Abstract
Objective
The incidence of testicular tumors is relatively low which are mainly malignant, so the main way to treat testicular tumors is radical testicular resection. Testicular adenomatoid tumor is a rare testicular benign tumor, but is easily misdiagnosed as malignant tumors with removal of organs. This article aims to explore the clinical features of testicular adenomatoid tumor and its treatment.
Methods
There were 133 cases of testicular tumor in the Peking University Third Hospital from May 1994 to November 2016. We conducted a retrospective analysis of three patients who underwent the treatment of partial orchiectomy with preservation of the organ and were pathologically diagnosed with testicular adenomatoid tumor after surgery. The follow-up was done by outpatient clinics and telephone inquiry after surgery. The related literature was also reviewed for further discussion.
Results
Of all the 133 patients, 116 had radical resection of the testis and 17 had partial testicular resection due to specific reasons (5 cases of epidermoid cyst, 4 cases of teratoma, 3 cases of seminoma, 3 cases of adenomatoid tumor, and 2 cases of Sertoli cell tumor). The mean age of the 3 patients was (42.67±10.97) years (30-49 years), the mean hospital stay was (9.00±5.20) d (6-15 d), the mean body mass index was (26.20±1.42) kg/m 2 (25.00-27.76 kg/m 2), the mean serum human choionic gonadotophin (HCG) was (1.15±0.11) IU/L (1.07-1.23 IU/L) (all normal) and the mean serum alpha-fetoprotein (AFP) was (2.12±0.66) μg/L (1.65-2.58 μg/L) (both were normal). Ultrasound features revealed a clear or unclear border, solid, moderate echo nodule tumor in the testis. The mean maximal diameter of the tumor was (1.00±0.44) cm (0.50-1.30 cm), and the mean duration of intraoperative warm ischemia time was (19.67±17.10) min (0-31 min) (only the last two cases). No recurrence or malignant transformation was observed during the follow-up.
Conclusion
Testicular adenomatoid tumor is mainly based on the characteristics of ultrasound to determine preoperatively, but easy to be misdiagnosed with testicular radical resection. The recommended surgery for adenomatoid tumor is partial resection of the testis via the inguinal approach according to the frozen section pathology to determine whether to retain the organ.
Keywords: Testicular neoplasms, Adenomatoid tumor, Organ-sparing, Partial orchiectomy
睾丸肿瘤的发生率相对较低,占男性全部恶性肿瘤的1%~2%,其中恶性占绝大多数,因此治疗睾丸肿瘤的主要方式是根治性睾丸切除术[1,2,3]。睾丸腺瘤样瘤是较罕见的睾丸良性肿瘤[4],以往国内外文献多以个案形式报道,也有报道因术前误诊为恶性肿瘤而切除器官[5,6,7,8],因此,有必要探讨睾丸腺瘤样瘤的临床病理特点,以便行保留器官的睾丸部分切除术,尤其对于年轻且有生育要求的患者极为重要。本文回顾性分析北京大学第三医院收治的3例睾丸腺瘤样瘤并行睾丸部分切除术患者的临床资料并结合相关文献进行讨论。
1. 资料与方法
1.1. 临床资料
回顾性分析北京大学第三医院自1994年5月至2016年11月收治的133例睾丸肿瘤的患者中组织病理诊断为睾丸腺瘤样瘤并行睾丸部分切除术的3例患者资料,术后进行门诊和电话随访。
1.2. 手术方法
术前1天清洗阴囊及会阴部,术区备皮,灌肠。椎管内麻醉后,常规消毒铺巾。采用腹股沟切口,游离精索至内环口水平,暂时阻断精索后,在无张力情况下将鞘膜及其内容物提起至腹股沟水平(预计手术时间长可用冰屑包裹睾丸及精索)。切开鞘膜后,探查睾丸附睾,沿睾丸背侧无血管区纵行切开白膜,将肿瘤及周围少许正常组织分离并完整切除,组织标本送快速冰冻切片。如果冰冻切片提示良性肿瘤则开放精索阻断后行睾丸部分切除(如果提示恶性则直接行根治性切除)。开放精索阻断后,电凝止血,间断缝合白膜。将睾丸还纳后,固定1~3针,放置橡皮片引流条,逐层缝合切口。经阴囊切口手术的患者在未阻断精索的条件下切除睾丸肿瘤及周围部分正常组织。
2. 结果
自1994年5月至2016年11月共收治133例睾丸肿瘤患者,从中筛查出3例睾丸腺瘤样瘤并行睾丸部分切除术的患者。133例患者中,116例行根治性睾丸切除术,17例行睾丸部分切除术(表皮样囊肿5例、畸胎瘤4例、精原细胞瘤3例、腺瘤样瘤3例和支持细胞瘤2例)。患者平均年龄为(42.67±10.97)岁(30~49岁),平均住院时间为(9.00±5.20)天(6~15天),平均体重指数为(26.20±1.42) kg/m2 (25.00~27.76 kg/m2),平均血清绒毛膜促性腺激素(human choionic gonadotophin,HCG)为(1.15±0.11) IU/L (1.07~1.23 IU/L)(均为正常),平均血清甲胎蛋白(alpha-fetoprotein,AFP)为(2.12±0.66) μg/L (1.65~2.58 μg/L)(均为正常),肿瘤平均最大径线为(1.00±0.44) cm (0.5~1.3 cm),术中平均阻断精索的时间为(19.67±17.10) min (0~31 min)(仅后两例)。
1.
