Ricerc@Sapienza

We agree that the ideal strategy in patients with an SMT would be to follow them with periodic US and perform surgery only in those who show significant growth during followup. This is our actual policy in masses less than 5 mm in diameter. In this group few patients required surgical exploration during followup. It is likely that in cases of such small lesions strict surveillance may not change the progression of germinal tumors, as reported by Bieniek et al, who noted a mean lesion diameter of 4.14 2.0 mm (reference 1 in Editorial Comment). However, sparse data are available in the literature on the natural history of larger masses when left untreated. Our study shows that even larger lesions up to 20 mm in diameter may be benign, indicating that strict surveillance might be justified even for masses larger than 5 mm. Our experience also demonstrates that with increasing lesion size the risk of cancer significantly increases 7 times per mm. This information could be used to better counsel patients about the risk of harboring TC and eventually better support a followup strategy in patients with an STM. We believe that 2 research lines which might help us in the near future are 1) study of the individual lesion growth rate, which could differentiate benign from malignant lesions, and 2) new imaging diagnostic tests such as contrast enhanced US1 or testicular magnetic resonance imaging, which might improve the diagnostic performance of scrotal US