Open Journal of Urology, 2013, 3, 281-286
Published Online November 2013 (http://www.scirp.org/journal/oju)
http://dx.doi.org/10.4236/oju.2013.37053
Open Access OJU
Nonpalpable Testicular Masses—Should We Be Worried?
Hamid Abboudi1, Sachin Malde2, Ahmad Mchaourab1, Ben Eddy1, Nitin Shrotri1
1Department of Urology, Kent and Canterbury Hospital, Canterbury, UK
2Department of Urology, Medway Maritime Hospital, Gillingham, UK
Received October 16, 2013; revised November 10, 2013; accepted November 17, 2013
Copyright © 2013 Hamid Abboudi et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Objective: To report our experience of a contemporary series of patients who underwent radical orchidectomy for
non-palpable testicular masses, in order to comment on their malignan t potential and identify any factors predictive of a
malignant outcome. Materials and Methods: We reviewed the case-notes of patients who underwent radical inguinal
orchidectomy over a 22-month period between January 2010 and October 2011. Results: A total of 71 patients were
analysed, with a mean (range) age of 45 years (17 - 82). Overall, 41 (57.7%) orchidectomies were malignant and 30
(42.3%) were benign. There were 20 (28%) non-palpable testicular masses found incidentally on ultrasound, and of
these 40% were malignant and 60% were benign. In total 6 of these non-palpable lesions were <1 cm in size, and of
these 66.6% were malignant and 33.3% were benign. The majority of tumours were in patients under the age of 50, but
there was no correlation between the lesion size and the risk of a malignant outcome. Conclusion: In view of the sig-
nificant rate of malignancy in non-palpable testicular masses we recommend surgical intervention over surveillance
alone. However, as the majority of these lesions may eventually turn out to be benign, we suggest that testis-sparing
surgery is the optimal approach, and should be performed in centres where the required radiological, histopathological,
and surgical expertise exists.
Keywords: Biopsy; Neoplasms; Or chidectomy; Testis; Ultrasonography
1. Introduction
Radical orchidectomy through an inguinal approach is
currently considered to be the gold-standard treatment for
all testicular masses suspicious for malignancy [1]. This
is based on historical data suggesting that 90% - 95% of
palpable testicular masses are malignant germ cell tu-
mours [2]. However, several factors have led to this tra-
ditional and routine strategy being questioned in recent
years. It is now recognised that a much higher propo rtion
of radical orchidectomies ultimately reveal benign pa-
thology and are therefore performed unnecessarily [3].
Furthermore, with the widespread use of high-resolution
scrotal ultrasound for a variety of complaints, a greater
number of incidental testicular lesions (as small as 1 mm)
are being increasingly identified. Although these lesions
are typically hypoechoic, and therefore difficult to dif-
ferentiate from seminomas, the rate of benign pathology
in these non-palpable, incidentally-discovered lesions has
been reported to be as high as 80% [4]. Clearly radical
orchidectomy represents overtreatment for this group of
men. In addition to this, there has been an increasing
trend towards organ-sparing surgery for a number of o the r
cancers, and positive data for testis-sparing surgery have
accumulated more recently [4]. Preserved fertility, a re-
duced need for androgen substitution, and an improved
health-related quality of life are potential benefits of this
organ-sparing approach but this is still not widely prac-
ticed due to uncertainty regarding the malignant risk of
these “incidentalomas”.
The optimal management of these small, non-palpable
testicular lesions is therefore controversial. Some advo-
cate frozen-section analysis (FSA) and testis-sparing sur-
gery whereas others recommend immediate radical or-
chidectomy, citing the inaccuracy of FSA and difficulty
of intra-operative localisation of the tumour as reasons.
Although several case series have reported on the ma-
lignant ris k of sm all, i ncide nt al ly-detecte d te sti cul ar masses,
results have been contradictory [5-14]. We report our
experience in a contemporary series of patients who un-
derwent radical orchidectomy for non-palpable testicular
masses and comment on their malignant potential.

H. ABBOUDI ET AL.
282
2. Materials and Methods
We retrospectively reviewed the case-notes of all patients
who underwent orchidectomy at our institution over a
22-month period bet ween January 2010 and October 2011.
Data was collected on patient age, presenting symptoms,
clinical examination findings, indication for ultrasound
scan, ultrasonic features, serum tumour markers, and f ina l
histological diagnosis.
Patients who underwent orchidectomy for testicular
torsion, abscesses, or other benign conditions were ex-
cluded.
Data was analysed on Microsoft™ Office Excel 2007.
The independent two-sample t-test was used to compare
two groups of independent parametric numerical data,
and the Mann Whitney test was used to compare non-
parametric data, with a two-sided P < 0.05 considered to
indicate statistical significance.