3例睾丸腺瘤样瘤患者的基本资料
Basic data of the 3 patients of testicular adenomatoid tumor
| No. | Age/years | Side | Chief complain |
| 1 | 49 | Left | Palpable mass in the left scrotum for 10 days |
| 2 | 30 | Right | Palpable mass in the right scrotum for 6 months |
| 3 | 49 | Right | Painful mass in the right testis for 2 months |
2.
3例睾丸腺瘤样瘤患者的围手术期资料
Perioperative data of the 3 patients of testicular adenomatoid tumor
| No. | HCG/(IU/L) | AFP/(μg/L) | The largest diameter/cm | Approach | Surgery | Ischemia time/min |
| HCG,human choionic gonadotophin;AFP,alpha-fetoprotein. | ||||||
| 1 | - | - | 0.5 | Scrotum | Partialorchiectomy | 0 |
| 2 | 1.23 | 1.65 | 1.3 | Inguinal | Partialorchiectomy | 28 |
| 3 | 1.07 | 2.58 | 1.2 | Inguinal | Partialorchiectomy | 31 |
病例1,患者男,49岁,主因“发现左阴囊内肿物10天”于1995年11月入院行经阴囊切口睾丸部分切除术,术后组织病理提示睾丸腺瘤样瘤,随访至今无复发。
病例2,患者男,30岁,主因“发现阴囊内肿物6个月”于2011年1月入院行经腹股沟睾丸部分切除术,术后组织病理提示睾丸腺瘤样瘤,随访至今无复发。
病例3,患者男,49岁,主因“发现睾丸肿物伴疼痛2个月”于2011年8月入院,超声提示等回声实性结节(图1),行经腹股沟睾丸部分切除术,术后组织病理提示睾丸腺瘤样瘤。免疫组织化学检查(图2)显示,细胞角蛋白(cytokeratin, CK)混(+),波形蛋白(vimentin, Vim)(+),Ki-67(2%+),Calretinin(+),上皮膜抗原(epithelial membrane antigen, EMA)(-)。随访至今无复发。
1.
睾丸腺瘤样瘤的超声图像
Ultrasonography of adenomatoid tumor of testis
2.
