| How do we view scrotal masses? | Firm intratesticular mass should be considered cancer until proven otherwise.
Patients with a presumptive diagnosis of epididymo-orchitis should be re-evaluated within 2 to 4 weeks of completion of an appropriate course of oral antibiotics |
| What is cryptorchidism? | Risk of testicular cancer in cryptorchidism is 3:14 times the normal incidence.
Present 10% of cases of testicular cancer, even in contralateral normal testicle
Orchiopexy does not prevent carcinogenesis but allows clinical surveillance |
| What are other risk factors for testicular cancer? | Cancer in the contralateral testis
Intratubular Germ Cell Neoplasia (ITGCN): Carcinoma in Situ of the Testis
Infertility |
| How is PE of testicular cancer? | Use both hands
Gentle handling
Begin with normal testis
Evaluate all scrotal components
Also examine: chest (gynecomastia), abdominal masses, supraclavicular nodes |
| How is epidemiology of testicular cancer? | Age: 20 to 35 yo
Slightly R > L Bilateral in 2%
Rare
Most common solid tumor of men age 20 to 34 y
Most curable solid neoplasm
Familial predisposition: 1st degree relatives
On presentation:
Painless hard mass or swelling of the testicle discovered incidentally
10%: acute pain (bleeding / infection)
10%: Signs of metastasis
On physical exam: Any testicular mass should be considered suspicious until proved otherwise |
| What is DD of testicular cancer? | Testicular torsion (Epididymitis or epididymo-orchitis, Hematoma / Hematocele, Hernia)
Non painful (Hydrocele, Spermatocele) |
| How is workup of testicular cancer? | US (hypoechoic lesion)
Tumor Markers (AFP [increases in cancer, normal pregnancy, and benign liver disease t1/2 = 5-7 days], HCG [produced by trophoblasts, malignancies marijuana, normal pregnancy, t1/2 = 24-36 h], LDH [increase stage disease]) |
| How is tx of testicular cancer? | Radical orchiectomy: Removal of the testis via an inguinal approach (early clamping of the spermatic cord)
pathologic diagnosis
local treatment
Transscrotal biopsy is to be condemned
Rarely, conservative surgery (partial orchiectomy) might be done
Do Sperm banking prior to starting treatment |
| What are types of germ cell tumors? | . |
| What are seminomas? | Most common histologic type overall
3 types:
Classic (or Typical): 82 to 85 % of all seminomas
Anaplastic
Spermatocytic (mainly in older men - no cases of metastasis)
Elevated HCG in 10 to 15%
Risk factors:
Tumor > 6 cm
Vascular/lymphatic invasion
No place for Retroperitoneal lymph node dissection (RPLND( |
| What are non-seminomatous germ cell tumors? | Embryonal carcinoma: dictates the risk of mixed tumors
Choriocarcinoma:
Important increase in HCG in 100%
Hematogenous spread
Teratoma:
Resistant to chemo and radio
Heterogeneous with both solid and cystic components
Yolk sac tumor:
Most common testis tumor of infants and children
Responsible for the production of AFP
Orchiectomy is usually curative (no additional treatment needed) |
| What types of testicular cancer do we see increased AFP? | In testicular cancer, ↑ AFP =
Embryonal carcinoma
Teratocarcinoma
Yolk sac tumor
Mixed tumors
No increase in pure choriocarcinoma or seminoma |
| What types of testicular cancer do we see increased HCG? | In testicular cancer, ↑ hCG =
Choriocarcinoma: 100%
Pure seminoma: 5 to 10%
No increase in pure embryonal cell carcinoma |
| How is metastatic workup? | Chest Radiography :
AP and lateral CXR are enough
CT chest:
Can detect small lesions of 2mm (might be benign)
Abdominal CT:
Detect retroperitoneal involvement (lymph nodes < 2cm)
Cannot distinguish fibrosis, teratoma, or malignancy
MRI of the brain: if multiple lung metastases, or high β-hCG
PET: No apparent advantage over CT (done in specific cases)
Repeat tumor markers after 1 month of surgery
They are very important for F/U
Staging is done based on pathology result of radical orchiectomy, tumor markers and imaging results |
| How is TNM classification of testicular cancer? ONLY T | T: Primary Tumor (T)
pTis: Intratubular germ cell neoplasia (CIS)
pT1: Tumor limited to the testis and epididymis
No vascular/lymphatic invasion
pT2: Tumor limited to the testis and epididymis
Vascular/lymphatic invasion OR
Tumor extending through the tunica albuginea with involvement of tunica vaginalis
pT3: Tumor invades the spermatic cord with or without vascular/lymphatic invasion
pT4: Tumor invades the scrotum with or without vascular/lymphatic invasion |
| How is TNM classification of testicular cancer? | . |
| How is classification of testicular cancer based on serum tumor markers S? | . |
| What are risk factors of NSGCT? | Risk factors
T2 or higher
ECC > 40%
Vascular/ lymphatic invasion
RPLND is an option
No place for RPLND if elevated tumor markers |
| What is retroperitoneal lymph node dissection? | Testicle embryology: close to the kidneys => primary lymphatic drainage is to the retroperitoneum
Lymphatic spread from right to left
Highly morbid surgery
Risk of retrograde ejaculation
=> Shift to modified RPLND with Nerve preservation |
| How is surveillence for testicular masses? | History and physical examination
Serum tumor markers
Chest radiography
CT abdomen and pelvis
Self-examination
Frequency depends on the stage of the disease
