Testis-Preserving Surgery in the Management of Leydig Cell Tumours: The Importance of Pre- and Intra- Operative Ultrasound
Introduction and Objectives
Leydig cell tumours account for 1-3% of testicular neoplasms. Incidence occurs in two peaks, in the 5-10 (all benign) and 30-60 (90% benign) age range; 10% are bilateral. Presentation is usually as an incidental finding on a scrotal ultrasound, but hormone-secreting variants can present with symptoms of excessive androgenisation, feminisation or precocious puberty. Conventional management is radical inguinal orchidectomy, which can be seen as overtreatment in the vast majority.
Materials and Methods
We present, as an example, the case of a 31 year-old man with a contrast ultrasound diagnosed 3mm Leydig cell tumour and normal tumour markers. Management consisted of ultrasound-guided wide local excision through an inguinal approach. This approach allowed an estimated loss of only 5-10% testicular volume. Histology confirmed a benign Leydig cell tumour and all resection margins were clear. We currently have a series of eight partial orchidectomies for contrast ultrasound diagnosed Leydig cell tumours. There are characteristic ultrasound findings, enhanced by the use of contrast, that allow a higher confidence in the pre-operative diagnosis. This allows us to offer the option of partial orchidectomy without the need for intra-operative frozen section.
From our eight patients, there are no incidences of local recurrences or distant metastatic disease. The follow-up period for these patients ranged from 8-48 months.
As a tumour that is predominantly benign and affects men for whom future fertility is a concern, the role of testis-conserving surgery is becoming an increasingly important consideration. Ultrasound is vital to make an accurate diagnosis and for intra-operative localisation of small, impalpable lesions. There is the option of utilising intra-operative frozen-section if the diagnosis is in doubt, although we do not find this to be necessary if contrast ultrasound imaging is used pre-operatively and an adequate cuff of tissue taken during resection. Careful selection of patients is key. We would recommend that this be considered for those with classic ultrasound images, small tumour mass and normal tumour markers.
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