INTRODUCTION

Although testicular cancer accounts for less than 1% of all tumors in men, it is the most common solid tumor in those aged 20 to 34 years, with a steadily increasing global incidence over the last few decades (1). The standard initial treatment of testicular tumors is radical orchiectomy. However, it is considered that fertility may be affected after orchiectomy in these patients, and thus, sperm banking is recommended before the operation (2). Another factor to considered is the negative psychological effects of orchiectomy on the patient. Therefore, many studies emphasize that patients should receive counseling on testicular prosthesis insertion before and after orchiectomy (3). For all these reasons, a correct diagnosis of testicular cancer is critical. For this purpose, scrotal ultrasonography (USG) and serum tumor markers [human chorionic gonadotropin (HCG), alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH)] are used (4). However, although 90% of testicular cancers are histologically germ cell tumors (5), these markers are expressed in <60% of cases (6). Which may result in unnecessary radical orchiectomy due to misdiagnosis. Therefore, particularly in intratesticular mass lesions with negative tumor markers, there is a need for additional predictive factors to predict malignant-benign differentiation to prevent overtreatment. Some studies have evaluated the relationship of testicular tumors with systemic inflammatory markers examined in routine peripheral blood count analysis, particularly the neutrophil-to-lymphocyte ratio (NLR) (7-9). However, none of these studies evaluated whether systemic inflammatory markers and NLR could be used in the prediction of the benign/malignant differentiation before orchiectomy in intratesticular masses with negative tumor markers. In the current study, we evaluated the usability of systemic inflammatory markers, NLR, and lesion size in the preoperative differentiation of benign and malignant intratesticular mass lesions.

METHODS

After obtaining approval from the University of Health Sciences Türkiye, Bakırköy Dr. Sadi Konuk Training and Research Hospital Ethics Committee (decision no: 2022-03-06, date: 07.02.2022) and written consent from the patients, we retrospectively reviewed the records of all patients who underwent radical inguinal orchiectomy with a preliminary diagnosis of testicular tumor between August 2007 and September 2020. The diagnosis of the patients and lesion size determination was undertaken using preoperative scrotal color Doppler USG and additionally by the magnetic resonance imaging of the scrotum in some cases. Patients with elevated testicular tumor markers, paratesticular lesions, metastases in relevant screening, single testis, another active infective focus, chronic inflammatory disease, known hematological pathologies, and incomplete pre-orchiectomy data related to tumor markers and hematological parameters were excluded from the study. Patients with histologically malignant pathologies after radical orchiectomy were classified as group 1, and those with benign lesions were classified as group 2. The patients’ demographic data (age, gender, etc.), preoperative biochemical results, and histopathological results of orchiectomy material were obtained from the hospital database. Biochemical tests included tumor markers (HCG, AFP, and LDH) and complete blood count (CBC) parameters. Additionally, NLR was calculated by dividing the neutrophil count by the lymphocyte count.

Statistical Analysis

Categorical variables were given as numbers and percentages, and continuous variables as mean and standard deviation. The normality of the distribution of continuous variables was evaluated with the Shapiro-Wilk test. The mean values of two normally distributed independent groups were compared with Student’s t-test, and those of two non-normally distributed groups were compared using the Mann-Whitney U test. The percentage of categorical variables was compared with the Pearson chi-square test, and the cut-off values for malignancy were determined using the receiver operating characteristics (ROC) curve analysis. The correlation between malignancy and tumor size and hematological parameters was tested using the sperm correlation analysis. The results were considered statistically significant at p<0.05.

