Management of Testicular Masses Incidentally Discovered by Ultrasound

0022-5347/94/1515-1263$03.00/0 THE JOURNAL OF UROLOGY Copyright © 1994 by AMERICAN UROLOGICAL ASSOCIATION, INC.

Vol. 151, 1263-1265, May 1994

Printed in U.S.A.

MANAGEMENT OF TESTICULAR MASSES INCIDENTALLY DISCOVERED BY ULTRASOUND WILLIAM G. HORSTMAN,* MARY M. HALUSZKA

AND

THOMAS K. BURKHARD

From the Departments of Radiology, Urology and Clinical Investigation, Naval Medical Center San Diego, San Diego, California

ABSTRACT

Incidental nonpalpable testicular masses were discovered in 9 patients during approximately 1,600 scrotal ultrasound examinations done for other indications. Of the 9 lesions 7 (78%) were benign (4 Leydig cell tumors, 2 Sertoli cell tumors and 1 interstitial fibrosis) and 2 (22%) were malignant (1 teratocarcinoma and 1 seminoma). Five lesions (55%) were less than 1 cm. (4 benign and 1 malignant), while 4 (45%) were 1 to 2 cm. (3 benign and 1 malignant). Seven lesions (78%) were hypoechoic, 1 (11%) was hyperechoic and 1 (11%) was cystic. We conclude that incidentally discovered nonpalpable lesions are usually benign. Management should include inguinal exploration with frozen section diagnosis. The testis can be spared if the lesion is benign. Ultrasound followup should be used only if there is a strong clinical suspicion of a nonneoplastic lesion, such as recent trauma or infection. It is suggested that nonpalpable tumors discovered in patients with metastatic germ cell tumor should be treated as malignant. KEY WORDS:

testicular neoplasms, ultrasound, Leydig cell tumor, Sertoli cell tumor

Ultrasound examination is used commonly to evaluate a wide variety of scrotal pathological conditions. It has been used primarily to evaluate palpable testicular or epididymal masses and hydroceles. Since the introduction of color Doppler ultrasound, acute and chronic scrotal pain and infertility have also become common indications for ultrasound. Occasionally during ultrasound examinations a clinically unsuspected intratesticular mass is discovered. Patients with incidental lesions frequently undergo radical orchiectomy, since 95% of the palpable intratesticular masses are malignant germ cell neoplasms 1 and the ultrasound findings are not specific enough to distinguish benign from malignant lesions. We reviewed the results of approximately 1,600 scrotal ultrasound examinations from 2 institutions and examined 9 incidentally discovered intratesticular masses. We report on the ultrasound appearance and histological diagnosis of the lesions, and suggest a management strategy for nonpalpable lesions. MATERIALS AND METHODS

Incidental testicular tumors were discovered in 9 patients during the course of approximately 1,600 ultrasound examinations performed for other indications. An incidental lesion was defined as a nonpalpable lesion that is an unexpected finding during an ultrasound examination. A nonpalpable testicular tumor in a patient who presents with retroperitoneal metastasis or a nonpalpable Leydig cell tumor in a patient with gynecomastia would not be considered incidental lesions. The first 7 patients were identified prospectively from 900 examinations performed at the Naval Medical Center San Diego (NMCSD) from 1984 to 1987. The last 2 patients were identified retrospectively by reviewing all of the testicular tumors discovered by ultrasound at Mallinckrodt Institute of Radiology (MIR) from March 1988 to March 1992. Patient age ranged from 25 to 68 years (mean age 35.88 years). Two tumors were discovered during followup examinations in patients with previous testicular tumors, 2 were discovered while evaluating epididymal masses (1 spermatocele and 1 post-inflammatory mass) and 1 was discovered when the patient presented with a contralateral

missed torsion. Three patients were being evaluated for infertility and 1 had nonspecific scrotal discomfort after vasectomy. Standard gray scale real-time and hard copy images were obtained in longitudinal and transverse planes through both testes. The images taken at NMCSD were obtained on a Phillips SDU 3000 scanner and a high resolution small parts 7.0 MHz. linear transducer was used. The images taken at MIR were obtained on an ATL Mark IV scanner and a high resolution 7.5 MHz. linear transducer was used. All patients were examined while in the supine position with the scrotum supported on a towel. Standard ultrasound coupling gel was used. RESULTS

