Appropriateness for testis-sparing surgery based on the testicular tumor size in a pediatric and adolescent population

Abstract

In children, most small testicular tumors are benign, and testicular-sparing surgery (TSS) is a viable treatment option. The objective of this study is to assess for correlation between the tumor size and final pathologic diagnoses appropriate for TSS for pediatric and adolescent patients with an intratesticular mass and negative serum tumor markers (STMs). A retrospective review of 24 patients (aged 0-18 years) who underwent radical or partial orchiectomy between 2003 and 2015. Patients with unifocal, unilateral intratesticular tumors and negative STMs were included. Tumors with benign and non-germ cell histology were considered appropriate for TSS, and active germ cell tumor elements on final histology were categorized as inappropriate for TSS. Baseline characteristics, tumor size, and frozen section results were evaluated for association, for the entire cohort and then for a subset of pubertal and postpubertal patients (defined as ≥10 years old). Patients with testicular tumor pathology inappropriate for TSS were significantly older (median age 17.1 years, P=0.03). A 2-cm size cutoff did not accurately predict pathology for the entire cohort, or for just pubertal and postpubertal patients (P=0.132, P=0.154, respectively). Frozen section and final pathology demonstrated good agreement (κ=0.826, P<0.001) as did pre-operative and final pathologic size measurement (κ=0.703, P<0.001). Frozen section analysis did not miss a TSS inappropriate pathology. The present data refute the finding in adults that a 2-cm cutoff accurately predicts pathology in pediatric patients with an intratesticular mass and normal STMs. These data suggest that TSS should still be offered, regardless of the tumor size alone, but frozen section appears to more accurately predict pathology than the tumor size, and its use should, thus, be emphasized. There are several limitations of this study to mention. First, this is a retrospective review of a small cohort of patients with a rare clinical scenario, which necessitated the combination of pediatric and adolescent patients. The study did not evaluate oncologic outcomes. In children with an intratesticular tumor and normal STMs, a tumor size cutoff of 2cm does not appear to accurately predict the final pathology. However, the data presented support the continued use intra-operative frozen section analysis in both children and adolescents undergoing TSS.