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The Royal Marsden

Testicular cancers

Mr Erik Mayer Consultant Urological surgeon, The Royal Marsden

The Royal Marsden

Contents

− Referral Guidelines

− Diagnostics

− Common misdiagnosis – Differential Diagnosis

– The newly diagnosed cancer patient

– The awkward Scrotum

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Referral Guidelines

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Quiz

The Royal Marsden

Question 1

1. Testicular torsion

2. Torted hydatid of Morgagni

3. Epididymal cyst(s)

4. Microlithiasis

5. Hydrocoele

6. Varicocoele

7. Epididymo-orchitis

8. Hernia

9. Testicular Rupture

10. Testicular Germ Cell Tumour

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Question 1.

1. Testicular torsion 2. Torted hydatid of

Morgagni 3. Epididymal cyst(s) 4. Microlithiasis 5. Hydrocoele 6. Varicocoele 7. Epididymo-orchitis 8. Hernia

9. Testicular Rupture 10. Testicular Germ Cell

Tumour Test

icula

r tors

ion

Epidid

ymal c

yst(s)

Hydroco

ele

Epidid

ymo-o

rchiti

s

Testicu

lar R

upture

4%0% 0%

2%0%0%

9%

2%2%

81%

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Question 2




4. Microlithiasis

5. Hydrocoele

6. Varicocoele


8. Hernia



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The Royal Marsden

Question 2




4. Microlithiasis

5. Hydrocoele

6. Varicocoele


8. Hernia


10. Testicular Germ Cell Tumour Test

icula

r tors

ion

Epidid

ymal c

yst(s)

Hydroco

ele

Epidid

ymo-o

rchiti

s

Testicu

lar R

upture

10% 9%

0% 0%

9%

67%

1%3%

1%0%

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Question 3




4. Microlithiasis

5. Hydrocoele

6. Varicocoele


8. Hernia

9. Adenomatoid Tumour


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Question 3


Morgagni 3. Epididymal cyst(s) 4. Microlithiasis 5. Hydrocoele 6. Varicocoele 7. Epididymo-orchitis 8. Hernia 9. Adenomatoid Tumour 10. Testicular Germ Cell

Tumour

Testicu

lar t

orsio

n

Epidid

ymal c

yst(s)

Hydroco

ele

Epidid

ymo-o

rchiti

s

Adenomat

oid T

umour

0%3%

1% 0%3%

5%

74%

1%3%

11%

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Question 4




4. Microlithiasis

5. Hydrocoele

6. Varicocoele


8. Hernia



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Question 4


Morgagni 3. Epididymal cyst(s) 4. Microlithiasis 5. Hydrocoele 6. Varicocoele 7. Epididymo-orchitis 8. Hernia 9. Testicular Rupture 10. Testicular Germ Cell

Tumour Testicu

lar t

orsio

n

Epidid

ymal c

yst(s)

Hydroco

ele

Epidid

ymo-o

rchiti

s

Testicu

lar R

upture

72%

2% 2%0% 0%

2%0%

23%

0%0%

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Question 5




4. Microlithiasis

5. Hydrocoele

6. Varicocoele


8. Hernia



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The Royal Marsden

Question 5




4. Microlithiasis

5. Hydrocoele

6. Varicocoele


8. Hernia


10. Testicular Germ Cell Tumour Test

icula

r tors

ion

Epidid

ymal c

yst(s)

Hydroco

ele

Epidid

ymo-o

rchiti

s

Testicu

lar R

upture

0%3%

0%3% 2%0%0%0%

92%

0%

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The Royal Marsden

Question 6




4. Microlithiasis

5. Hydrocoele

6. Varicocoele


8. Hernia



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The Royal Marsden

Question 6


Morgagni 3. Epididymal cyst(s) 4. Microlithiasis 5. Hydrocoele 6. Varicocoele 7. Epididymo-orchitis 8. Hernia 9. Testicular Germ Cell

Tumour 10. Testicular rupture Test

icula

r tors

ion

Torted h

ydatid

of M

orgag

ni

Epidid

ymal c

yst(s)

