How to manage testicular capillary haemangioma

Testicular tumors are predominantly malignant (95% cases), as opposed to lesions originating from the peritesticular tissue. Unfortunately, preoperative discrimination between benign and malignant tumors is not always straightforward. Moreover, some of the tumors may be extremely complex in terms of the diagnosis and treatment⁽¹⁾.

Radical orchidectomy remains the treatment of choice in the case of malignancy, whereas benign testicular tumors should be managed less aggressively: a testis-sparing approach appears to be appropriate from both oncological and functional point of view.

The vast majority of small testicular tumors are benign (75%–86% of cases <16 mm in their largest diameter). Similarly, larger lesions (up to 30 mm) also tend to be predominantly benign in as many as 65% of all such cases⁽²⁾. However, only 10% of all palpable tumors are reported as benign⁽³⁾. Of note is the fact that these data have been retrospectively collected from men who underwent testis-sparing surgery, hence heavily biased due to the study design. In addition, there are no prospective head-to-head studies comparing testis-sparing surgery and radical orchidectomy in small asymptomatic incidental testicular tumors.

Hemangiomas of the testis are an excellent example of rare tumors which can pose a significant diagnostic and therapeutic dilemma. There have been merely 55 similar cases reported since 1946. Their exact etiology, as well as the precipitating risk factors remain largely unknown. Prior irradiation and chemotherapy have been reported as potentially causative in few cases only. Testicular hemangiomas, similarly to their malignant counterparts, may be completely asymptomatic, or present as either indolent or rapidly growing lesions. They are homogenously hypoechoic and hypervascular on ultrasound. However, occasionally they may have a heterogeneous ultrasound appearance^(4–6). MRI is not always useful in differentiating between benign and malignant testicular tumors. Nor are tumor markers, which can be normal in some germinal tumors^{(4, 7, 8)}. In the majority of reported cases, hemangiomas of the testis have been limited to the organ with only very few invading the tunica albuginea. Additionally, some microscopic features of the capillary, epithelioid and anastomosing hemangiomas may suggest a malignant potential, hence, be misleading and result in unnecessary orchidectomy. Nevertheless, histological examination with immunohistochemical tumor marker staining helps make the correct ultimate diagnosis. In those cases tumor enucleation with testis-sparing approach is appropriate. However, if the exact tumor character is debatable and cannot be determined, it is safer to opt for radical orchidectomy than leave a scrotal scar and a testis containing a malignant neoplasm.