3. Results
A total of 148 orchidectomies were performed over this
time-period. Seventy-seven did not meet the study inclu-
sion criteria (i.e. were not radical inguinal orchidecto-
mies) and were therefore exclud ed, resulting in a total of
71 patients available for further analysis, with a mean
(range) age of 45 years (17 - 82). Overall, 41 (57.7%)
radical orchidectomies ultimately revealed malignant
pathology and 30 (42.3%) were benign (Table 1).
There was a statistically significant difference in the
mean age of those with malignant compared to benign
lesions, with older patients more likely to have benign
pathology. The mean (SD) age of those with malignant
lesions was 40.9 (17.8) years and for benign lesions was
51.0 (16.5) years (P = 0.01).
There were 20 (28%) non-palpable testicular masses
found on ultrasound, and of these 8 (40%) were malig-
nant and 12 (60%) were benign (Table 2).
Table 1. Summary of final pathology of all radical orchidec-
tomies.
Pathology Total number
Malignant 41
Seminoma
Teratoma 21 2
Mixed germ cell tumour 10
B-cell lymphoma/leukaemia 6
Leydig cell tum ou r 1
Rhabdomyosarcoma 1
Benign 30
Epidermoid cyst 8
Adenomatoid tumour 1
Inflammation 11
Haemorrhagic i nfarction 4
Atrophy/fibrosis 2
Benign paratesticular pseudocyst
Normal 1 3
Table 2. Characteristics of patients with non-palpable testicular masses (malignant lesions highlighted in bold).
Patient number Age Indication for ultrasound Ultrasonic features Size of lesion (mm) Final pathology
1 52 Scrotal pain Hypoechoic 40 × 27 Granulomatous orchitis
2 35 Scrotal pain Inflammation and infarction N/A Inflamm ation
3 65 Scrotal pain Anechoic lesion 3 Inflammation
4 44 Haematospermia Mixed echog enicity 29 × 23 Benign testicular cyst
5 72 Scrotal swelling post-hernia repairMass containing debris N/A Haematoma
6 52 Atrophic testis Hypoechoic 6 × 5 Seminoma
7 55 Groin pain Atrophic testis N/A Atrophy
8 63 Scrotal pain Hypoechoic 6 × 8 Inflammation
9 68 Scrotal pain Mixed echogenicity 18 × 12 Granulomatous orchitis
10 55 Retroperitoneal
lymphadenopathy on CT scan Hypoechoic 10 Atrophy/fibrosis
11 34 Scrotal pain Heterogenous mass 20 Seminoma
12 47 Retroperitoneal
lymphadenopathy on CT scan Hypoechoic 13 Seminoma
13 56 Scrotal pain Complex mass 11 Normal
14 26 Scrotal pain Multiple echogenic lesions 10 Infarct
15 27 Scrotal pain Well-defined “onion-ring” appearance14 Epidermoid cyst
16 44 Scan done for inguinal hernia Hypoechoic 17 × 12 Seminoma
17 30 Scrotal pain Hypoechoic 10 Seminoma
18 32 Scrotal pain Hypoechoic 5 × 7 Seminoma
19 34 Scrotal pain Multiple hypoechoic lesions 17 Seminoma
20 78 Scrotal pain and swelling Multiple hypoechoic lesions 20 B-cell lymphoma
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H. ABBOUDI ET AL. 283
Serum tumour markers were normal in all cases of
non-palpable lesions apart from one (who was being in-
vestigated following a finding of retroperitoneal lym-
phadenopat hy on CT).
Stratification by age
When this patient group with non-palpable masses was
stratified b y age, those w ith cancer w ere generally yo un g er
than those with benign disease (median 39 years vs. me-
dian 55 years). All germ cell tumours were diagnosed in
patients under the age of 50, except one who had a
seminoma in an atrophic testicle.
Stratification by tu mour diameter
The overall mean tumour diameter for these non-pal-
pable lesions was 1.4 cm, with malignant lesions having
a slightly smaller mean diameter than benign ones (1.3
cm v. 1.5 cm), although this was not significant (P =
0.64). Furthermore, when the size of each lesion was
analysed as a proportion of the entire testicular size, there
was no significant difference between benign and malig-
nant pathologies (Table 3). The mean size of the mass in
relation to the size of the testicle was 42.1% for malig-
nant lesions and 42.3% for benign lesions (P = 0.98).
Analysis of hypoechoic lesions
Hypoechoic lesions are the ultrasonic hallmark of semi-
nomatous tumours. There were a total of 6 hypoechoic,
non-palpable lesions less than 1 cm (Table 4). Of these,
4 (66.6%) were malignant and 2 (33.3%) were benign.
None of these patients had raised serum tumour markers.