Of the 9 incidental testicular lesions discovered during the course of the study 7 (78%) were benign (4 Leydig cell tumors, 2 Sertoli cell tumors and 1 interstitial fibrosis) and 2 (22%) were malignant (1 seminoma and 1 teratocarcinoma) (see table). The clinical histories included 2 patients undergoing followup examinations because of previous contralateral malignant testicular tumors, 3 with infertility, 2 with epididymal masses, 1 with persistent pain after vasectomy and 1 with contralateral missed torsion. The lesions ranged from 0.3 to 1.5 cm. large (mean 0.88 cm.). Of the 9 lesions 7 (78%) were homogeneous hypoechoic (fig. 1), 1 Sertoli cell tumor was hyperechoic (fig. 2, A) and the teratocarcinoma was cystic (fig. 2, B). The lesions could not be distinguished by size, ultrasound characteristics or the clinical history of the patients.

Accepted for publication October 22, 1993. The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Navy, Department of Defense or the United States Government. * Requests for reprints: c/o Clinical Investigation Department, Naval Medical Center, San Diego, California 92134-5000. 1263

Nine testicular lesions incidentally found by ultrasound Pt. Age

Size (em.)

Ultrasound

Pathological Finding

46

1.1

Hypoechoic

Leydig cell

55

0.5

Hypoechoic

Leydig cell

28 28 32 39

0.5 0.5 1.4 0.5

Hypoechoic Hypoechoic Hypoechoic Hypoechoic

Sertoli cell Sertoli cell Leydig cell Seminoma

25

0.3

Hypoechoic

34 68

1.5 0.6

Cystic Hypoechoic

Interstitial fibrosis Teratoca. Leydig cell

Clinical History Contralat. teratoca. 17 yrs. ago Contralat. lymphoma 2 yrs. ago Ipsilat. spermatocele Contralat. missed torsion Infertility Bilat., nonspecific scrotal pain after vasectomy Infertility Infertility Ipsilat. epididymal mass after episode of epididymitis

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MANAGEMENT OF TESTICULAR MASSES INCIDENTALLY DISCOVERED BY ULTRASOUND

FIG. 1. A, longitudinal view of testes in patient with infertility demonstrates 1.4 cm. hypoechoic Leydig cell tumor (arrows). B, longitudinal view of testes in patient with bilateral scrotal pain after vasectomy reveals 0.5 cm. hypoechoic seminoma (arrows).

FIG. 2. A longitudinal view oftestes in patient with contralateral missed torsion shows inhomogeneous hyperechoic 1.2 cm. Sertoli cell tumor (cursors). B,'transverse view of testes in patient with infertility demonstrates 1.5 cm. predominantly cystic teratocarcinoma (arrows). DISCUSSION

Scrotal ultrasound is a common diagnostic procedure with many clinical indications. Historically, the most common indication has been the evaluation of palpable scrotal masses to differentiate intratesticular from extratesticular lesions and to exclude contralateral lesions. With the addition of color Doppler ultrasound, patients with acute or chronic scrotal pain and infertility are also frequently being evaluated. Uncommonly, a nonpalpable, clinically unsuspected intratesticular mass will be discovered during ultrasound examination. In the past many of these patients had undergone radical orchiectomy because 90 to 95% of the palpable intratesticular neoplasms are malignant germ cell tumors1 and it was believed that most incidental lesions would also be malignant. Unfortunately, ultrasound cannot differentiate benign from malignant lesions. Many cases of incidental lesions have been reported in the literature. Most of these reports described nonpalpable lesions discovered in patients with known metastatic germ cell tumors 2-5 and were almost always malignant. Others have reported the discovery of nonpalpable Leydig cell tumors in patients with gynecomastia. 6- 10 The largest series of nonpalpable lesions included in 5 patients described by Corrie et al. 11 In their series all 5 lesions were benign: 2 were solid neoplasms and 3 were pathologically proved, and the ultrasound appearance of these lesions was not described. Additionally, all of these patients had strong clinical signs concerning the nature of the lesions. Two of these patients with Leydig cell tumors presented with gyne,comastia -and ultrasound was performed to evaluate for the possibility of a Leydig cell tumor. Two patients had recent scrotal infectious or inflammatory episodes and the lesions resolved without surgery. One patient had had a recent episode of scrotal trauma and the lesion also resolved. Although

