PEDIATRIC TESTICULAR TUMORS: CONTEMPORARY INCIDENCE AND EFFICACY OF TESTICULAR PRESERVING SURGERY PETER D. METCALFE,* H. FARIVAR-MOHSENI,† WALID FARHAT, GORDON MCLORIE,‡ ANTOINE KHOURY AND DARIUS J. BA ¨ GLI§ From the Division of Urology, Hospital For Sick Children, University of Toronto, Toronto, Ontario, Canada ABSTRACT Purpose: Testicular tumors in the pediatric population are fundamentally distinct from their adult counterparts. We reviewed a contemporary single series from a large pediatric health science center. We also examined our experience with testis conserving surgery and then used it to develop a preoperative management algorithm. Materials and Methods: A retrospective review was performed of all testicular tumors at a single institution from 1984 to 2002. Data were compiled using the American Academy of Pediatrics testis tumor registry data collection form. We further examined partial orchiectomies for indications and outcomes with respect to cancer control and testicular viability. Results: A total of 51 primary testicular lesions were identified. Patient age was prenatal to 16 years with a scrotal mass the most common presentation (81%). Mature teratoma, rhabdomyo- sarcoma, epidermoid cyst, yolk sac and germ cell tumors accounted for 43%, 26%, 10%, 8% and 6% of cases, respectively. This distribution was markedly different from the last reported American Academy of Pediatrics data base. Organ preserving surgery was planned and achieved in 13 cases. All surgeries were successful with respect to cancer control and testicular preserva- tion. Conclusions: We believe that the higher incidence of teratoma is more representative of this population and yolk sac tumor is a minority diagnosis. The single institution review eliminates the interinstitutional referral heterogeneity that may have skewed larger data bases. Further- more, the concept of testicular preserving surgery becomes an attractive option since we present its safety and efficacy. The management algorithm should facilitate the preoperative decision to perform less radical surgery and help preserve testicular tissue. KEY WORDS: testis, testicular neoplasms, algorithms Prepubertal testicular and paratesticular tumors account for only 1% to 2% of all pediatric solid tumors with an inci- dence of approximately 0.5 to 2/100,000 individuals. 1 These tumors are fundamentally different from their postpubertal counterpart. At our hospital comprehensive experience with these tumors has been accumulated and we subjected this series to retrospective review. Our data demonstrate that benign tumors 2 are most common. We also examined our experience with teste preserving surgery because we believe that many of these patients are excellent candidates and stand to gain substantially from this selective management. PATIENTS AND METHODS All cases of testis pathology (testicular and paratesticular) recorded from 1984 to 2002 were reviewed. They were iden- tified through a combination of the pathology and surgical log data bases at our hospital. Children are treated at our insti- tution until age 18 years, thus, defining our age limit. All nonprimary and germ cell tumors were excluded from review since the latter are often excluded from classification of pre- pubertal testicular tumors. Tumor review criteria included patient age at diagnosis, presentation, radiological investi- gation and tumor markers. Outcome data included histopa- thology, evidence of metastases, treatment modalities and outcomes. RESULTS Clinical review. A total of 101 cases were identified, of which 50 of nontesticular origin were excluded, including 45 of acute lymphoblastic leukemia, 4 of lymphoma and 1 of known metastatic Wilms tumor. There were 3 germ cell tumors in 12, 16 and 17-year-old boys, respectively. There- fore, 48 cases were used for comprehensive analysis. Patient age at diagnosis was prenatal to approximately 11 years (mean 43 and median 18 months). Of the tumors 55% were on the left side. A scrotal mass was by far the most common presenting symptom in these patients, accounting for 85% of present- ing signs or symptoms (table 1). Trauma and persistent swelling, hydrocele or hernia, or severe bruising were the next most common presentations. Tumors were also diag- nosed because of ultrasound for undescended testicle and 1 was found in an ipsilateral testis during followup for previous contralateral testicular teratoma. A single case of gonado- blastoma presented as virilization in a prepubertal female. Ultrasonography. Preoperative ultrasound was done in 44 of 48 patients. The 4 patients in whom ultrasound was not done eventually proved to have paratesticular rhabdomyo- sarcoma. In no case was a paratesticular tumor misdiag- nosed as an intratesticular tumor. In 12 of 44 cases a specific pathological diagnosis was suggested and all proved to be Accepted for publication July 18, 2003. Study received institutional review board approval. * Current address: Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada. † Current address: University Urology Group, University of Mis- sissippi, Jackson, Mississippi 39216. ‡ Current address: Division of Urology, Children’s Hospital of Michigan, Wayne State University, Detroit, Michigan 48201. § Corresponding author: Division of Urology M292, Hospital for Sick Children, 555 University Ave., Toronto, Ontario, Canada M5G 1X8 (e-mail: dbagli@sickkids.ca). 0022-5347/03/1706-2412/0 Vol. 170, 2412–2416, December 2003 THE JOURNAL OF UROLOGY ® Printed in U.S.A. Copyright © 2003 by AMERICAN UROLOGICAL ASSOCIATION DOI: 10.1097/01.ju.0000097383.09743.f9 2412