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Reply to Julian Chavarriaga and Robert Hamilton's Letter to the Editor re: Manolis Pratsinis, Christian Fankhauser, Katerina Pratsinis, et al. Metastatic Potential of Small Testicular Germ Cell Tumors: Implications for Surveillance of Small Testicular Masses. Eur Urol Open Sci 2022;40:16–8. Should We Be Afraid of Surveillance? Clinically Meaningful Reasons Why Offering Surveillance for Incidentally Detected Small Testicular Masses Remains a Safe Approach

Open AccessPublished:October 03, 2022DOI:https://doi.org/10.1016/j.euros.2022.09.011
      The low proportion of malignant tumors among small testicular masses (STMs) [
      • Toren P.J.
      • Roberts M.
      • Lecker I.
      • Grober E.D.
      • Jarvi K.
      • Lo K.C.
      Small incidentally discovered testicular masses in infertile men – is active surveillance the new standard of care?.
      ,
      • Bieniek J.M.
      • Juvet T.
      • Margolis M.
      • Grober E.D.
      • Lo K.C.
      • Jarvi K.A.
      Prevalence and management of incidental small testicular masses discovered on ultrasonographic evaluation of male infertility.
      ,
      • Ory J.
      • Blankstein U.
      • Gonzalez D.C.
      • et al.
      Outcomes of organ-sparing surgery for adult testicular tumors: a systematic review of the literature.
      ] has led to an ongoing debate regarding the choice between surveillance and surgical exploration, even among the major urological guidelines [
      • Laguna M.
      • Albers P.
      • Algaba F.
      • et al.
      EAU guidelines: testicular cancer.
      ,
      • Stephenson A.
      • Eggener S.E.
      • Bass E.B.
      • et al.
      Diagnosis and treatment of early stage testicular cancer: AUA guideline.
      ].
      This debate is caused by the limited and therefore unconvincing data on the trade-offs between histological clarification and ongoing surveillance. On the one hand, testis-sparing surgery with frozen section analysis poses a high risk of overtreatment and a low risk of pain or complications leading to subsequent orchiectomy, hypogonadism, infertility, and absence from work, among other side effects. On the other hand, surveillance requires repeated appointments for blood measurements and ultrasound, and may have a negative psychological impact on many men who do not require any follow-up at all. Our study [
      • Pratsinis M.
      • Fankhauser C.
      • Pratsinis K.
      • et al.
      Metastatic potential of small testicular germ cell tumors: implications for surveillance of small testicular masses.
      ] adds some evidence suggesting that there is indeed limited metastatic potential in men with STMs. This means that curative treatment with orchiectomy alone may be withheld and patients may later require systemic chemotherapy with its associated long-term toxicity. We believe that the evidence generated by this study is important to consider when discussing the trade-off between surveillance and surgical exploration for STMs.
      We would like to thank Julian Chavarriaga and Robert Hamilton for their letter contributing to this important debate and would appreciate a discussion on potential prospective follow-up protocols for men with STMs. Such protocols should not only define the frequency of current tests, including ultrasound and traditional serum tumor markers, but should also consider the role of newer diagnostics such as microRNA 371 [
      • Fankhauser C.D.
      • Nuño M.M.
      • Murray M.J.
      • Frazier L.
      • Bagrodia A.
      Circulating MicroRNAs for detection of germ cell tumours: a narrative review.
      ] and magnetic resonance imaging, as well as invasive methods including fine needle aspiration, core needle biopsies, ablative local treatment, and surgical exploration.
      Conflicts of interest: The authors have nothing to disclose.

      References

        • Toren P.J.
        • Roberts M.
        • Lecker I.
        • Grober E.D.
        • Jarvi K.
        • Lo K.C.
        Small incidentally discovered testicular masses in infertile men – is active surveillance the new standard of care?.
        J Urol. 2010; 183: 1373-1377
        • Bieniek J.M.
        • Juvet T.
        • Margolis M.
        • Grober E.D.
        • Lo K.C.
        • Jarvi K.A.
        Prevalence and management of incidental small testicular masses discovered on ultrasonographic evaluation of male infertility.
        J Urol. 2018; 199: 481-486
        • Ory J.
        • Blankstein U.
        • Gonzalez D.C.
        • et al.
        Outcomes of organ-sparing surgery for adult testicular tumors: a systematic review of the literature.
        BJUI Compass. 2021; 2: 306-321
        • Laguna M.
        • Albers P.
        • Algaba F.
        • et al.
        EAU guidelines: testicular cancer.
        European Association of Urology, Arnhem, The Netherlands2022
        • Stephenson A.
        • Eggener S.E.
        • Bass E.B.
        • et al.
        Diagnosis and treatment of early stage testicular cancer: AUA guideline.
        J Urol. 2019; 202: 272-281
        • Pratsinis M.
        • Fankhauser C.
        • Pratsinis K.
        • et al.
        Metastatic potential of small testicular germ cell tumors: implications for surveillance of small testicular masses.
        Eur Urol Open Sci. 2022; 40: 16-18
        • Fankhauser C.D.
        • Nuño M.M.
        • Murray M.J.
        • Frazier L.
        • Bagrodia A.
        Circulating MicroRNAs for detection of germ cell tumours: a narrative review.
        Eur Urol Focus. 2022; 8: 660-662

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