these lesions were nonpalpable, they were not truly incidental and on the basis of this series Corrie et al recommended monthly ultrasound followup. If the lesion did not resolve excisional biopsy could be performed. We describe a total of 9 incidental testicular lesions, 8 of which were neoplastic and all were pathologically proved. Of the 9 lesions 7 (78%) were benign (4 Leydig cell and 2 Sertoli cell tumors, and 1 area of fibrosis) while 2 (22%) were malignant germ cell tumors (1 seminoma and 1 teratocarcinoma). These lesions could not be distinguished by the ultrasound appearance, since 78% were homogeneous and hypoechoic, nor was clinical history helpful. In fact, 2 patients had a misleading clinical history, since both had undergone previous contralat· eral orchiectomy for malignant disease and both had Leydig cell tumors. This finding is in contrast to other case reports of synchronous and metachronous malignant tumors found in patients with a contralateral palpable tumor .12-14 Gonadal stromal tumors, including Leydig and Sertoli cell tumors, represent approximately 5% of all intratesticular tumors in an unselected population but they represent 66% of the tumors in our series. Leydig cell tumors are more common and have a trimodal age distribution: 5 to 10, 30 to 40 and greater than 60 years old. Of the tumors 10% are bilateral, and they can cause systemic endocrine manifestations by producing estrogen, progesterone and occasionally corticosteroids. Of the men 20 to 30% have gynecomastia, a change in libido or impotence due to estrogen production. Sertoli cell tumors are less common but can also present with endocrine symptoms. Either type of tumor can become large enough to be palpable and 5 to 10% of either are malignant. 1 The determination of malignancy is clinical, with metastatic spread as the only definite indicator. Light and electron microscopic findings are nonspecific. 15 Large lesions (greater than 5 cm.) and tumors in

MANAGEIvIENT OF TESTICULAR MASSES INCIDENTALLY DISCOVERED BY ULTRASOUND

older men tend to be more aggressive. l6 Given the generally benign behavior of these lesions, especially the smaller lesions, we believe that local excision with testicular sparing is an appropriate therapy. Our results and other reports of benign incidental tumorsl? lead us to conclude that incidentially discovered lesions are likely to be benign. We believe that if the tumor markers and chest radiograph are normal, these patients should undergo excisional biopsy through an inguinal approach. If needed, ultrasound guidance can be used to localize a nonpalpable mass. The testis can be spared if intraoperative frozen section diagnosis is benign. If the tumor is malignant radical orchiectomy can be performed. Similar management can be done if the patient has endocrine symptoms or gynecomastia. We would also manage a patient with a previous contralateral malignant lesion in this manner, since both patients in our series with contralateral palpable malignant neoplasms had metachronous incidental Leydig cell tumors. The 22% incidence of malignant tumors in our series and other reports of malignancy in truly incidental lesions l8 underscore the importance of rapid diagnosis and therapy. The only situation in which we would perform ultrasound followup is in a patient who had recent trauma, infection or another clinical situation that would suggest that the intratesticular lesion is not neoplastic. If the patient initially presents with a retroperitoneal or distant metastatic germ cell neoplasm, a nonpalpable tumor is likely to be malignant and radical orchiectomy may be performed. REFERENCES

1. Morse, M. J. and Whitmore, W. F.: Neoplasms of the testis. In:

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Campbell's Urology, 5th ed. Edited by P. C. Waish, R F. Gittes, A. D. Perlmutter and T. A. Stamey. Philadelphia: W. B. Saunders Co., vol. 2, chapt. 33, pp. 1535-1582, 1986. Powell, S., Hendry, W. F. and Peckham, M. J.: Occult germ-cell testicular tumours. Brit. J. Ural., 55: 440, 1983. Peterson, L. J., Catalona, W. J. and Koehler, R K: Ultrasound localization of a non-palpable testis tumor. J. Urol., 122: 843, 1979. Glazer, H. S., Lee, J. K. T., Melson, G. L. and McClennan, B. L.: Sonographic detection of occult testicular neoplasms. AJR, 138: 673,1982. Bockrath, J. M., Schaeffer, A. J., Kies, M. S. and Neiman, H. L.: Ultrasound identification of impalpable testicle tumor. J. Urol., 130: 355, 1983. Corrie, D., Norbeck, J. C., Thompson, I. M., Rodriguez, F., Teague, J. L., Rounder, J. B. and Spence, C. R: Ultrasound detection of bilateral Leydig cell tumors in palpable normal testes. J. Urol., 137: 747, 1987. Haas, G. P., Pittaluga, S., GOl'mella, L., Travis, W. B., Shel'ins, R. J., Doppman, J. L., Linehan, W. M. and Robertson, C.: Clinically occult Leydig eel! tumor presenting as gynecomastia. J. Urol., 142: 1325, 1989. Hendry, W. S., Garvie, W. H., Ah-See, A. K. and Bayliss, A. P.: Ultrasonic detection of occult testicular neoplasms in patients with gynaecomastia. Brit. J. Rad., 57: 571, 1984. Mellor, S. G. and McCutchan, J. D.: Gynaecomastia and occult Leydig cell tumour of the testis. Brit. J. Urol., 63: 420, 1989. Emory, T. H., Charboneau, J. W., Randall, R. V., Scheithauer, B. W. and Grantham, J. G.: Occult testicular interstitial-cell tumor in a patient with gynecomastia: ultrasonic detection. Radiology, 151: 474, 1984. Corrie, D., Mueller, K J. and Thompson, 1. M.: Management of ultrasonically detected nonpalpable testis masses. Urology, 38: 429, 1991. Lewi, H. J., Walker, L., Gharmool, B. K, McCallum, H. M. and Hutchison, A. G.: Occult primary seminoma: eighteen-year delay in presentation. Urology, 31: 253, 1988.