睾丸腺瘤样瘤的组织病理(HE ×200)
Pathology of adenomatoid tumor of testis (HE ×200)
3. 讨论
睾丸腺瘤样瘤是一种较为罕见的肿瘤[9,10],多发生于20~50岁青年男性,临床上通常无症状,一般为单发、质韧、无明显触痛,少数以疼痛等类似于炎症表现起病,且体积较小(多数直径≤2 cm),血清肿瘤标志物常正常[7,9-10],因此临床上容易误诊或漏诊,以往文献报道中有误诊为恶性肿瘤而行睾丸根治性切除的病例[7,8]。本中心133例睾丸肿瘤患者中,3例为腺瘤样瘤且全部行睾丸部分切除术,其他病例中,116例行睾丸根治性切除术,14例行睾丸部分切除治疗其他睾丸肿瘤(表皮样囊肿5例,畸胎瘤4例,精原细胞瘤3例和支持细胞瘤2例)。腺瘤样瘤约占睾丸肿瘤的2%,3例患者中,2例为无痛性肿物,另1例以阴囊疼痛的炎症表现在外院就诊,按炎症治疗1个月后又行超声诊断为“睾丸肿瘤”而来我院就诊,最后行经腹股沟阻断精索的睾丸部分切除术,术中组织冰冻切片病理检查提示腺瘤样瘤或支持细胞瘤,术后石蜡组织病理确认为腺瘤样瘤,术后效果良好,至今无复发。
睾丸的超声检查对于诊断腺瘤样瘤有重要的价值[9,11-12],当超声检查提示睾丸内较小、表浅、等回声或低回声的肿物应该考虑为良性肿瘤可能。阴囊内腺瘤样瘤的超声特点为边界清晰或不清晰、实性、中等回声结节,必要时可行剪切波弹性成像技术来帮助判断[12]。CT检查对于帮助判断睾丸肿瘤的性质和明确有无腹膜后淋巴结转移意义较大,MRI检查可以较清楚地显示肿瘤边界与周围组织的关系,但CT和MRI检查对于诊断腺瘤样瘤没有明显特异性表现。
腺瘤样瘤的诊断最终需依靠组织病理学检查[4,10-11]。目前比较公认的说法为腺瘤样瘤起源于间皮组织,肉眼上多呈实性质韧的结节,无明显包膜,切面呈灰白或灰黄色,多呈编织状纹理。镜下主要病理特征为类上皮细胞内出现的空泡样结构[4,10-11]。综合以往文献的报道,免疫组织化学检查中有诊断意义的有:Vim、CK、EMA、间皮细胞(mesothelial cell, MC)等[4,7]。本研究中患者3的免疫组织化学结果提示CK混(+),Vim(+),Ki-67(2%+),Calretinin(+),EMA(-),与文献中的报道基本一致。
对于双侧睾丸肿瘤、或功能性/解剖性孤立睾丸、或肿瘤直径小于2 cm且体积小于睾丸的30%的局限性恶性肿瘤、或怀疑良性肿瘤的患者可以考虑行保留睾丸的睾丸部分(含肿瘤)切除术。当然,对于怀疑恶性肿瘤或组织病理已经证实的恶性肿瘤患者仍需要严密把握手术指征并且与患者说明手术风险,必要时联系精子库并冻存精液。更重要的是术后需要严密随访,因为术后出现睾丸原位癌的可能性高达82%。本中心另有17例行睾丸部分切除术治疗其他睾丸肿瘤(表皮样囊肿5例、畸胎瘤4例、精原细胞瘤3例、腺瘤样瘤3例和支持细胞瘤2例),治疗方式中,2例为经阴囊睾丸部分切除术治疗良性肿瘤(1例表皮样囊肿和1例腺瘤样瘤),其他均采用经腹股沟切口的睾丸部分切除术。
对于术前诊断怀疑为腺瘤样瘤的患者,推荐行经腹股沟途径的睾丸部分切除术[9,13-14],尤其是对于年轻且有潜在生育要求的患者。有研究认为经腹股沟阻断精索行术中冰冻是治疗该类肿瘤的金标准[9,13]。术中冰冻对于判断睾丸肿瘤良恶性的敏感性和特异性都较高[13]。术中冰冻切片组织病理对于睾丸肿瘤的良恶性的判断几乎完全准确,衡量的指标即为诊断的特异性,也就是说,冰冻组织病理诊断为良性与最终病理诊断为良性的准确率为100%[13]。标准的术式为采用腹股沟切口,游离精索至内环口水平,暂时阻断精索后,在无张力情况下将鞘膜及其内容物提起至腹股沟水平(预计手术时间长可用冰屑包裹睾丸及精索),沿睾丸背侧无血管区纵行切开白膜,将肿瘤及周围少许正常组织分离并完整切除,组织标本送快速冰冻切片病理检查。如果冰冻切片病理检查提示良性肿瘤则开放精索阻断后行睾丸部分切除,如果提示恶性则直接行根治性切除。
睾丸腺瘤样瘤的预后较好,本组3例患者均无复发或转移等情况,但需注意的是,有研究表明其仍存在恶性倾向,甚至有1例睾丸腺瘤样瘤在1个月内迅速增大而发生睾丸实质内浸润生长的情况[6,15],因此,对于此类患者术后需要定期复查。
综上所述,睾丸腺瘤样瘤的临床表现无明显特异性,容易误诊为恶性肿瘤而行睾丸根治性切除,但我们推荐的术式为腹股沟切口阻断精索后行睾丸部分切除,并依据冰冻组织病理检查决定保留器官的术式。
(本文编辑:任英慧)
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