CASE I

1. CASE I ‘I have noticed a lump in my scrotum. Have I got cancer?’

2. Summary • Tom is a 28-year old male who presents with a swelling in the right testicle. He first became aware of the lesion a couple of weeks ago when he was playing with his 18-month old daughter who accidentally head-butted him. He has not felt any pain in the testicle.  However, on closer questioning he says that he has noticed a dragging/ heavy sensation in the scrotum off and on over the last few months. He had attributed this symptom to the fact that he has recently taken to jogging to work. On examination he is found to have a non-tender, 2-cm rubbery mass at the apex of the right testicle. The lesion is ovoid.  The left testicle is of normal size and consistency.

3. What is the likely differential diagnosis? • TESTICULAR CANCER • Epidemiology • Incidence = 6.2/100000, Cure = 95% (80% w. mets), Peak incidence = 15-35 (2nd highest in this group after melanoma) • Risk factors = hx of testicular maldescent (x5), family hx, hx of cancer in other testicle, vasectomy/bicycle riding have not been supported studies. • Clinical Presentation • Painless nodule/swelling (15% w. pain) present for weeks/months • Dull ache or heavy sensation in the lower abdomen, perianal area, or scrotum • 10% present w. signs of mets

4. Types of Testicular Cancer • Types • Germ Cell Tumours (95%) • Seminoma = from germinal epithelium of seminiferous tubules, Seminomas are relatively slow growing and exhibit late invasion. They are usually discovered and surgically removed before metastases can occur • Nonseminoma = embryonalcarci- noma, choriocarcinoma, yolk-sac tumours and ter- atoma *NOTE* Mixed histo = nonseminoma • Other (5%) • ie. Sertoli cell tumours, Leydig cell tumours

5. Differentials for Scrotal Mass • Varicocele – varicose vein along spermatic cord • Hydrocele – fluid collection in the scrotum • Hematocele – blood collection in the scrotum • Spermatocele – cyst-like mass that contains fluid + dead sperm • Hernia • Orchitis • Epididymitis • Testicular torsion • Trauma • Mumps

6. What is the most important diagnosis to exclude? • HERNIA!!!! • Strangulated hernia = medical emergency • Remember you can’t get above a hernia • Hernias = more prominent standing or coughing • If you can’t reduce the suspected hernia then it is likely incarcerated or strangulated

7. Q3 What additional features in the history would you seek to support this diagnosis? • Any hx of malignancy especially other testicle? • Any family hx? • Any testicular pain? • Any hx of testicular maldescent? • Any symptoms of mets? • A neck mass (supraclavicular lymph node metastasis) • Cough or dyspnea (pulmonary metastasis) • Anorexia, nausea, vomiting, or gastrointestinal hemorrhage (retroduodenal metastasis) • Lumbar back pain (bulky retroperitoneal disease involving the psoas muscle or nerve roots) • Bone pain (skeletal metastasis) • Central or peripheral nervous system symptoms (cerebral, spinal cord, or peripheral root involvement) • Unilateral or bilateral lower extremity swelling (iliac or caval venous obstruction or thrombosis)

8. What clinical examination would you perform and why? • Testicular Exam • The normal gonad is homogeneous in consistency, freely movable, and separable from the epididymis. Any firm, hard, or fixed area within the substance of the tunica albuginea should be considered suspicious until proved otherwise. Further evaluation of the affected side should be directed toward possible involvement of the spermatic cord, scrotal investments, or skin. • Examination of lump looking at: • Site, size, shape, surface, skin (any overlying lesion/dimple/punture etc.), scar • Tenderness (indicator of inflammation, infection, pressure, tissue destruction), temp, transillumination(w. torch indicated fluid • Consistency: e.g. lymph node is usually soft; if firm or rubbery, it may indicate lymphoma; if hard and fixed, it may indicate malignancy. • Attachment: if attached to the skin (e.g. sebaceous cyst), it should move with the skin; if in the subcutaneous tissue (e.g. lipoma), then the skin should move over the lump. • Mobility: if it is in the muscle or tendon, then it should move with muscle contraction; if in the bone, then the lump will be immobile. • Pulsation: which may be arterial (e.g. aneurysm) or because the lump is attached to or lying next to an artery. • Fluctuation: contains fluid. • Irreducibility: used to describe a hernial lump that cannot be manually reduced. • Regional lymph nodes: it is always important to check in cases of malignancy/infection • Edge: is the edge or border easily defined or not? • Mnemonic: 6 Students and 3 Teachers go for a CAMPFIRE

9. What investigations would be most helpful and why? • Scrotal ultrasound • Scrotal ultrasound can distinguish intrinsic from extrinsic testicular lesions with a high degree of accuracy, and can detect intratesticular lesions as small as 1 to 2 mm in diameter. A cystic or fluid-filled mass is unlikely to represent malignancy. In comparison, seminomas appear as well-defined hypoechoic lesions without cystic areas, while nonseminomatous germ cell tumors (NSGCTs) are typically inhomogeneous with calcifications, cystic areas, and indistinct margin • Radiological Imaging • CT of abdo + pelvis and XRAY of chest to look for mets

10. What investigations would be most helpful and why? • Bloods • FBC + Serum Tumor Markers • alpha fetoprotein (AFP), the beta subunit of human chorionic gonadotropin (beta-hCG, since the alpha subunit is common to several pituitary hormones), and lactate dehydrogenase (LDH). • Radical Inguinal Orchiectomyvs Biopsy • Radical inguinal orchiectomy should be performed to permit histologic evaluation of the primary tumor and to provide local tumor control • Less radical approach of biopsy is only appropriate for the management of incidental nonpalpable testicular masses diagnosed by ultrasonography in men with normal tumor markers. If germ cell tumor is found orchiectomy will follow • Retroperitoneal lymph node dissection  • Only reliable method to identify nodal micrometastases given the high false negative rate with CT scan

11. Staging

12. What treatment options are available? • Stage I seminoma — For patients with a stage I seminoma, an extremely high cure rate can be achieved with radical orchiectomy. This may be followed by active surveillance, RT to paraaortic lymph nodes, or single agent carboplatin chemo • Stage II seminoma — Following orchiectomy, men with stage II seminoma are usually managed with radiation therapy (RT) or cisplatinbased combination chemotherapy depending upon the extent of retroperitoneal disease. • Stage I NSGCT — Orchiectomy is the initial step in diagnosis and treatment for patients with a stage I NSGCT. Subsequent management with active surveillance, retroperitoneal lymph node dissection, or an abbreviated course of adjuvant chemotherapy are all associated with a cure rate over 98 percent for appropriately selected patients. • Stage II NSGCT — Management of patients with stage II NSGCTs depends upon the extent of disease and whether retroperitoneal lymph node involvement is documented pathologically or is based upon imaging studies: • Men with clinical evidence of lymph node involvement can be managed with either surgery or chemotherapy if the extent of disease is limited. For those with more extensive disease, chemotherapy is generally used. • For men who have positive lymph nodes identified at a retroperitoneal lymph node dissection, chemotherapy may be used as an adjuvant, depending upon the extent of nodal disease, or patients may be followed expectantly.