evaluated with 10 MHz. transducer. A and B, vessel within testicle on longitudinal and oblique scans. C, cyst in contralateral testis of same patient.
FIG. 2. A, nonpalpable cyst 7 mm. in diameter shown by 7.5 MHz. transducer. Note typical criteria of cyst. B, palpable lesion evaluated with 10 MHz. transducer shows multiple cysts in testicle.
Patients with intratesticular cysts who did not undergo an operation Pt.-Age WF-61 DH-60 MJ-36
SK-54
Surveillance Time (mos.) 6 6 7 8 9
LK-63 FL-50 AR-59 GA-41
12 14 16
PK-69
21
Indications for Sonography Hydrocele Hydrocele Palpable cyst of epididymis Hydrocele Trauma to the contralat. testicle Palpable testis lesions bilat. Epididymitis Seminoma on contralat. side 8 yrs. previously Palpable lesion on lt. side
lesion is only a few millimeters in diameter and in the center of the parenchyma intraoperative localization is problematic and sometimes can be done only via intraoperative ultrasound. Diagnosis of an intratesticular lesion and adoption of a surveillance strategy without histological confirmation of the nature of the lesion mean proceeding still further. At first sight this approach must appear to be irresponsible to urologists who were taught that every intratesticular lesion was malignant until proved otherwise. There is no doubt about the truthfulness of this statement but the question is if this proof must be histological. In our series only 2 patients had a palpable lesion. In other words, the intratesticular lesion in 7 patients would have remained unrecognized unless sonographic exploration of the scrotum would have been done for other reasons. Presumably, there are patients with a pre-clinical testicular tumor who can be treated only after detection. Approximately 97% of all
FIG. 4. Specimen evaluated with 10 MHz. transducer. A, cyst of testicle. B, enlarged image of same lesion shows echogenic rim (compression of surrounding normal parenchyma).
testicular tumors are palpable 10 and the majority of all tumor patients can be cured to date. This fact implies that even if a malignancy is coexistent with a cyst or another benign lesion the chances for survival are good if malignant change is detected early. Based upon these considerations surveillance strategies may be justified. If in the future no manifestation of malignant disease is noted and the sonographic appearance still is the same, this may be accepted as proof of nonmalignancy.
SURVEILLANCE STRATEGY FOR INTRATESTICULAR CYSTS
It should be emphasized that not all intratesticular lesions without internal echoes are cysts. Multiple longitudinal and transverse scans must be done to arrive at the diagnosis, since a vessel imaged on an oblique scan may mimic a cyst (fig. 3). Even worse, a necrotic area within a testicular neoplasm may be mistaken for a cyst. Therefore, it is necessary to search for any other changes that disturb the sonographic architecture of the testicular parenchyma. The only additional change that might be seen within the testis without giving rise to suspicion is a small, slightly more echogenic rim surrounding the cyst (fig. 4). This phenomenon is caused by compression of the normal parenchyma. With high resolution sonography solid intratesticular lesions can be found before they are clinically evident. These lesions should be treated in the conventional manner. If ultrasound reveals a classical benign cyst, the patient can be spared exploration with 2 exceptions: 1) if any sonomorphological changes appear in the course of surveillance and 2) if, after proper information about the outcome of the sonographic investigation and its consequences, the patient appears not to be reliable enough for a wait and watch policy. Therefore, the decisionmaking process of the urologist must include different parameters to find the best form of therapy for the patient. The understandable desire of the surgeon to spare the patient an
315
unnecessary operation should under no circumstances leave an untreated malignant testicular tumor. REFERENCES 1. Belville, W. D., Insalaco, S. J., Dresner, M. L. and Buck, A. S.:
Benign testis tumors. J. Urol., 128: 1198, 1982. 2. Rifkin, M. D. and Jacobs, J. A.: Simple testicular cyst diagnosed preoperatively by ultrasound. J. Urol., 129: 982, 1983. 3. Chang, S. Y., Ma, C. P. and Tzeng, C. C.: Benign testicular tumors. Eur. Urol., 13: 242, 1987. 4. Takihara, H., Valvo, J. R., Tokuhara, M. and Cockett, A. T. K.: Intratesticular cysts. Urology, 20: 80, 1982. 5. Kratzik, C., Hainz, A., Kuber, W., Donner, G., Lunglmayr, G., Frick, J. and Schmoller, H.J.: Sonographic appearance of benign intratesticular lesions. Eur. Urol., 15: 196, 1988. 6. Haas, G. P., Shumaker, B. P. and Cerny, J. C.: The high incidence of benign testicular tumors. J. Urol., 136: 1219, 1986. 7. Bullock, N.: Benign testicular tumours. Brit. Med. J., 295: 456, 1987. 8. Baker, W. C., Bishai, M. B. and DeVere White, R. W.: Misleading testicular masses. Urology, 31: 111, 1988. 9. Schnell, D., Thon, W. F., Stief, C. G., Heymer, B. and Altwein, J. E.: Organerhaltendes Vorgehen bei gutartigem Hodentumor? Akt. Urol., 18: 127, 1987. 10. Kratzik, C., Kuber, W., Donner, G., Lunglmayr, G., Frick, J. and Schmoller, H. J.: Impact of sonography on diagnosis of scrotal diseases: a multicenter study. Eur. Urol., 14: 270, 1988.