RESULTS

The study included a total of 78 patients with testicular tumor markers (HCG, AFP, and LDH) within normal limits who underwent radical inguinal orchiectomy with a preliminary diagnosis of testicular tumor. The demographic data and laboratory characteristics of the patients are shown in Table 1. According to postoperative mass specimen histopathology, 47 (60.3%) patients were in the malignant group (group 1) and 31 (39.7%) were in the benign group (group 2). The mean age of the patients significantly differed between the groups, being determined as 35±9.8 years for group 1 and 44.4±18.5 years for group 2 (p=0.046). There was no significant difference between the two groups in relation to the laterality and preoperative diagnostic imaging methods used (Table 2). The mean lesion size was 3.74±2.24 cm in group 1 and 1.87±1.30 cm in group 2, indicating a significantly higher value for the former (p<0.001). Of the patients with malignant histopathology, 37 (79%) had seminoma, five (11%) had Leydig cell tumors, two (4%) had mixed germ cell tumors, two (4%) had embryonal carcinomas, and one (2%) had a yolk sac tumor. Of the patients with benign histopathology, twelve (39%) had fibrotic granulation, three (10%) had adenomatoid tumors, three (10%) had nodular Leydig cell hyperplasia, one (3%) had angyomixoma, one (3%) had hemorrhagic infarct, two (6%) had interstitial congestion, two (6%) had interstitial hyalinization, four (13%) had seminiferous tubular atrophy, two (6%) had intraparenchymal hemorrhage, one (3%) had leiomyoma. There was no significant difference between the groups in terms of testicular tumor markers. For groups 1 and 2, the mean white blood cell (WBC) counts were determined as 8.60±2.23 and 7.54±2.02 µ/L, respectively; the mean neutrophil counts as 5.30±1.77 and 4.34±1.40 µ/L, respectively, the mean neutrophil ratios as 63.0±8.22 and 56.9±7.28%, respectively; the mean lymphocyte ratios as 26.2±6.69 and 31.9±6.05%, respectively; and the mean NLR values as 2.72±1.44 and 1.87±0.54, respectively. The mean WBC count, neutrophil count, neutrophil ratio, and NLR were significantly higher in group 1 (p=0.037, p=0.014, p<0.001, and p=0.002, respectively), whereas the mean lymphocyte ratio was significantly higher in group 2 (p<0.001). There was no significant difference between the groups in terms of the remaining hematological parameters (Table 2).

The ROC curve analysis was performed to calculate the cut-off and area under the curve (AUC) values of the parameters predicting malignancy. The cut-off and AUC values were determined as 1.95 cm and 0.802, respectively for tumor size; 7.72 µ/L and 0.638, respectively for WBC; 5.32 µ/L and 0.649, respectively for neutrophil count; 64.2% and 0.686, respectively for neutrophil ratio; 29.7% and 0.267, respectively, for lymphocyte ratio; and 2.72 and 0.707, respectively for NLR (Table 3 and Figure 1). The correlation analysis performed between a malignant pathological result and tumor size, WBC count, neutrophil count, neutrophil ratio, lymphocyte ratio, and NLR revealed that malignancy development correlated negative with the lymphocyte ratio and a positive correlation with the remaining parameters (Table 4).

DISCUSSION

The standard initial treatment of testicular tumors is radical orchiectomy (2). However, an unpredictable diagnosis may result in patients being more exposed to harmful effects on endogenous testosterone, fertility, and body image due to overtreatment (10). Therefore, many researchers have conducted studies on partial orchiectomy in testicular tumors (10,11). Studies on all testis-sparing procedures recently show the importance of an accurate diagnosis preoperatively (10,11). Negative tumor markers, which are used to support the diagnosis process, may make it difficult to differentiate between benign and malignant intratesticular mass lesions. Thus, there is a need for additional predictive factors that can predict the benign-malignant differentiation in this patient group.

Technological developments recently have improved the resolution of USG devices and increased the diagnosis of incidental testicular masses. Carmignani et al. (12) reported that non-palpable testicular lesions with a size of less than 2.5 cm on USG could be diagnosed incidentally, and 80% of these lesions had a benign histology result. In another study by Guner and Tonyalı (13), it should be considered that the lesions may be highly benign, especially in patients aged between 15-34 years, who are small, non-palpable, do not cause elevation in serum tumor markers, and where testicular tumors are common, and if necessary, testicular sparing surgery should be planned. In the current study, we evaluated whether tumor size could be a predictive parameter in the differentiation of benign and malignant lesions. We determined that the mean tumor size was 3.74±2.24 cm in the malignant group and 1.87±1.30 cm in the benign group, being significantly higher in the former (p<0.001). Similarly, the increase in tumor size showed a significant correlation with malignancy, with the cut-off value being calculated as 1.95 cm. Thus, our results contribute to the current literature by demonstrating that tumor size can be a predictive parameter in the differentiation of benign and malignant lesions.

Studies conducted in the past decade suggest that immune and inflammatory cells contribute to angiogenesis to facilitate the survival and even proliferation of cancer cells during tumor development stages, and they produce various cytokines and chemokines for this purpose (14). In particular, the excessive release of interleukin (IL)-8 from tumor cells has a chemoattractant effect on neutrophils. It is known that IL-8 not only contributes to angiogenesis but also facilitates the growth and migration of tumoral cells with the enzymes secreted by neutrophils (15). Lymphocytes, on the other hand, are known as a surrogate for host cell-mediated immunity, playing a role in host defense against malignancy. In a patient with cancer, the lymphocyte count can be reduced by lymphocytic cytokines secreted by the tumor. This has been proven by the in vivo demonstration of ligands such as FasL and tumor necrosis factor b produced for cancer-induced lymphocyte apoptosis in cancer cases (16). All this evidence suggests that systemic inflammatory markers that can be determined in a simple CBC analysis can support the preliminary diagnosis of many malignancies and provide preliminary information about their prognosis.