Three out of 4 patients (75%) with malignant tumours
were under 50, whilst of those over 50 with hypoechoic
lesions <1 cm in size only 1 out of 3 (33.3%) had a germ
cell tumour, and this was in an atrophic testicle.
4. Discussion
Testis-sparing surgery is currently only recommended for
highly-selected patients—those with synchronous bilat-
eral testicular tumours, metachronous tumours, or tumour s
in a solitary testicle. Furthermore, it is recommended that
patients have sufficient pre-operative serum testosterone
levels, and that the tumour volume is less than 30% of
the total testicular volume in order to pursue this more
conservative surgical approach [1].
For all other patients who do not meet these criteria,
radical inguinal orchidectomy remains the standard of
care. The case for patients with equivocal lesions and a
normal contralateral testis, however, is less clear-cut.
High-resolution ultrasound can detect intra-testicular le-
sions as small as 1mm, and therefore a greater number of
non-palpable, incidental lesions are being identified. Op-
tions for further management of this group include ultra-
sonic surveillance, excision biopsy and FSA, partial or-
chidectomy, or radical orchidectomy. The main factor
affecting the choice of approach is the perceived malig-
nant risk of the testicular lesion. A number of small
case-series have attempted to determine the malignant
potential of non-palpable testicular lesions but results
have been contradictory.
In this study, we report a high overall rate of benign
pathology following radical orchidectomy which may be
related to the greater use of scrotal ultrasound for a vari-
ety of complaints. The use of more conservative surgical
options could have potentially prevented 42.3% of pa-
tients from having an orchidectomy. Non-palpable le-
sions accounted for a significant proportion of all tes-
Table 3. Table showing proportion of testicle taken up by
mass lesion (malignant lesions highlighted in bold).
Size of lesion (mm)Size of testis (mm) Proportion of testis
taken up by lesion (%)
40 55 72.7
3 40 7.5
29 45 64.4
11 26 42.3
10 50 20.0
14 39 35.9
8 35 22.9
18 32 56.3
10 17 58.8
20 30 66.7
13 26 50.0
17 38 44.7
10 35 28.6
6 37 16.2
17 41 41.5
20 42 47.6
Table 4. Characteristics of patients with small (≤1 cm), non-palpable, hypoechoic lesions (malignant lesions highlighted in bold).
Patient number Age Reason for presentation Examination findingsUltrasound findings Final pathology
1 24 Unknown No mass palpable 2 hypoechoic lesions-12 and 5 mm Mixed germ cell tumour
2 52 Small testicle
Atrophic testicle,
no mass palpable 6 × 5 mm hypoechoic lesion Seminoma
3 30 Testicular pain No mass palpable 10 mm hypoechoic lesion Seminoma
4 32 Testicular pain No mass palpable 5 × 7 mm hypoechoic lesion Seminoma
5 63 Enlarged testicle No mass palpable 8 × 6 mm hypoechoic lesion Inflammation
6 55
Retroperitoneal
lymphadenopathy on CT No mass palpable 10 mm hypoechoic lesion Atrophy/fibrosis
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H. ABBOUDI ET AL.
284
ticular masses in this series, and our rate of malignant
pathology of 40% is higher than that of other published
reports. This may be due to the fact these were not all
“incidentally” found lesions as some were being investi-
gated for retroperitoneal masses, and so the malignancy
rate would be expected to be higher.
In an early study of incidentally-discovered, non-pal-
pable testicular masses, Horstman et al. [8] found a 2 2 .2 %
rate of malignancy. The mean tumour diameter of ma-
lignant lesions in that stud y was comparable to our series.
A more recent study by Sheynkin et al. [15] confirmed
these results, with only 2 of 8 non-palpable testicular
masses proving to be malignant following radical or-
chidectomy. Another study by Leroy et al. [16] provided
further support for the low rate of malignant pathology in
small, non-palpable testicular masses by demonstrating a
27% rate of malignancy in lesions with a mean diameter
of 7.5 mm. These reported hig h r ates of benign pat h o l ogy
are for lesions with a mean size of 1 cm or less, although
our study shows that the chance of benign pathology is
still significant even with lesion s up to 2 cm, and this has
been confirmed by an earlier study [17].
However, other studies have reported contradictory
results. Comiter et al. [9] found a high rate of malignant
pathology (73%) amongst no n-palpable testicular masses,
although this stu dy included patients with retroperitoneal
or neck masses in whom testicular ultrasound was per-
formed in order to identify a potential primary tumour,
and therefore this higher rate of malignancy would be
expected. Hindley et al. [18] reported 3 out of 4 non-pal-
pable lesions to be seminomatous, whilst Avci et al. [14]
reported 8 out of 9 non-palpable masses to be malignant.