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Vol. 143, February Printed in U.S.A.
SURVEILLANCE STRATEGY FOR INTRATESTICULAR CYSTS: PRELIMINARY REPORT CH. KRATZIK, A. HAINZ, W. KUBER, G. DONNER, G. LUNGLMAYR, J. FRICK, H. J. SCHMOLLER AND G. AMANN From the Departments of Urology, Radiology and Pathology, University of Vienna, Medical School, Vienna, Krankenhaus Oberwart, Krankenhaus St. Polten, Krankenhaus Mistelbach/Zaya, and Landeskrankenanstalten Salzburg, Salzburg, Austria
ABSTRACT
We treated 15 patients with all sonographic criteria of a simple testicular cyst. Of the patients 6 were operated on and the diagnosis was confirmed histologically, while 9 did not undergo an operation but are under close observation (mean surveillance 11 months). All patients are without any detectable malignancy. The possibility of a surveillance strategy in simple intratesticular cysts is discussed. (J. Ural., 143: 313-315, 1990) The incidence of benign intratesticular lesions seems to be higher than previously believed. 1 Simple intraparenchymal testicular cysts are a benign condition for which, if diagnosed correctly, patients may be spared an operation. The question is if there are methods to determine preoperatively whether intratesticular lesions are benign. High resolution sonography has an important role in the diagnosis of intratesticular changes. Simple parenchymal cysts have a pathognomonic echo pattern and, therefore, they can be diagnosed accurately by preoperative ultrasound examination. 2- 5 This fact, as well as the surveillance strategies after semicastration for testicular malignancy combined with the progress in the management of testicular tumors, motivated us to try a wait and watch policy in patients with cysts. MATERIAL AND METHODS
The 15 patients with intratesticular cysts were divided into 3 groups: group 1 was composed of 3 patients treated with radical orchiectomy (the first 3 patients in the series), group 2 included 3 who underwent an organ-preserving operation and group 3 included 9 who did not undergo an operation but who were kept under close surveillance. Histological confirmation of the diagnosis was obtained in all 6 patients in groups 1 and 2 (fig. 1). The surveillance scheme in group 3 consisted of tumor markers and sonography every 4 weeks for 6 months, then every 2 months until the end of year 1, every 3 months until the end of year 2 and then at 6-month intervals. Chest x-ray and sonograms of the retroperitoneum were done in all patients at diagnosis. Ultrasound equipment used were the Squibb Medical Systems Ultramark 4, Kretz Combison 320, Siemens Sonoline SL and Squibb Medical Systems ATL/ATR 4000 S/L devices. The scan head frequency ranged from 5 to 10 MHz. RESULTS
Tumor markers, chest x-rays and sonograms of the retroperitoneum were normal throughout. The sonograms of all patients showed criteria typical of cystic lesions. There were no internal echoes and an echo enhancement behind the lesion was present consistently. In most cases a roundish appearance also was found. A lateral shadow sign was demonstrable in only the larger lesions (diameter more than 1 cm., fig. 2). The ultrasonographic report in group 1 (patients treated by orchiectomy only) mentioned an intratesticular lesion. By reviewing the sonograms retrospectively the criteria of a cyst were found in all 3 patients. In group 2 (organ-preserving operation) the preoperative ultrasound report mentioned an Accepted for publication September 15, 1989.
313
FIG. 1. L, lumen of cyst with degenerated keratin lamellae. W, fibrous cyst wall. P, testicular parenchyma. H & E, reduced from XlOO.
intratesticular cyst. All of these patients have been without any recurrent cyst and free of any malignant change. All patients in group 3 (those under surveillance) also have been free of any detectable malignancy. In none of the patients was any change in the sonographic appearance of the cystic lesion found. Patient age, surveillance interval and indications for ultrasound examination, including palpatory findings, are presented in the table. Four patients had a cyst in the right and 3 in the left testes, and 2 had multiple cysts bilaterally. DISCUSSION
Simple intraparenchymal testicular cysts are relatively rare. Nevertheless, the number of reported cases has increased during the last years. 6 Possible explanations might be that high resolution sonography is used more often and that the interest in benign intratesticular lesions has increased. Opinions on the treatment of choice for benign intratesticular lesions are divided. Some investigators postulated radical orchiectomy because benign lesions may coexist in testicles with unrecognized malignant areas and, therefore, there is no guarantee whether an intratesticular lesion is benign and can be enucleated without orchiectomy. 7 On the other hand, there are reports about organ-preserving procedures for benign disease. 6 •8 The latter approach is supported by the fact that in a followup study of benign intratesticular tumors no patient had evidence of recurrence. 9 In this context it should be mentioned that an organ-preserving operation on a small cyst can be a difficult task. If the
314
KRATZIK AND ASSOCIATES
FIG. 3. Specimen evaluated with 10 MHz. transducer. A and B, vessel within testicle on longitudinal and oblique scans. C, cyst in contralateral testis of same patient.