Necessary for a minimum of 5 years after orchiectomy |
| What are prognostic classifications of testicular cancer? | Good prognosis (non seminoma [no nonpulmonary visceral metastasis, AFP<1000, hCG < 5000, LDG<1.5 higher limit]
Seminoma [normal AFP w/any hCG and LDH, no nonpulmonary metastiasis])
Intermediate Prognosis ( Non seminoma [no nonpulmo..., Any of AFP 1000-10000, hCG 5000-50000, LDF >1.5-10 upper limit]
Seminoma [normal AFP, nonpulmonary visceral metastasis])
Poor prognosis (Non seminoma only! non pulmo metastasis, AFP>10000, hCG>50000, LDH >10 upper limit]) |
| How is usual progonsis of testicular cancer? | Usually it is good with survival up to 98% in stage 1 disease
Pulmonary metastasis doesn’t hinder the prognosis
Tumor markers are important for prognostic classification
Seminomas are never of poor prognosis |
| What are extragonadal germ cell tumors? | Very rare
Most common sites of origin: mediastinum, retroperitoneum, sacrococcygeal region, and pineal gland
Very bad prognosis |
| What are non germ cell testicular tumors? | . |
| What is leydig cell tumor? | Feminizing tumor (increase testosterone and estrogens)
In prepubertal age: precocious puberty (virilism)
Gynecomastia (feminization)
10% metastasis
Treatment: radical orchiectomy |
| What is sertoli cell tumor? | Gynecomastia without virilism
10% metastasis
Treatment: radical orchiectomy |
| What is Gonadoblastoma? | Patients are phenotypic females, usually presenting with primary amenorrhea and hypertrophy of the clitoris
50% bilateral
Treatment: radical orchiectomy |
| What are paratesticular cancers? | They are most commonly benign
Most common are adenomatoid tumors (mainly in epididymis)
Rhabdomyosarcoma is the most common malignant paratesticular tumor |
| What are other scrotal masses? | Most commonly:
Epididymal origin:
Normal epididymis!!
Spermatocele (Also known as a spermatic cyst or epididymal cyst, Painless benign fluid-filled cyst, Doesn’t cause infertility, Doesn’t require treatment)
Epididymitis / orchitis
Hydrocele (Collection of fluid between the tunica vaginalis and the testis (within the tunica vaginalis))
Hematoma / Hematocele
Hernia |
| What is epididymo-orchitis? | Epididymitis = inflammation of the epididymis
Orchitis
= inflammation of the testis
Very rarely isolated => viral (mumps, EBV)
Usually spread from epididymis
Inflammation might be chronic
May be acute bacterial UTI/STD, non bacterial infectious (viral, ricketsial), non infectious (idiopathic, trauma, autoimmune)
for epididymis may be amiodarone induced/associated with syndrome (Behcet) |
| What are symptoms of epididymo-orchitis? | Scrotal swelling, erythema, pain / tenderness
Symptoms of prostatitis in older men (storage urinary symptoms)
Symptoms of an STD in sexually active men (urethral discharge, dysuria)
Systemic signs: fever, leukocytosis and high CRP
To differentiate from torsion:
Normal vertical lying testis
Cremasteric reflex preserved
Positive Prehn’s sign (pain relief on scrotal elevation) |
| How is dx and tx of epididymo-orchitis? | Diagnosis:
Urinalysis and culture
Urethral swab (if STD suspected)
Scrotal Doppler: increased flow
Treatment:
(Bed rest, Scrotal support, Hydration. Antipyretics. Anti-inflammatory agents / Analgesics, Antibiotic therapy (for UTI vs STD)) |
| What are causes of hydrocele? | Congenital: persistence or delayed closure of the process vaginalis
Testicular cancer: hydrocele exist in 10% of tumors and in 25% of yolk sac tumors Always do an U/S in case of hydrocele
Varicocele repair : section of lymphatic vessels associated with the spermatic cord (3% to 39%)
Acute scrotum: torsion, infection
Filariosis
Communicating Hydrocele (congenital)
hydrocele will vary in size, usually related to activity |
| How is presentation of hydrocele? | Presentation: non painful
Physical examination:
Non tender
Transillumination +
Testicle can’t be palpated if large hydrocele under tension (=> do U/S) |
| How is tx of hydrocele? | Treatment:
Monitor in infants
Operate if doesn’t resolve after 12 to 18 months of age
Aspiration is contraindicated
Surgical treatment :
Inguinal approach if communicating hydrocele or if presence of tumor
Otherwise: scrotal approach: hydrocelectomy |
| What is cryptorchidism? | = undescended testis
= failed to descend to the scrotum
Testis is retained at any point along the normal path of descend
Right side: 50%
Left side: 30%
Bilateral: 20%
Ectopic testis:
Testicle not in the scrotum
AND not on the normal path of testicular descent |
| What are types of cryptorchidism? | . |
| What are retractile testis? | The testis lies in the upper part of the scrotum (overactive cremasteric reflex)
Goes down during sleep
The testis can be brought down
Only needs monitoring
By puberty, testis grows in size and remains in the scrotum |
| How is tx of cryptorchidism? | Hormone therapy: Not routinely used
Orchiopexy
Treatment of choice
Done between 6 and 12 months of age
Allows self examination
Laparoscopic surgery : For non palpable Testis (=> testis in the abdomen)
Orchiectomy: if atrophic testis / older age |
| What are complications of cryptochidism? | Torsion of the testis
Atrophy
Sterility: Poor spermatogenesis after 6 yrs
Malignancy: importance of self examination |