In terms of being able to predict a malignant outcome,
we found no correlation between the diameter of the le-
sion, the size of the lesion in proportion to the size of the
testis, and final pathology. However, age appeared to be
a good predictor of malignant germ cell tumour, as the
majority occurred in those under the age of 50. In fact,
there was only 1 case of seminoma in a patient over the
age of 50, and this patient had an atrophic testis. There-
fore, if a non-palpable lesion is found in a patient over
the age of 50, in the absence of risk factors for germ cell
tumours (cryptorchidism, atrophic testis), a conservative
surgical approach or ultrasonic surveillance represent
valid management options after careful patient counsel-
ling.
Various alternative options have been studied in an at-
tempt to determine the malignant potential of these le-
sions prior to radical surgery. The use of magnetic reso-
nance imaging (MRI) has been supported by some au-
thors as a means to improve the sensitivity and specific-
ity in diagnosing malignant lesions [19]. MRI can be
useful as a problem-solving tool in cases where ultra-
sound is equivocal, and can help to identify benign pa-
thology such as orchitis, haemorrhage, infarction, and
fibrosis. In one study of 36 intratesticular lesions, MRI
correctly identified 28 out of 28 lesions as being malig-
nant and 7 out of 8 lesions as being benign (sensitivity
100%, specificity 87.5%) [20]. However, this study in-
cluded patients with large (mean tumour diameter 5.2
cm), palpable lesions. Its utility in patients with small,
non-palpable lesions remains to be determined, and it is
therefore unlikely to replace ultrasonography as a first-
line investigation.
Excision biopsy and FSA has taken on a greater role in
a number of centres, the main aim being the identifica-
tion of malignant lesions and confirmation of adequate
margin excision. If malignancy is confirmed the surgeon
can proceed with radical orchidectomy. However, if the
lesion is shown to be benign the remnant testis can be
returned to the scrotum, thereby preventing an unneces-
sary orchidectomy. In specialist units with the appropri-
ate histological expertise this approach has been shown
to have excellent results. FSA reported a correct diagno-
sis in all 26 cases described by Tokuic et al. [21] and in
the 317 malignant testicular tumours reported by Elert et
al. [22] FSA confirmed the correct diagnosis in all cases.
However, this experience is not universal [13] and de-
pends on the expertise of the pathologist and adequacy of
the frozen section. Furthermore, there remain concerns
regarding the possibility of missing a multifocal tumour
or intra-tubular germ cell neoplasia (ITGCN), with some
data suggesting that additional tumours are found distant
to the index mass in up to 63% of men considered suit-
able for testis-sparing surgery [23]. Patients should be
counselled regarding the need for delayed orchidectomy
(if the permanent section demonstrates malignancy), or
adjuvant radiotherapy for ITGCN. In this respect, how-
ever, testis-sparing surgery has been shown not to com-
promise oncological safety. In the largest series to date,
the German testicular cancer study group treated 101
men with bilateral tu mours or tumours in a solitary testi-
cle with testis-sparing surgery. All patients with ITGCN
were offered post-operative radiotherapy. Cancer-spe-
cific survival after a mean of 80-month follow-up was
excellent (100 of 101), with local recurrence in only 6 of
101, 4 of whom had refused adjuvant radiotherapy [24].
There are a number of benefits to this organ-sparing
approach. Firstly, it prevents the overtreatment of the
majority of men whose non-palpable lesions are benign.
There is some evidence to suggest that loss of a testicle
impairs fertility, endocrine function, and has a negative
impact on psychosocial well-being [4]. Preserving as mu ch
testicular parenchyma as possible is therefore beneficial,
providing oncological control is not jeopardised. In the
series by Heidenreich et al. [24], only 10 of 101 men
treated with testis-sparing developed new-onset hypo-
gonadism at a mean of 80-months follow-up. Further-
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H. ABBOUDI ET AL. 285
more, if a man wishes to father children, adjuvant radio-
therapy after testis-sparing surgery can be deferred until
this has occurred, although close ultrasonic surveillance
of the remnant testis is required.
5. Conclusion
In conclusion, our series confirms previous results show-
ing that the majority of non-palpable testicular masses
less than 2 cm in diameter are benign lesions. In view of
the possible significant risk of malignancy, however, we
recommend that all such lesions are managed surgically,
with excision biopsy, frozen-section analysis and testis-
sparing surgery the optimal approach. If the lesion proves
to be benign, the patient is spared the overtreatment of
orchidectomy with its negative impact on endocrine and
exocrine function and psychosocial well-being. It is im-
portant that this approach be undertaken in centres with
specialist histopathological and surgical expertise. In pa-
tients over the age of 50 without any risk factors for
germ-cell tumours, the risk of malignancy appears low
and a more conservative approach could be taken. In any
case, patients should be counselled that radical orchidec-
tomy remains the standard of care for oncological control,
and if the testis-sparing approach is undertaken then
close surveillance will be required for many years.
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