FIG. 2. A, nonpalpable cyst 7 mm. in diameter shown by 7.5 MHz. transducer. Note typical criteria of cyst. B, palpable lesion evaluated with 10 MHz. transducer shows multiple cysts in testicle.
Patients with intratesticular cysts who did not undergo an operation Pt.-Age WF-61 DH-60 MJ-36
SK-54
Surveillance Time (mos.) 6 6 7 8 9
LK-63 FL-50 AR-59 GA-41
12 14 16
PK-69
21
Indications for Sonography Hydrocele Hydrocele Palpable cyst of epididymis Hydrocele Trauma to the contralat. testicle Palpable testis lesions bilat. Epididymitis Seminoma on contralat. side 8 yrs. previously Palpable lesion on lt. side
lesion is only a few millimeters in diameter and in the center of the parenchyma intraoperative localization is problematic and sometimes can be done only via intraoperative ultrasound. Diagnosis of an intratesticular lesion and adoption of a surveillance strategy without histological confirmation of the nature of the lesion mean proceeding still further. At first sight this approach must appear to be irresponsible to urologists who were taught that every intratesticular lesion was malignant until proved otherwise. There is no doubt about the truthfulness of this statement but the question is if this proof must be histological. In our series only 2 patients had a palpable lesion. In other words, the intratesticular lesion in 7 patients would have remained unrecognized unless sonographic exploration of the scrotum would have been done for other reasons. Presumably, there are patients with a pre-clinical testicular tumor who can be treated only after detection. Approximately 97% of all
FIG. 4. Specimen evaluated with 10 MHz. transducer. A, cyst of testicle. B, enlarged image of same lesion shows echogenic rim (compression of surrounding normal parenchyma).
testicular tumors are palpable 10 and the majority of all tumor patients can be cured to date. This fact implies that even if a malignancy is coexistent with a cyst or another benign lesion the chances for survival are good if malignant change is detected early. Based upon these considerations surveillance strategies may be justified. If in the future no manifestation of malignant disease is noted and the sonographic appearance still is the same, this may be accepted as proof of nonmalignancy.
SURVEILLANCE STRATEGY FOR INTRATESTICULAR CYSTS
It should be emphasized that not all intratesticular lesions without internal echoes are cysts. Multiple longitudinal and transverse scans must be done to arrive at the diagnosis, since a vessel imaged on an oblique scan may mimic a cyst (fig. 3). Even worse, a necrotic area within a testicular neoplasm may be mistaken for a cyst. Therefore, it is necessary to search for any other changes that disturb the sonographic architecture of the testicular parenchyma. The only additional change that might be seen within the testis without giving rise to suspicion is a small, slightly more echogenic rim surrounding the cyst (fig. 4). This phenomenon is caused by compression of the normal parenchyma. With high resolution sonography solid intratesticular lesions can be found before they are clinically evident. These lesions should be treated in the conventional manner. If ultrasound reveals a classical benign cyst, the patient can be spared exploration with 2 exceptions: 1) if any sonomorphological changes appear in the course of surveillance and 2) if, after proper information about the outcome of the sonographic investigation and its consequences, the patient appears not to be reliable enough for a wait and watch policy. Therefore, the decisionmaking process of the urologist must include different parameters to find the best form of therapy for the patient. The understandable desire of the surgeon to spare the patient an
315
unnecessary operation should under no circumstances leave an untreated malignant testicular tumor. REFERENCES 1. Belville, W. D., Insalaco, S. J., Dresner, M. L. and Buck, A. S.:
Benign testis tumors. J. Urol., 128: 1198, 1982. 2. Rifkin, M. D. and Jacobs, J. A.: Simple testicular cyst diagnosed preoperatively by ultrasound. J. Urol., 129: 982, 1983. 3. Chang, S. Y., Ma, C. P. and Tzeng, C. C.: Benign testicular tumors. Eur. Urol., 13: 242, 1987. 4. Takihara, H., Valvo, J. R., Tokuhara, M. and Cockett, A. T. K.: Intratesticular cysts. Urology, 20: 80, 1982. 5. Kratzik, C., Hainz, A., Kuber, W., Donner, G., Lunglmayr, G., Frick, J. and Schmoller, H.J.: Sonographic appearance of benign intratesticular lesions. Eur. Urol., 15: 196, 1988. 6. Haas, G. P., Shumaker, B. P. and Cerny, J. C.: The high incidence of benign testicular tumors. J. Urol., 136: 1219, 1986. 7. Bullock, N.: Benign testicular tumours. Brit. Med. J., 295: 456, 1987. 8. Baker, W. C., Bishai, M. B. and DeVere White, R. W.: Misleading testicular masses. Urology, 31: 111, 1988. 9. Schnell, D., Thon, W. F., Stief, C. G., Heymer, B. and Altwein, J. E.: Organerhaltendes Vorgehen bei gutartigem Hodentumor? Akt. Urol., 18: 127, 1987. 10. Kratzik, C., Kuber, W., Donner, G., Lunglmayr, G., Frick, J. and Schmoller, H. J.: Impact of sonography on diagnosis of scrotal diseases: a multicenter study. Eur. Urol., 14: 270, 1988.
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