Because a testicular mass might be encountered unexpectedly during inguinal hernia repair, hydrocelectomy or orchidopexy, it is important to understand the basic principles of the care of a child with a testicular tumor. Failure to do so could result in tumor spread or necessitate a hemiscrotectomy or orchiectomy that otherwise might have been avoided. Most surgical protocols are based on traditional adult protocols and certainly need to be updated, but this has yet to occur, probably due to the small numbers and a lack of controlled studies. Nevertheless, with the current trend towards testis-sparing surgery, it should no longer be assumed that every testicle with a tumor must automatically be removed.
As a general rule, a testicular mass should never be approached through a scrotal incision or percutaneous trans-scrotal biopsy. This should only be done through an inguinal incision, usually made somewhat larger than a typical inguinal hernia incision and always involving opening the external ring so that the testis can be delivered easily into the wound without risk of rupture. If a testicular mass is discovered incidentally intra-operatively, the testis should be delivered through the inguinal incision and carefully inspected. A call should be made immediately to either a local pediatric urologic oncologist or to one of the national experts designated by the Children’s Oncology Group, for purposes of an intra-operative consultation. At this point, depending on the circumstances and availability of expertise, the decision might be to remove the testis, to control the spermatic cord with a tourniquet and perform a biopsy for frozen-section analysis, or to place the testis back in its anatomic position in anticipation of a more definitive operation in the near future. The same approach should be used with paratesticular tumors, which can also be malignant and are treated using a very similar approach.
A painless testicular mass is presumed to be malignant until proven otherwise. The next step should always include scrotal US and measurement of tumor markers (AFP, HCG). Boys with gynecomastia should also be examined very carefully for the rare hormonally active testicular tumor but routine scrotal US is probably unnecessary and certainly not cost-effective. Metastatic workup for testicular tumors includes a chest X-ray and abdominal CT scan, and for paratesticular rhabdomyosarcoma includes a bone marrow biopsy.
A small testicular teratoma or epidermoid cyst in a prepubescent child can usually be easily excised with a small margin of normal parenchyma. Testicle-sparing surgery might also be recommended for Leydig cell tumors. For most other lesions, an incisional or excision biopsy with frozen-section diagnosis can usually help with decision making regarding orchiectomy. If orchiectomy is recommended, this should include a radical orchiectomy with high ligation of the spermatic cord. If the tumor is truly a surprise, it is usually best to consult the parents, intra-operatively if necessary, before an orchiectomy is performed. While it is generally considered better to have removed a testis for what was felt to be a possible malignancy than to preserve one that ultimately harbors a cancer, the decision should not be made lightly, especially since it would be difficult to justify the loss of an otherwise normal testis for a small benign lesion that could easily have been simply enucleated. Difficulty also arises in the rare situation of a testicular hematoma that is thought to possibly represent a ruptured testicular tumor. This is an extremely rare occurrence, but intra-operative biopsy should be performed if this a pathologist is available.
Retroperitoneal lymph node dissection for staging purposes in boys with testicular cancer is rarely necessary anymore, having been supplanted for the most part by modern medical imaging. This is a good thing as the morbidity from an extensive dissection can be severe. It is also sometimes requested in boys who have persistent tumor marker elevation but normal imaging after orchiectomy. There is probably little therapeutic benefit to removing positive retroperitoneal lymph nodes. We are occasionally asked to biopsy a suspicious node after the completion of therapy because of concerns about recurrence. If feasible, this should be performed laparoscopically.