Micr

olithia

sis

Hydroco

ele

Varicoco

ele

Epidid

ymo-o

rchiti

s

Hernia

Testicu

lar G

erm C

ell Tum

our

2%

11%

6%

0%

5%

11%

58%

0%

8%

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Diagnostics

– History

– Clinical Examination

– Genitals

– Abdomen

– Supraclavicular Lymphadenopathy

– Urine Dipstick & Pregnancy Test

– Tumour Markers

– Ultrasound

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History

Symptoms

• Hard, painless lump

- Partner detection

• 5-10% scrotal pain

• - Intra-tumoural haemorrhage

- Trauma brings attention to abnormality

• Metastatic

- Weight loss

- Shortness of Breath

- Back/abdominal pain

- Neck lumps

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Key Points in a Scrotal Mass History

– The Lump

– How was it detected (in the bath etc.)?

– How long has it been there?

– Is it changing in size?

– Painful or painless

– Sexual history – Any recent STIs

– Any lower urinary tract symptoms

– Any recent testicular trauma

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Key points continued

− Any abdominal or neck lumps (lymphadenopathy)

− Any SOB or abdominal pain

− PMH

− Previous orchidopexy/maldescent of testicle

− Have they had testicular US scan before/been encouraged to regularly self examine

− FH of testicular Cancer

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Clinical Examination

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Which tumour markers might be raised in testicular cancer?

1. CA 19-9, CA 125

2. CEA, B-HCG

3. AFP, B-HCG, LDH

4. CA 125, AFP

5. None of the above

CA 19-9

, CA 1

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CEA, B-H

CG

AFP, B

-HCG, L

DH

CA 125, A

FP

None of t

he above

0%

23%

0%6%

71%

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Tumour Markers

AFP - raised in 50-70% of NSGCT – May be elevated with:

– hepatic dysfunction, cirrhosis, and – drug or alcohol abuse

- normal <10ng/mL – βhCG - raised in:

• 100% Choriocarcinoma • 60% Embryonal carcinoma • 55% Teratocarcinoma • 25% Yolk Cell Tumour • 7% Seminomas

- normal <5mIU/mL – False positive elevations - marijuana use – LDH- ↑in 30% to 80% of pure seminoma and 60% of

nonseminomas.

Useful in diagnosis, risk stratification & monitoring

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Ultrasound

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What I discuss with the patient

− Diagnosis

− Prognosis

− CxR/CT scan/tumour markers

− Need for Surgery as first line treatment

− Testicular Prosthesis

− Fertility/Sperm Storage

− Possible further treatment

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Headline Statistics

– Affects 7 in 100,000 men

– Most common solid cancer in men 20-45

– Rare below 15 and above 60

– Responsible for just over 1% of all male cancers.

– Estimated that the lifetime risk of developing testicular cancer in 2012 is 1 in 195 for men in the UK.

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European Age-Standardised Incidence Rates per 100,000

Population, Males, Great Britain

Headline Statistics

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Headline Statistics European Age-Standardised Mortality Rates per

100,000 Population, Males, UK

One-, Five- and Ten-Year Net Survival (%), Adults Aged 15-99, England & Wales

1-Year Survival (%)

5-Year Survival (%)

10-Year Survival (%)

Men

Net Survival 99.1 98.3 98.2

95% LCL 99.1 98.3 98.2

95% UCL 99.1 98.3 98.2

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Operating is not always best for the patient

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Orchidectomy: Inguinal vs. Scrotal approach

– Meta-analysis

– Scrotal violation → ↑ local recurrence from 0.4 – 2.9%

Capelouto et al., 1995

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Prosthesis

– Infection risk

– Think Chemotherapy

– Long-term safety

– Cosmesis/Migration

– About 25% uptake

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Sperm Storage

– Andrology Lab - Hammersmith

– Hep B/C, HIV & CMV screening

– No desperate need to do pre-op although is recommended in

EAU guidelines (3 samples/3 day abstinence)

– Cost associated after year one

– Collecting and freezing the samples can cost between £200

and £400. Then you pay about £300 a year to store them

– Standard storage period 10 years

– Quality of the sperm not guaranteed

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Further Treatment

– Oncological outcomes – overall survival

– Reducing burden of follow-up

– Minimising ‘overtreatment’ and treatment related morbidity

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So it’s NOT Cancer

Most testicular lumps are NOT cancer. At a testicular clinic at the Queen Elizabeth Hospital in Birmingham, only 76 cancers were found out of 2,000 men seen with a testicular lump. This means that fewer than 4 in every

