Painless & Solid Scrotal Swelling

By: Hakimah Khani Binti Suhaimi Supervised by: Dr Mular Paw

Urology Posting, 5th Rotation, 6th Batch

4/10/2012

Testicular Tumors
Benign Hence,

testicular tumors are rare.

classification of testicular tumors are based on the cell of origin, instead of benign vs malignant in other tumors.

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Testicular Tumors

Commonest malignancy in young men. 90% arise from germ cells and are either seminomas (40%) or teratomas (30%) or mixed (10%) 10% are non-germ cells; lymphomas (7%), sertoli cell tumors or leydig cell tumors

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Germ-cell Testicular Tumors

Seminomas in 35 45y. Teratomas in 20 35y. Maldescent testis predisposes to seminomas.

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Germ-cell Testicular Tumors

Symptoms

Signs

Painless swelling of the testis

Position Localized scrotal swelling which you can get above it, normal epididymis, vas deferens and spermatic cord

Early stage usually chance discovery Many present late when the whole scrotum is preoccupied w/ tumors May have dull, aching and dragging pain in the scrotum and groin if significantly enlarged Almost diagnostic Malaise, LoA, LoW

Sensation LOSS OF NORMAL TESTICULAR SENSATION (Normally, testicles are very sensitive to touch, whatmore to palpation) Heavier as compared to the unaffected testis

Tenderness

Non-tender

Temperature & color Normal (unless if the tumor mets to the skin and skin becomes ulcerated very unlikely and rare because testicular tumors mets via lymphatics and lymphatic drainage for testicles are to paraaortic lymph nodes, whereas scrotal skin inguinal lymph nodes)

Heaviness in the scrotum

Constitutional symptoms

Shape & size Surface Consistency Fluctuancy Association

Variable, but usu. spherical Smooth / craggy (if nodes present) Firm-hard, dull on percussion Non-fluctuant Maybe assoc. with hydrocele (secondary)

Symptoms of metastasis

Metastasizes via lymphatic spread to paraaortic lymph nodes

Abdominal discomfort swelling, dyspnea Hematogenous Uncommon spread /

Transillumination Does not transillumate

Signs of mets Paraaortic, supraclavicular nodes 4/10/2012

Non Germ-cell Testicular Tumors

Arise from intersticial cells of the testis (1.5%) Additional characteristics:

Sertoli cell tumor Feminizes (Estrogen)

Usually postpuberty Loss of libido Gynecomastia Aspermia Usualy prepuberty Sexual precocity Extreme muscular development

Leydig cell tumor Masculinizes (Androgen)

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Ix

Scrotal US Tumor markers

(AFP, -hCG and LDH) The testis is mostly replaced by a solid

CXR CT Scan

mass with poorly defined margins and heterogeneous echo pattern with infiltrating aspect. A rim of normal testicular parenchyma surrounds the mass.

Color and power Doppler shows increased vascularity in the testicular mass.

Staging

Stage 1 : Localized tumor, no spread Stage 2 : Nodes below diaphragm Stage 3 : Nodes above diaphragm Stage 4 : Pulmonary or Hepato mets
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Rx

Orchidectomy

Removal of testis In other dz like orchitis, incision is done at the lesion, but in tumors, incision is done at the inguinal (as in hernia) to prevent hematogenous spread to the skin. Spermatic cord is clamped prior to removal of testis to ensure no introduction of tumor cells into the spermatic cord Radiotherapy - Seminoma Chemotherapy - Teratoma

Adjuvants

Seminomas microscopic sheets of cells resembling spermatocytes, pinkish on macroscopic appearance Teratomas microscopic totipotent cells in the rete testis, yellowish on macroscopic appearance

Prognosis

Seminoma

No mets Mets

: 95% 5-year survival rate : 75% 5-year survival rate

Teratoma

Stage 1, 2 : 85% 5-year survival rate Stage 3,4 : 60% 5-year survival rate
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Image 3a (left): Orchidectomy specimen showing complete replacement of the normal testicular parenchyma with the classical "cut-potato" appearance of a seminoma. The tunica albuginea is intact.

Image 4a (right): Orchidectomy specimen showing a teratoma with areas of cyst formation and haemorrhage.

http://www.imagingpathways.health.wa.gov .au/includes/dipmenu/a_scrot/image.html
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Histological section of a seminoma showing groups of malignant cells with large nuclei and prominent nucleoli. There are also intervening fibrous bands with an infiltrate of lymphocytes and plasma cells.
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Histological section of a teratoma (non-seminomatous germ cell tumour) showing hyaline cartilage and islands of columnar epithelium. http://www.imagingpathways.health.wa.gov .au/includes/dipmenu/a_scrot/image.html
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DDx for PAINLESS, SOLID Scrotal Swelling

Chronic haematocele

Initially in acute haematocele (blood collection in the tunica vaginalis due to trauma), it is painful. But if the blood is not drained, it will form clots, which is hard, and painless.

Gumma

Congenital syphilis causes testicular atrophy But in adults inflammation in the interstitial spaces round, hard, insensitive mass over the testis = biliard ball testis
Infection develops slowly rarely has acute pain Differ from tumors in the sense that;

Tuberculous epididymis

Epididymis Hard, knobbly Spermatic cord Thickened Vas deferens Irregular

Lymphedema (Filariasis / Elephantiasis)

Thickened skin Can hardly palpate the testis

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Quiz

What is the peak age incidence of seminomas? What is the peak age incidence of nonseminomatous germ cell tumors (NSGCT)? What is the S&S of a testicular tumor? What investigations are required? What surgery is usually necessary? What other therapeutic options exist for seminomas and NSGCTs?
http://www.storyq.net/slide_boxes/16700

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