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13. Gleich, P.: Testicular carcinoma in situ and nonpalpable seminoma eight years after contralateral teratocarcinoma. Urology, 36: 181, 1990. 14. Sanchez, S. and Mahlin, M.: Simultaneous bilateral testicular tumors, one side clinically occult: detection by ultrasonography. J. Urol., 135: 591, 1986. 15. Mostofi, F. K. and Price, K B., Jr.: Tumors of the male genital system. In: Atlas of Tumor Pathology. Washington, D. C.: Armed Forces Institute of Pathology, 2nd series, fasc. 8, p. 86, 1973. 16. Symington, T. and Cameron, K. M.: Endocrine and genetic lesions. In: Pathology of the Testis. Edited by R. C. B. Pugh. Oxford: Blackwell Scientific Publications, chapt. 8, p. 259, 1976. 17. Stoll, S., Goldfinger, M., Rothberg, R., Buckspan, M. B., Fernandes, B. J. and Bain, J.: Incidental detection of impalpable testicular neoplasm by sonography. AJR, 146: 349, 1986. 18. Csapo, Z., Bornhof, C. and Giedl, J.: Impalpable testicular tumors diagnosed by scrotal ultrasonography. Urology, 32: 549, 1988.

EDITORIAL COMMENTS This is one of the larger series of incidentally discovered testicular lesions. The management of these incidentally found lesions is changing as more are discovered by ultrasound alone. Because many of these tumors are benign, the discussion has focused on a more conservative approach. The authors make a reasonable case for conservatism as opposed to routine radical orchiectomy. The surgical approach, however, should still be via the inguinal region with preparation for radical orchiectomy should the biopsy be malignant. Jerome P. Richie Division of Urology Brigham and Women's Hospital Boston, Massachusetts The authors present 9 cases of incidental, nonpalpable testis masses in a combined prospective and retrospective study of 1,600 testicular ultrasound scans. The criteria for incident masses were rigid and excluded patients with gynecomastia or retroperitoneal masses. The finding that 7 of 9 patients had benign lesions is a significant variance with the 90 to 95% incidence of malignant germ cell tumors in patients with palpable testicular lesions. The findings presented make the recommendation of an inguinal approach with frozen section biopsy and testicular preservation in all except those with a biopsy proved malignancy a reasonable approach. The criteria of incidental must be adhered to strictly. Testis tumor markers can be used to help decrease the likelihood of a lesion being a germ cell tumor. Despite these efforts to prevent over treatment of incidental testicular masses, the reader is reminded that missing the diagnosis of a malignant germ cell tumor can have serious adverse effects on the ultimate outcome of the patient. Randall G. Rowland Department of Urology University Hospital Indianapolis, Indiana REPLY BY AUTHORS We appreciate and agree with the Editorial Comments. As noted there is a trend toward conservative management in cases of incidentally discovered tumors. Our study reports this trend and takes the demontration of a benign, incidental testis lesion out of the realm of an anecdotal observation. We also agree with the caveats that the criteria for defining a lesion as incidental must be adhered to strictly, and the surgical approach must be inguinal and radical orchiectomy performed if the lesion is malignant. Since 22% of the incidental lesions in our series were malignant, the most important consideration should be avoiding delay in treatment. We recommend immediate surgery with frozen section biopsy rather than ultrasound followup when an incidental lesion is discovered. We would rather perform an orchiectomy for a benign lesion than fail to remove a malignant mass.