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Case Report |
1 Department of Radiology, Stony Brook University School of Medicine, Stony
Brook, NY 11790.
2 Department of Urology, Stony Brook University School of Medicine, Stony Brook,
NY 11790.
Received October 29, 2004;
accepted after revision December 14, 2004.
Address correspondence to H. L. Cohen, 78 Grove Ave., Cedarhurst, NY
11516-2311
(hcohenmb{at}optonline.net).
Keywords: intraoperative sonography • organ (testis) sparing surgery • testis
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-fetoprotein < 9; HCG < 5). On preoperative sonography, a
nonpalpable 6 x 5 x 4-mm hypoechoic intratesticular lesion was
discovered in the lower one third of the right testicle
(Fig. 1A). Intraoperative
sonography was planned to possibly spare the testicle. At surgery, the
testicle was delivered through an inguinal exploration and was placed on ice
slush. The tumor was localized by intraoperative sonography
(Fig. 1B) performed on an
Acuson Sequoia 512 (Siemens Medical Solutions) using a 15L8W linear-array
transducer with a 52-mm footprint at 15 MHz. A 30-gauge needle was placed by a
urologist into the lesion using sonographic guidance
(Fig. 1C) provided by the
radiologist. The urologist dissected along the needle track and visualized the
tumor under the operating microscope. The lesion
(Fig. 1D) was then resected
under the operating microscope and sent for frozen section analysis.
Intraoperative frozen section analysis showed a benign Leydig cell tumor.
Intraoperative sonography was repeated after tumor excision and showed no
residual mass. The testicle was placed back into the scrotum. The patient
recovered without complication. Final pathology of the specimen confirmed the
frozen section diagnosis. The patient has been followed and no recurrence has
been noted.
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Our technique included sonographic analysis of the mass within the testicle while the patient was on the operating table. This was done to determine the position of the mass and the best approach to use for placement of a localizing needle under sonographic guidance. In both cases, a 30-gauge needle was advanced under real-time guidance into the lesion from a lateral approach just off the transducer, which was placed directly above the mass. No standoff pad was used for case 1. In case 2, a fluid-filled Pen-rose drain was used as a standoff pad to improve imaging of the mass for the guidance procedure.
There are no imaging criteria that allow the differentiation of benign from malignant disease [5]. The classic teaching is that with rare exception, solid intratesticular tumors are to be considered malignant. A number of small studies have, however, shown some predominance of benign tumors over malignant tumors among groups of patients with nonpalpable testicular tumors [6-9].
Until recently, orchiectomy was performed in all cases of intratesticular tumors. However, recent work involving testis-sparing surgery has added a new dimension to the treatment options for nonpalpable testicular masses, especially in patients with a solitary testis or synchronous bilateral tumors, where preservation of testicular tissue is particularly important. A number of urology articles have reported good results with testis-sparing tumor excision from the testicle. Heidenreich et al. [2] reported the largest series: 73 patients underwent tumor excision and 72 (98.6%) survived without evidence of disease. Half of the patients who wanted to father a child did so successfully and 85% of these patients had normal testosterone levels after surgery.
Testicular preservation is recommended in patients with intraoperatively proven benign testicular masses [1, 6, 7, 8]. Organ-sparing surgery for a malignant tumor is a more controversial approach since it does not follow the principles of radical cancer surgery. Limited data and long-term results of testis-sparing surgery in patients with palpable malignant bilateral tumors or tumor in a solitary testis are encouraging. However, potential complications, including local recurrence, systemic progression, and residual disease, must be considered [2].
To provide for the possibility of testis-sparing surgery, precise intraoperative sonographic localization of the lesion and accurate frozen section analysis are necessary. Again, this method allows maximal preservation of testicular parenchyma and its vasculature. Patients undergoing this procedure may, therefore, avoid lifelong androgen substitution and the psychosocial stress of castration and maintain fertility.
Sonographically guided needle placement into small or nonpalpable testicular tumors in the operating room can help specify the exact position of the tumor within the testicle and may allow surgical removal of the tumor without orchiectomy, sparing as much normal testicular parenchyma as possible. Microsurgical excision may be the procedure of choice for maximal tissue preservation. Further experience with this testis-sparing imaging-based approach will hopefully confirm its worth.
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  O. Buckley, R. F. Browne, and W. C. Torreggiani Intraoperative sonographically guided needle localization of nonpalpable testicular tumors. Am. J. Roentgenol., July 1, 2006; 187(1): W123 - W123. [Full Text] [PDF]
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H. L. Cohen Reply Am. J. Roentgenol., July 1, 2006; 187(1): W124 - W124. [Full Text] [PDF]
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