MRI
Although outside the remit of this review, dynamic contrast-enhanced MRI (DC-MRI) also shows potential in characterisation of testicular lesions. MRI offers the advantage of multiplanar and diffusion-weighted imaging, with the addition of dynamic contrast enhancement characteristics displayed by time intensity curves. Using DC-MRI, Tsili et al13
evaluated 44 men with 26 intratesticular lesions and found that the
‘relative percentages of maximum time to peak’ was the statistically significant factor (p <0.001) in predicting malignant versus benign lesions. DC-MRI may have a problem-solving role in managing indeterminate lesions in difficult cases.
Testicular-sparing surgery (TSS) Despite the lack of randomised controlled trials comparing radical orchidectomy and testis-sparing surgery, TSS is thought to be an effective management option for smaller intratesticular lesions in selected patients3
Previous concerns regarding the risk of incomplete excision, tumour seeding or intraoperative sampling error, have proved to be largely unfounded in recent years, with frozen section examination (FSE) now contributing to a greater diagnostic accuracy, allowing the option to proceed to radical orchidectomy in the same operative procedure as TSS if required. FSE has a quoted 10% false-negative rate but its use in practice varies between centres, with the major limitation being difficulties in histologically differentiating a seminoma from a Leydig cell tumour, despite the differing macroscopic appearances14
to be a safe option for treating small TGCT, particularly when postoperative radiotherapy is administered in patients with co-existing carcinoma-in-situ, and may be an attractive treatment option in difficult cases of small malignant tumours, for example in monorchidism or bilateral intratesticular lesions15
. This also
means that if TSS is performed on a lesion with a false-negative ultrasound and FSE result, the patient is not disadvantaged. However, the requirement of such surgical and pathological expertise argues the necessity for these procedures to be carried out in specialist centres3,14
.
Ultrasound plays a vital role in the preoperative and intraoperative localisation of lesions deemed suitable for TSS. In the postoperative setting, testicular ultrasound is also crucial in assessing for the presence of any residual lesion3
. Preoperative percutaneous testicular biopsy is regarded as
controversial due to concerns over tumour seeding and scrotal violation. However, some centres routinely perform percutaneous biopsy of equivocal lesions, despite the lack of current evidence or consensus in the role of biopsy technique16 work-up of equivocal testicular lesions.
and biopsy may come to play a crucial role in the future
Interval imaging There is a current lack of evidence or guidelines as to the role of serial ultrasound as a management strategy for small, incidentally detected intratesticular lesions. Interval ultrasonography could be a potential alternative to surgery or to delay surgical intervention in those lesions with biochemical and imaging features of benignity, particularly where preservation of testicular tissue is crucial. As a pragmatic approach three monthly ultrasound for the first year is often recommended; the need for continuing surveillance of a stable lesion beyond 12-18 months is, as yet, uncertain.
-62- -62-
.
. TSS has been shown
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