A scrotal swelling in a 27-year-old man

Published on 10/04/2015 by admin

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Problem 8 A scrotal swelling in a 27-year-old man

Jimmy Lam

A 27-year-old man presents to his general practitioner with a 12 month history of a swelling in the left side of his scrotum. This has been causing significant discomfort particularly when walking. During the same time period he has lost 50 kg.

Q.1

What is the most important diagnosis to exclude and what other information should be sought from his history?

The patient is mildly autistic, unemployed, and is looked after by his older brother. He has hypothyroidism and attention deficit hyperactivity disorder. There is no history of any previous testicular or scrotal problems such as maldescent or trauma. There is no apparent history of any infections.

Q.2

What are the key features of the physical examination?

On examination of the scrotum and contents there is a 10 cm irregular firm mass replacing the left testis. This is not tender and not tethered to the scrotal skin. The right testis is normal to palpation. On abdominal examination there is an ill-defined fullness palpable just above the umbilicus to the left of the midline. There was no obvious gynaecomastia or supraclavicular lymph node enlargement.

Q.3

What further investigations are required and why?

You arrange an urgent ultrasound of the abdomen and testis as well as baseline bloods investigations and testicular tumour markers. In addition, and because of the abdominal findings, you arrange a CT of the chest and abdomen (Figures 8.1, 8.2). The haematological and biochemical values are within normal limits. The tumour marker and imaging studies are shown.

image

Figure 8.1

image

Figure 8.2

Investigation 8.1 Summary results

LDH 922 IU/L (50–280)
AFP 3 µg/L (<11)
HCG 7 IU/L (<5)

Q.4

Interpret the laboratory results and imaging studies.

You appreciate that the patient almost certainly has metastatic testicular cancer and this is most likely to be a seminoma. There is no role for a trans-scrotal needle biopsy of the testicular mass and this can potentially result in tumour seeding and scrotal violation as the testis and scrotum lymphatics drain to different sites.

The patient subsequently undergoes a left radical inguinal orchidectomy and the diagnosis of seminoma confirmed.

Q.5

Describe the further management required for this patient.

Answers

A.1 The patient may well have a hydrocele with an underlying testicular malignancy. About 10% of patients with a testicular tumour have a previous history of cryptorchidism. Other conditions to consider include various inflammatory processes producing an epididymitis and/or an orchitis. Any history of pain, acute swelling, urethral discharge or infection might suggest exposure to a sexually transmitted disease or urinary tract infection.

A.2 In any man presenting with a scrotal swelling, it is important to elicit the anatomical characteristics of the swelling in order to define the structures from which the swelling has arisen. Conditions within the scrotum to consider include:

• Inguinoscrotal hernia (inability to get above the swelling).
• Hydrocele (testis cannot be palpated as a distinct entity).
• Epididymal cyst (swelling attached to the testis).
• Testicular neoplasm (distinct testicular enlargement).

If a testicular tumour is suspected, a complete physical examination is performed looking for possible metastatic disease. Evidence of any supraclavicular lymphadenopathy, pleural effusion, hepatosplenomegaly or abdominal lymphadenopathy should be sought.

A.3 Baseline investigations to include the following:

• Full blood count (anaemia from chronic disease), serum electrolytes (possible renal impairment), liver function tests (liver metastases).
• Chest X-ray (pulmonary metastases).
• Scrotal imaging with ultrasound to define the testicular mass and to examine the contralateral testis.

Testicular tumour markers are prognostic factors and also contribute to diagnosis and staging. The follow markers are routinely performed:

• Alpha fetoprotein (AFP) (originates from yolk sac cells and may be produced by pure embryonal carcinoma, teratoma, yolk sac tumour or mixed tumours).
• Human chorionic gonadotropin (hCG) (produced by trophoblastic tissue and seen in all patients with choriocarcinoma and 40–60% of embryonal carcinoma and 5–10% of patients with pure seminomas).
• Lactic acid dehydrogenase (LDH) is a less specific marker and its level is usually proportional to tumour volume and may be elevated in 80% of patients with advanced testicular cancer.

