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Testicular self-examination in childhood can sometimes do more harm than good.
A boy of 12 was referred with a painless swelling of the left testis, discovered two months earlier during self-examination encouraged by his school. He was in early puberty and the left testis had a firm 1 cm diameter swelling in the lower pole that appeared hypoechoic on ultrasound. Frozen section during surgical exploration revealed indeterminate histology, therefore an orchidectomy was performed.
The histological appearance was of an interstitially infiltrating cellular tumour surrounding small immature seminiferous tubules (Figure 1). Abundant slit-like vascular spaces were lined by plump spindle-shaped endothelial cells with very occasional mitotic figures and mild pleomorphism but no atypia. The cells showed factor-VIII-related antigen immunoreactivity, confirming its vascular nature (Figure 2). The features were those of a benign cellular capillary haemangioma of the testis.
At one-year follow up there was no clinical evidence of recurrence.
We have found only five previously reported cases of capillary haemangioma of the testis in a child. In most cases these tumours arise in the skin but they can affect the internal viscera as well. They usually regress spontaneously by the age of 5-9 years1. Cutaneous lesions lend themselves to careful observation but intrascrotal lesions causing testicular masses warrant surgical exploration. The natural history of testicular capillary haemangiomas is unknown, but none of the previous cases have displayed malignant properties.
The management of testicular masses presenting in childhood is governed by the pubertal status of the patient. Prepubescent tumours are often benign, the commonest neoplasms being yolk sac tumours and teratomas. The proportion of benign tumours has been reported as 30-70% compared with only 5% in adults2, and those that are malignant have a much lower incidence of metastasis3.
The principle of testicle-sparing surgery is well established for prepubertal tumours. A diagnosis is suggested by preoperative ultrasound scan and tumour marker measurement, and the benign nature of the lesion should be confirmed by frozen section. If this is not definitive, as in this case, orchidectomy must be performed. It has been suggested that orchidectomy must also be performed if there is any evidence of pubertal changes on clinical examination or frozen section, because of the higher risk of malignant germ-cell tumours3.
There is debate over the validity of testicular self-examination (TSE) as a screening tool for testicular cancer4. Although testicular cancer is the most common cancer in young men, it is not thought to be a major public health issue since all forms of cancer are rare in this age group. Current 5-year survival rates for early testicular cancer exceed 90%, and there is no evidence that TSE would improve survival further. TSE is estimated to have a high sensitivity rate for testicular cancer since 97% of men with the disease have a palpable mass4, but the specificity and positive predictive value are lower (81% and 33%, respectively). The role of TSE in children is even more controversial because of the low incidence of malignant tumours in this age group. There is a wide variation in testicular sizes between boys of different and similar ages, and once discovered, a lump raises concern for the patient and parents. Orchidectomy performed in children and young adults has considerable psychological implications.
TSE seems not to be widely practised, possibly because young men know little of testicular cancer or how to examine themselves5. There is a drive, therefore, for health education programmes, including schools and colleges, to include sessions on testicular cancer in the hope that increased awareness will facilitate detection of early stage disease. The American Academy of Pediatrics however, recommends that TSE should start only at the age of eighteen6. In the UK formal guidelines have not been developed. Although TSE cannot be recommended as a screening tool for testicular cancer in symptom-free individuals, there is a strong case, with the increasing incidence of testicular cancer and the decreasing age of puberty, for making children and young adults more aware of the disease and the examination technique.
We thank Mr John Chapman, consultant urologist, Northampton General Hospital, for help.