100 testicular lumps (4%) are cancer

The awkward Scrotum

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Differential Diagnosis

– Any cause of scrotal lump/pain

– Testicular torsion

– Torted hydatid of Morgagni

– Epididymal cyst(s)

– Hydrocoele

– Varicocoele

– Epididymitis (orchitis)

– Hernia

– Adenomatoid Tumour

Other findings on Ultrasound

Microlithiasis

Varicocoele

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Microlithiasis

– Common – up to 10% men referred for Ultrasound

– Increasingly detected with higher frequency US

– Is it Premalignant?

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Varicocele – Abnormal dilatation of the testicular

veins in the pampiniform plexus

– 2-22% incidence of normal men, and

25% of infertile men

– Typically pain coming on when standing/

ambulating

– No pain at night

– 90% Left and 10% bilateral

o 10 cms longer and into renal vein.

o ‘nutcracker effect’ left renal vein

between the aorta and SMA.

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Varicocoele

– Consider underlying cause if:

• Sudden onset of varicocoele

• Right sided varicocoele

• Does not collapse on being supine

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– Grade 0:

– subclinical varicocoele.

– Grade 1:

– palpable only with valsalva.

– Grade 2:

– Clinically palpable in upright position.

– Grade 3:

– Gross varicocoele with ‘bag of worms’ visible through skin.

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Varicocoeles and fertility

– Varicocoeles do not cause infertility

– Routine testing of semen parameters not

required

– Do not require treatment unless associated

with abnormal semen parameters and low

testicular volume in the context of infertility

– Always consider female infertility factors

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Treatment

– Treatment Conservative/embolisation/ ligation

– Be guarded about outcome

– Natural History may demonstrate improvement

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Torsion

– Testicular torsion

– Torsion of a testicular appendage (appendix testis, Hydatid of Morgagni)

– Torsion

– Acute testicular pain (unilateral)

– Radiation to lower abdomen

– Nausea & vomiting

– Negative urine dipstick

– Main investigation is scrotal exploration

– (Ultrasound)

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Testicular Torsion Torsion of Hydatid

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Torsion

− Immediate referral to A&E

− No investigation needed

− Scrotal exploration, untwisting of testicle and bilateral 3-point

fixation with non-absorbable sutures in adult, dartos pouch in

children

− Warm ischaemia time 6 hours

− Torted Hydatid of Morgagni – conservative treatment an option

if diagnosis clear

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Infection

–Acute epididymitis/Epididymo-orchitis

– Bacterial

– In older men, UTI organisms

– In younger men, Chlamydia and Gonococcus

History

– Examination; tender swelling of epididymis +/- secondary

hydrocoele

– 21 days of appropriate antibiotic but warn patient that swelling

may persist >6 weeks

– Scrotal support

– Patient typically ends up with repeat ultrasound

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Follow-up Ultrasound

– Epididymal/Testicular abscess

– Testicular infarction

– Underlying tumour

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Infection

–Orchitis

Can be extension of epididymorchitis

Viral

• Mumps, ?other viruses

• History of parotitis

• Supportive measures – analgesia, bed rest

• Steroids? Tunical incision

If bilateral, mumps orchitis post-puberty may lead to

atrophy and subfertility

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Epididymal cysts and hydroceles

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Aetiology

Epididymal Cyst

– Possible results from

epididymal tube

obstruction

Hydrocoele

-Excess fluid production

Inflammation

Tumours

-Decreased fluid absorption

Post treatment for varicocoele

-Congenital

Patent Processus Vaginalis

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Clinical Appearance

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Epididymal Cyst

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Management

Epididymal Cyst

– Conservative

- Why not to operate:

– Pain does not improve

– Pain can be made worse

– Recurrence

– Epididymal obstruction

Hydrocoele

– Conservative

– Aspiration

– Aspiration + Sclerotherapy

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Inguino-scrotal Hernia

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Take Home Messages

− Scrotal Lumps and Bumps can be difficult to confidently

diagnose

− Always get an Ultrasound (urgent vs. routine)

− If in doubt 2WW referral

− Elements of managing new testicular cancer patient

− Benign scrotal pathology can generally be managed

conservatively

− Except torsion

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