A.4 There is elevation of two of the tumour markers and a heterogenous mass occupying most of the left testis. The CT scan shows a large nodal mass in the left para-aortic region. The clinical, biochemical and radiological picture would fit for a stage II seminoma of the testis.

A.5 This patient has stage IIC seminoma (pT2N3M0S2). He will require chemotherapy and a typical regimen would be three cycles of combined cisplatin, etoposide and bleomycin.

With such advanced disease there is a high likelihood of recurrence and he will require regular follow-up. Initially this will be 3 monthly physical examination, tumour markers and CXR and 6 monthly CTs for 2 years, then 6 monthly physical examination, tumour markers and CXR and annual CTs for 3 years, then annual physical examination, tumour markers and CXR thereafter.

Sperm abnormalities are common in patients with testicular tumours and treatment with chemotherapy and radiotherapy can further impair fertility. Therefore patients in the reproductive age group should be offered fertility assessment, semen analysis and cryopreservation. Cryopreservation should be performed prior to chemotherapy treatment.

Revision Points

Testicular cancer more commonly affects young men and prognosis following treatment is excellent. The incidence is estimated at 6–7 per 100,000 Australian Men. Testicular cancer affects young men more commonly with about half of the new diagnoses made in men under the age of 33. There are three peak incidences: late adolescence to early adulthood (20–40 years), late adulthood (60 years and older) and infancy (under 10 years). Testicular cancer is more common in whites than blacks with the incidence of testicular cancer lowest in developing countries, particularly across Africa and Asia.

There has been an increasing incidence of testicular cancer reported in many Western countries but at the same time mortality has also declined substantially, due probably to improvements in chemotherapy. The mortality rate has decreased from 50% in the 1970s to less than 5% in 1997.

Pathology

• 90–95% of testicular tumours are germ cell tumours.
• These are further subdivided into different histologic subtypes:

– seminoma 30–60%
– pure embryonal carcinoma 3–4%
– teratoma 5–10%
– choriocarcinoma 1%
– mixed 60%.

Risk Factors

• Cryptorchidism increases the risk by 3–14 times. 10% of testicular cancer has a preceding history of cryptorchidism.
• 2–3 % are bilateral.
• History of exogenous oestrogen exposure.

Presentation

• Testicular nodule or painless swelling of testis (the commonest presentation).
• Acute testicular pain (10–20% of presentations).
• Metastases (10%) e.g. neck mass, back pain, respiratory symptoms.
• Gynaecomastia 5%.

Examination

• Scrotal examination.
• Evidence of metastatic disease.

Investigation

• Scrotal ultrasound.
• Testicular tumour markers.
• Full blood count, serum biochemistry.
• Chest X-ray.
• CT abdomen/pelvis.

Staging

Staging is based on the American Joint Committee on Cancer (AJCC) staging for germ cell tumours, the TNMS staging system.

Treatment

Principles of treatment of germ cell tumours are best approached with multimodal therapy supervised by a multidisciplinary team. Treatment of the primary tumour is via radical inguinal orchidectomy which provides local control as well as histological diagnosis and local staging information. Further treatment with adjuvant chemotherapy (single agent carboplatin or cisplatin-based chemotherapy) or radiotherapy (para-aortic nodes or retroperitoneal) is based on disease factors (such as stage of disease and prognostic factors) and patient factors (likely compliance with follow-up and patient preference based on side-effect profile).

Prognosis

The outlook for men diagnosed with testicular cancer has dramatically improved due to advances in chemotherapy and the 5-year relative survival is at least 92.8% for all age groups under 60 years.

Testicular cancer accounted for 0.1% of all cancer-related deaths and in 2004 there were 675 cases nationally with 14 deaths related to testicular cancer. In Western communities the lifetime risk of developing testicular cancer by age 75 is about 1 in 200.

Issues to Consider

• How would the management have differed if the tumour had been a teratoma?
• Why is maldescent a risk factor for testicular cancer?
• Are there other reasons apart for advances in chemotherapy that could explain the improved prognosis in these patients?

Further Information

, www.cancer.org.au. The website of the Cancer Council Australia

, www.andrologyaustralia.org. The website of Andrology Australia

, www.uroweb.org. The website of the European Association of Urology

, www.auanet.org. The website of the American Urological Association

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