Management of Small Testicular Masses: A Delphi Consensus Study

Karl H Pang; Giuseppe Fallara; João Lobo; Hussain M Alnajjar; Vijay Sangar; Conrad von Stempel; Dean Y Huang; Arie Parnham; Walter Cazzaniga; Francesco Giganti; Aiman Haider; Ashwin Sachdeva; Maarten Albersen; Costi Alifrangis; Marco Bandini; Fabio Castiglione; Hielke-Martijn De Vries; Christian Fankhauser; Daniel Heffernan Ho; David Nicol; Jonathan Shamash; Anita Thomas; Miles Walkden; Alex Freeman; Asif Muneer; EAU-YAU Penile and Testis Cancer Working Group

doi:10.1016/j.euo.2024.10.010

Management of Small Testicular Masses: A Delphi Consensus Study

Eur Urol Oncol. 2024 Nov 4:S2588-9311(24)00239-6. doi: 10.1016/j.euo.2024.10.010. Online ahead of print.

Authors

Karl H Pang¹, Giuseppe Fallara², João Lobo³, Hussain M Alnajjar¹, Vijay Sangar⁴, Conrad von Stempel⁵, Dean Y Huang⁶, Arie Parnham⁷, Walter Cazzaniga⁸, Francesco Giganti⁵, Aiman Haider⁹, Ashwin Sachdeva⁴, Maarten Albersen¹⁰, Costi Alifrangis¹¹, Marco Bandini¹², Fabio Castiglione¹³, Hielke-Martijn De Vries¹⁴, Christian Fankhauser¹⁵, Daniel Heffernan Ho¹⁶, David Nicol⁸, Jonathan Shamash¹⁷, Anita Thomas¹⁰, Miles Walkden¹⁸, Alex Freeman⁹, Asif Muneer¹⁹; EAU-YAU Penile and Testis Cancer Working Group

Affiliations

¹ Department of Andrology, University College London Hospitals NHS Foundation Trust, London, UK; Division of Surgery and Interventional Science, University College London, London, UK.
² Division of Urology, IRCCS European Institute of Oncology, Milan, Italy.
³ Department of Pathology, Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal; Cancer Biology and Epigenetics Group, IPO Porto Research Center (GEBC CI-IPOP), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Center Raquel Seruca (P.CCC) & CI-IPOP@RISE (Health Research Network), Porto, Portugal; Department of Pathology and Molecular Immunology, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal.
⁴ Department of Surgery, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, University of Manchester, Manchester, UK.
⁵ Division of Surgery and Interventional Science, University College London, London, UK; Department of Radiology, University College London Hospitals NHS Foundation Trust, London, UK.
⁶ Department of Clinical Radiology, King's College Hospital NHS Foundation Trust, London, UK; Department of Imaging Sciences, School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
⁷ Department of Surgery, The Christie NHS Foundation Trust, Manchester, UK.
⁸ The Royal Marsden NHS Foundation Trust, London, UK.
⁹ Department of Histopathology, University College London Hospitals NHS Foundation Trust, London, UK.
¹⁰ University Hospitals Leuven, Leuven, Belgium.
¹¹ Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK; Department of Oncology, Barts Health NHS Trust, London, UK.
¹² Urological Research Institute, San Raffaele Scientific Institute, Milan, Italy.
¹³ Department of Urology, King's College Hospital NHS Foundation Trust, London, UK.
¹⁴ Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
¹⁵ Cantonal Hospital Lucerne, Lucerne, Switzerland; University of Zurich, Zurich, Switzerland.
¹⁶ Department of Radiology, NHS Greater Glasgow and Clyde, Glasgow, Scotland.
¹⁷ Department of Oncology, Barts Health NHS Trust, London, UK.
¹⁸ Department of Radiology, University College London Hospitals NHS Foundation Trust, London, UK.
¹⁹ Department of Andrology, University College London Hospitals NHS Foundation Trust, London, UK; Division of Surgery and Interventional Science, University College London, London, UK; NIHR Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK. Electronic address: [email protected].

PMID: 39500644
DOI: 10.1016/j.euo.2024.10.010

Abstract

Background and objective: The majority of small testicular masses (STMs) are benign and therefore radical orchidectomy (RO) may represent overtreatment. In appropriately selected patients, surveillance or testis-sparing surgery (TSS) is an alternative option to preserve testicular function. Since there are no clear guidelines, we aimed to develop consensus recommendations on the management of STMs.

Methods: A four-round Delphi study was conducted by 24 experts representing multiple subspecialties to reach consensus. Consensus was defined as ≥75% of the participants scoring within the same 3-point grouping (1-3, disagree; 4-6, uncertain; 7-9, agree.). The first two rounds were survey based, the third round was an online meeting to discuss uncertainties from the first two rounds, and the fourth round was a review of the final consensus statements from rounds 1-3.

Key findings and limitations: The initial survey consisted of 126 statements. Following the four rounds of assessment, a list of 96 statements were produced, which focused on clinical and biochemical assessment, colour Doppler ultrasound (CDUS) characteristics, and management options including surveillance, RO, and TSS. Management should be personalised according to risk factors for testicular cancer, fertility status, uni- or bilateral tumours, status of the contralateral testis, and CDUS characteristics, with solid lesions displaying vascularity and hypoechogenicity being more suspicious for malignancy. The consensus statements are prone to a bias, and some may not reflect robust, randomised evidence.

Conclusions and clinical implications: The expert panel has produced consensus recommendations on the management of STMs, and TSS should be considered in patients with an STM. The recommendations could aid in the dissemination of best practice.

Patient summary: There are no clear guidelines on the management of small testicular masses. Excising the whole testicle (radical orchidectomy) with a small or an indeterminate mass may affect fertility and hormonal function. A panel of experts was formed, and consensus recommendations were developed on how to deal with small and indeterminate testicular masses, which include surveillance or testis-sparing surgery.

Keywords: Consensus; Delphi; Orchidectomy; Small testicular mass; Testicular cancer; Testis-sparing surgery.