Some studies have stated that systemic inflammatory markers and NLR may be important markers in predicting the prognosis of urological malignancies (17). Recently, many researchers have presented an association between testicular cancer and systemic inflammatory markers and NLR (7-9). Gokcen et al. (7) compared peripheral blood count and NLR between 39 patients that underwent radical orchiectomy for testicular cancer and 82 patients that underwent varicocelectomy and reported that the WBC count of the testicular cancer group was significantly higher (8.4±2.2 vs. 7.1±1.5). Similarly, in our study, WBC count was significantly higher in the malignant group, and its cut-off value was determined as 7.72 in the ROC analysis. In another study comparing the preoperative peripheral blood values between 36 patients with testicular cancer and 36 patients that underwent varicocelectomy, the authors reported that the neutrophil count and neutrophil ratio were significantly higher and the lymphocyte ratio was significantly lower in the testicular cancer group (8). Similarly, we observed that neutrophil count and neutrophil ratio were significantly higher in the malignant group, whereas lymphocyte ratio was significantly lower. We calculated the cut-off values of neutrophil count, neutrophil ratio, and lymphocyte ratio as 5.32, 64.2, and 29.7, respectively. In the literature, the mean NLR value in testicular cancer ranges from 2.37 to 3.18, and NLR is reported to be significantly higher in patients with localized testicular cancer compared to controls (8,9,18). Ilktac et al. (18) determined the mean NLR value of patients with localized testicular cancer as 2.78±1.84 before radical orchiectomy and 1.57±0.58 postoperatively, noting a significantly higher mean value in the preoperative period. In our study, the mean NLR value was 2.72±1.44, and it was significantly higher in the malignant group. A common goal of these studies was to determine the optimal cut-off value of NLR in testicular cancer (7,8). Gokcen et al. (7) determined the cut-off value of NLR for testicular cancer as 2.25, while another study determined the NLR cut-off value as 2.06 for testicular cancer (8). In our study, the NLR cut-off value was 2.72. Almost all the studies discussed in this paper evaluated the relationship of testicular cancer with systemic inflammatory markers and NLR, selecting controls from patients that underwent varicocelectomy due to another pathophysiology. In contrast, in our control group, we included patients that underwent orchiectomy with a preliminary diagnosis of testicular cancer but were found to have benign specimen pathology results. Thus, unlike the literature, all the patients included in our sample had negative testicular tumor markers. Therefore, we consider that the systemic inflammatory markers and NLR data obtained from our study can provide a new perspective for the literature in terms of the differentiation of benign/malignant testicular masses with negative tumor markers before orchiectomy.

This study has certain limitations, such as the retrospective and single-center design. Therefore, our findings should be confirmed by prospective randomized studies.

CONCLUSION

Tumor diameter, WBC count, neutrophil count, neutrophil ratio, lymphocyte ratio, and NLR can be used as predictive factors in the differentiation of benign-malignant intratesticular masses with negative testicular cancer markers before radical orchiectomy to prevent overtreatment. While the increased values of tumor diameter, WBC count, neutrophil count, neutrophil ratio, and NLR correlate with the possibility of malignancy, a decreased lymphocyte ratio can be evaluated in favor of malignancy. 

ETHICS

Ethics Committee Approval: Ethics committee approval was received for this study from the Ethics Committee University of Health Sciences Türkiye, Bakırköy Dr. Sadi Konuk Training and Research Hospital Ethics Committee (decision no: 2022-03-06, date: 07.02.2022).

Informed Consent: Written informed consent was obtained from patients who participated in this study.

Authorship Contributions

Surgical and Medical Practices: T.K., A.B., A.İ.T., Concept: T.K., F.A., M.E., H.P., A.B., A.İ.T., Design: F.A., A.E.F., M.E., E.G., Data Collection or Processing: F.A., A.E.F., İ.E., E.G., H.P., Analysis or Interpretation: T.K., E.G., H.P., K.G., Literature Search: T.K., A.E.F., M.E., E.G., K.G., Writing: T.K., F.A., A.E.F., H.P.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.