04/07/2023Urology Posting, 5th Rotation, 6th Batch1

Painless & Solid Scrotal Swelling

By: Hakimah Khani Binti Suhaimi

Supervised by: Dr Mular Paw

04/07/20232

Testicular Tumors

Benign testicular tumors are rare.

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

04/07/20233

04/07/20234

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

04/07/20235

Germ-cell Testicular Tumors Seminomas in 35 – 45y. Teratomas in 20 – 35y. Maldescent testis predisposes to seminomas.

04/07/20236

Germ-cell Testicular Tumors Symptoms

Painless swelling of the testis 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

Heaviness in the scrotum Almost diagnostic

Constitutional symptoms Malaise, LoA, LoW

Symptoms of metastasis Metastasizes via lymphatic

spread to paraaortic lymph nodes

Abdominal discomfort / swelling, dyspnea

Hematogenous spread - Uncommon

Signs Position

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

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)

Shape & size Variable, but usu. spherical Surface Smooth / craggy (if nodes

present) Consistency Firm-hard, dull on percussion Fluctuancy Non-fluctuant Transillumination Does not transillumate Association Maybe assoc. with hydrocele

(secondary)

Signs of mets – Paraaortic, supraclavicular nodes

04/07/20237

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

Leydig cell tumor – Masculinizes (Androgen) Usualy prepuberty Sexual precocity Extreme muscular development

04/07/20238

Ix Scrotal US Tumor markers

(AFP, ß-hCG and LDH) CXR CT Scan

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

 

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

The testis is mostly replaced by a solid mass with poorly defined margins and heterogeneous echo pattern with infiltrating aspect. A rim of normal testicular parenchyma surrounds the mass.

04/07/20239

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

Adjuvants Radiotherapy - Seminoma Chemotherapy - Teratoma

Prognosis Seminoma

No mets : 95% 5-year survival rate Mets : 75% 5-year survival rate

Teratoma Stage 1, 2 : 85% 5-year survival rate Stage 3,4 : 60% 5-year survival rate

Seminomas – microscopic - sheets of cells resembling spermatocytes, pinkish on macroscopic appearance

Teratomas – microscopic – totipotent cells in the rete testis, yellowish on macroscopic appearance

04/07/202310

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

04/07/202311

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.

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

04/07/202312

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’

Tuberculous epididymis Infection develops slowly – rarely has acute pain Differ from tumors in the sense that;

Epididymis – Hard, knobbly Spermatic cord – Thickened Vas deferens – Irregular

Lymphedema (Filariasis / Elephantiasis) Thickened skin Can hardly palpate the testis

04/07/202313

Quiz What is the peak age incidence of

seminomas? What is the peak age incidence of non-

seminomatous 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