Intraoperative Consultation for Testicular Tumors: Challenges and Implications for Treatment

Abstract

Intraoperative pathologic consultation provides critical information that determines immediate diagnostic decision making for optimal patient care. The most frequent indications for intraoperative consultation during testis surgery include assessment of testicular/paratesticular lesions, retroperitoneal lymph nodes in patients with a history of testicular cancer, and rarely surgical margin status during partial orchiectomy. In the vast majority of cases, gross examination of a testicular mass may suffice, but frozen section evaluation plays a significant role in preventing unnecessary orchiectomy in some cases, including fibrous pseudotumor, adenomatoid tumor, epidermoid cyst/dermoid cyst, teratoma in prepubertal boys, and other neoplasms generally with a benign course. An increasing number of partial orchiectomy have been performed mostly in patients with small non-palpable benign lesion. When a partial orchiectomy specimen from a patient with germ cell tumor is submitted for intraoperative frozen section, in addition to evaluating whether invasive tumor is at the margin, the presence of intratubular germ cell neoplasia in the grossly normal parenchyma should also be carefully assessed. For assessment of lymph nodes, the number and selection of tissue for frozen section are both important for an accurate diagnosis. However, the pathologist should be aware that permanent sections may reveal viable tumor cells even if the frozen sections show totally necrotic and/or fibrotic tissue. Furthermore, the metastatic tumors may show a variety of histologic features, not only germ cell tumor but also components of carcinomatous or sarcomatous transformation. Other common pitfalls in the frozen section diagnosis include various types of artifacts such as thermal injury, crush artifact, and freeze artifact. Recognizing these artifacts, familiarizing with all the diagnostic entities in different age groups, as well as clinical, imaging, and tumor markers prior to the intraoperative consultation are important for an adequate interpretation of the testicular specimen.