Inguinoscrotal massCase Presentation

Patient data

J.F

40/M

Feb 9 1972

Single

Filipino, Roman Catholic

San Miguel, Pasig

"luslos" (inguinoscrotal mass)

Chief complaint

History of Present Illness

round palpable inguinal mass (quail egg size), right

More apparent when lifting heavy objects

Reducible

No pain, swelling

No urinary symptoms

4 years PTC

History of Present IllnessGradual increase in

size (chicken egg)

Involving the scrotum

Irreducible

No pain

Consult at a hospital, advised surgery, deferred

2 years PTC

History of Present Illness

Persistence of symptoms

Still increasing in size, palm size

Still no pain

No discoloration

Consult at hospital, referred to this institution

2 weeks PTC

Past Medical History

(+) Bilaterally undescended testes

(-) HTN

(-) DM

(+) allergy to shrimps

No previous hospitalization

No previous surgeries

Family history

(-) undescended testes in brother

(+) HTN

(-) DM

Personal & Social History

Construction worker

Lives in apartment-type house with 2 families

Previous smoker, 7 pack years, quit 10 yrs ago

Occasional alcohol drinker

Denies drug use

Water comes from MWSS

Garbage collected regularly

Patient has no children, no wife

Heterosexual, does not use protection,

Currently not sexually active

Review of Systems

No recent weight loss

No fever

No cough and colds, no dyspnea

No abdominal pain

No changes in bowel movement

No changes in urination

Physical examination

BP 130/80

T 37 C

PR 88 bpm, regular

RR 16 bpm

BMI 23.3

VAS 0/10

General: Conscious, coherent, not in cardiorespiratory distress, not in pain

Skin: warm to touch, no active lesions

Head and Neck: Anicteric sclerae, pink conjunctiva, (-)TPC, (-) CLAD

Cardiovascular:Adynamic precordium, PMI at 5th ICS along L MCL, normal rate and rhythm, good S1, S2, no murmurs

Respiratory: symmetric chest expansion, clear breath sounds, no rales/crackles

Gastrointestinal: Flat, normoactive bowel sounds, soft, non-tender

Urogenital: (+) scrotal mass, R

8 x 10 x 6 cm, firm, smooth borders, non-nodular

(-) Transillumination

No palpable testis and masses in Left scrotum

Extremities: Full and equal pulses, Full ROM

Incarcerated inguinal hernia, R

Primary Impression

Differential Diagnoses

Testicular Testicular neoplasianeoplasia

Undescended Undescended testes, 36 yo, testes, 36 yo, painless firm painless firm

testicular masstesticular mass

HydrocoeleHydrocoele Painless scrotal Painless scrotal massmass

(-) (-) transilluminatiotransillumination, usually soft n, usually soft

massmass

VaricocoeleVaricocoele Painless scrotal Painless scrotal massmass

Usually soft Usually soft mass, not roundmass, not round

DiagnosticsUltrasound of the scrotum

Tumor serum markers

AFP

B HCG

LDH

DiscussionTesticular cancer

Testicular cancer

Most common malignancy in 15-35 yo men

95% are Germ Cell tumors

Cell types: seminoma (50%) , embryonal cell carcinoma, yolk sac tumor, teratoma, choriocarcinoma

Seminoma and non-seminoma

SeminomaClassic, anaplastic, spermatocytic

Typical/classic - 82-85% of all seminomas, mostly in 30s, may occur in 40s-50s

Syncyciotrophoblasts - b HCG production

Anaplastic - 5-10%

30% mortality

Lethal- greater mitotic activity, higher rate of local invasion, inc metastatic spread, higher b HCG production

Spermatocytic Seminoma

2-12%

Cells closely resemble different phases of maturing spermatogonia

Low metastatic potential

Non-seminomaEmbryonal carcinoma - irregular mass

cut surface: variegated, grayish white, fleshy tumor often with areas of necrosis or hemorrhage and poorly defined capsule

Choriocarcinoma - hemorrhagic

Teratoma- derived from ectoderm, mesoderm, endoderm

Yolk sac tumor- most common in infants and children

Mixed tumors

60% have more than 1 histologic pattern

Usual combination

Risk factors: GCT

20-34 yo

American blacks

Family history

Risk factors: (testicular CIS)

Cryptorchidism (3%)

Family history of testicular carcinoma (5-6%)

Contralateral testis with unilateral testicular cancer (5-6%)

Atrophic contralateral testis with testiculat cancer (30%)

Somatosexual ambiguity (25-100%)

Infertility (0.4-1.1%)Harland et. al 1998

Approach to a patient with testicular massCBC, creatine, electrolytes, liver enzymes

Serum tumor markers – diagnosis, staging, prognosis; before and after orchiectomy

Chest X-ray

Testicular ultrasound

Biopsy may be considered

Sperm banking

Chest CT indicated if the abdominopelvic CT shows retroperitoneal adenopathy or abnormal Chest X-ray

Management

Inguinal orchiectomy – primary treatment

Open inguinal biopsy of contralateral testis usually not done, may be considered for cryptochidism

Definition of stage and risk classification – American Joint Committee on Cancer (AJCC) an International Germ Cell Cancer Consensus Group (IGCCCG)

Extent of disease

Levels of serum tumor markers post-orchiectomy

Pure Seminoma IA and IB

Inguinal orchiectomy

Surveillance

Radiotherapy

Chemotherapy (1-2 cycles of carboplatin)

Survival 99%

Relapse rate 99% in 5 years

Follow-up every 3-4 months, for 1-2 years

Then every 6-12 months for 3-4 years, then annuallu

Campbell et al Urology

NCCN Guidelines on Testicular Cancer