Testicular tumors in children

Purpose: The aim of this study was to present an updated picture of surgica l management of pediatric testicular tumors based on our 30 years' experien ce, which consisted of one of the largest noncollected series treated in a single medical center. Methods: Records of children who were treated for testicular tumor in our u nit from 1970 to 1999, inclusive, were reviewed retrospectively. Informatio n recorded for each patient included age, sex, past medical history, clinic al characteristics, diagnostic procedures, treatment methods, histopatholog ic findings, and outcome. Results: Fifty-one patients with a mean age of 3.8 +/- 0.5 years were treat ed for testicular tumors. Of these, 35 (69%) had germ cell testis tumor (GC T) and 16 (31%) had non-germ cell testis tumor (NGCT). Endodermal sinus tum or and paratesticular rhabdomyosarcoma were the dominant histologic subtype s in each group, respectively. The most common mode of presentation was pai nless scrotal mass. At initial presentation, retroperitoneal (n = 5), both retroperitoneal and lung (n = 2), and retroperitoneal and liver (n = 3) met astases were recorded in 10 (19%) patients. Initial operative procedures we re radical inguinal orchiectomy (RIO) (n = 29), scrotal orchiectomy (SO; n = 9), bilateral RIO (n = 2), both RIO and unilateral retroperitoneal lymph node (RPLN) excision (n = 6), testis-sparing enucleation of the tumor (n = 5). SOs were performed elsewhere, and these patients underwent high ligatio n (n = 4) and both high ligation plus RPLN excision (n = 5) in our unit. Hi stopathologically, spermatic cord invasion and RPLN involvement were presen t in 10 patients. Scrotal recurrences were encountered in 2 patients who ha d scrotal orchiectomy initially. Retroperitoneal recurrences were noted in a patient presenting with stage I embryonal carcinoma and in 2 patients pre senting with group IV paratesticular rhabdomyosarcoma, The mean follow-up p eriod was 89 +/- 10 months. Four patients with stage IV embryonal carcinoma (n = 2) and group IV paratesticular rhabdomyosarcoma (n = 2) died of progr ession of the disease. All remaining patients were alive and disease free a t their last outpatient appointment. No significant difference was noted wi th regard to 5-year survival rates between (1) malignant GCT and paratestic ular rhabdomyosarcoma patients (91% v 80%) and (2) patients treated by RIO (88%), SO plus high ligation (87%), and RIO plus RPLN excision (80%). Five- year survival rates were 100% for stage I, II, III patients and 33.3% for s tage IV and group IV patients presenting with malignant testicular tumors ( P < .05). Conclusions: Childhood testicular tumors deserve special attention from the therapeutic point of the view. A solid scrotal mass should be considered m alignant until proved otherwise. Any suspicion of the testicular tumor warr ants an inguinal approach to prevent scrotal violation by the tumor. Curren t trends emphasize that testis-sparing surgery should be per-formed for ben ign lesions such as teratoma, leydig cell tumor, and epidermoid cyst based on frozen biopsy findings. Literature findings and our experience suggest t hat RIO is the accurate treatment for stage I malignant GCT and group I and IIa paratesticular rhabdomyosarcoma. RPLN excision is not of benefit eithe r as a staging or therapeutic procedure in stage I and group I and IIa dise ases of these tumors. RPLN excision should be reserved for (1) malignant GC T patients who have persistent elevation of alpha-fetoprotein after orchiec tomy in the presence of normal total body CT scan, and for patients present ing with stage II and III disease with definitive abnormality on CT scans, and (2) group IIb, IIc, and III paratesticular rhabdomyosarcoma patients wi th radiologic evidence of retroperitoneal involvement on CT scans. High lig ation should be done as a complementary procedure after SO to increase the survival rates. Copyright (C) 2001 by W.B. Saunders Company.