Testicular Mass (Case 32)

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Testicular Mass (Case 32)

Christopher Greenleaf MD, Tamara Donatelli DO, Jennifer Sherwood MD, and Mary Denshaw-Burke MD

Case: You are consulted by your hospital urologist: “A 19-year-old male presents with a 3.0-cm firm asymptomatic testicular mass of concern. By exam, this does not appear to be a hernia, hydrocele, or varicocele. Please evaluate.”

Differential Diagnosis

Benign

Malignant

Infection: epididymo-orchitis

Benign tumors: Sertoli-Leydig cell

Seminomas

Nonseminomatous germ cell tumors (NSGCTs)

Speaking Intelligently

The urologist seeing a patient with an asymptomatic scrotal mass directs the physical examination toward differentiating the benign from the malignant causes. An inguinal hernia can be invaginated at the inguinal ring. A hydrocele will have a cystic consistency. A varicocele will often feel like a “bag of worms.” These benign conditions result in relatively soft, compressible masses of the scrotum. A malignant mass, however, palpates as a firm lump with a “woody” or heavy consistency. Almost all scrotal masses should be imaged to further define anatomic features. If the suspicion is high for malignancy, the next step is to obtain an ultrasonogram. A trans-scrotal biopsy should never be performed, because it can disrupt the lymphatic channels and lead to metastases or obscure the anatomy during future inguinal orchiectomy. If a malignant tumor is suspected on exam and imaging, surgical intervention must be instituted quickly (ideally within 48 hours due to the rapid tumor doubling time).

The medical oncologist consulted on this patient with a possible testicular cancer suggested by physical exam and ultrasonography should order testing for the preoperative tumor markers α-fetoprotein (AFP), lactate dehydrogenase (LDH), and the β subunit of human chorionic gonadotropin (β-hCG). Metastatic workup for a testicular tumor should include a chest radiograph and a CT scan of the abdomen and pelvis, and occasionally a CT scan of the chest.

PATIENT CARE

Clinical Thinking

• All solid/hard scrotal masses are considered malignant until proven otherwise.

• Groin pathology may present as abdominal complaints and vice versa; however, testicular tumors are usually asymptomatic.

• Suspected testicular tumors require urgent surgical removal (radical orchiectomy via an inguinal approach).

• Patients with testicular tumors frequently require additional therapy (such as chemotherapy or radiation therapy), depending on the tumor pathology discovered after resection.

• After radical orchiectomy, tumor markers (AFP, β-hCG) will have to be monitored until they reach the lowest possible point.

History

• A careful history of the onset and course of a painless mass should be obtained. Particularly helpful are the following questions:

• How long has it been there?

• Does it come and go?

• Has there previously been pain?

• Is there associated erythema or edema?

• If it is persistent, is it staying stable in size or getting bigger or smaller?

• Review of systems should focus on the presence of systemic symptoms such as fever and chills, weight loss, and night sweats; back pain; abdominal symptoms such as pain, distension, nausea, and bowel changes; and genitourinary symptoms such as dysuria and urethral discharge.

Physical Examination

The importance of the physical exam is to differentiate benign from malignant processes and to evaluate for possible metastases.

• The physical exam should begin with particular attention to the lymph nodes (especially supraclavicular area). The lungs should be auscultated carefully, particularly with attention to any pulmonary findings that may be problematic for potential future use of bleomycin (a critical chemotherapeutic agent for treatment of testicular cancer).

• The abdominal exam should pay close attention to any scars and/or tenderness in any quadrants. Most importantly, one should carefully feel for any masses (in the setting of testicular cancer, an abdominal mass can indicate massive retroperitoneal lymph node metastases).

• An inguinal exam focuses on signs of lymphadenopathy or inguinal hernias, and potential involvement of the spermatic cord with tumor. The scrotum should be invaginated through the internal ring to inspect for any laxity or bulges within the inguinal canal that may signal an inguinal hernia. The patient should cough and perform a Valsalva maneuver to increase intra-abdominal pressure, which aids in revealing an occult hernia.

• The scrotal exam includes inspection of skin and rugations, and palpation of testicles, epididymides, and spermatic cords. One should evaluate for skin changes (i.e., loss of normal rugation), erythema, edema, induration, and tenderness. The posterolateral portion of the testis is covered by the epididymis, which should be nontender. The spermatic cord runs in the most superior aspect of the scrotum and should be palpated gently between thumb and forefinger. The testes should be examined with the patient in both the recumbent and standing positions. Start at the base of the scrotum and palpate the testes, which should be firm but not hard. It should be noted whether fluid is present around the testicles and whether a mass is palpable (frequently the testicle itself cannot be palpated because of the presence of scrotal fluid or a mass replacing the testicle).

Tests for Consideration

When you have diagnosed a likely testicular cancer by physical exam and ultrasonography:

• Serum markers of AFP, β-hCG, and LDH should be obtained immediately.	$24, $21, $9
• Seminomas can be associated with elevated β-hCG (in ~10% of cases), but usually the tumor markers are normal.
• NSGCTs produce AFP and/or β-hCG.
• LDH, a nonspecific marker of tumor burden, may be elevated in patients with either seminomas or NSGCTs.
• These tumor markers should be obtained both before and after orchiectomy, as it is critical to follow their values as a measure of residual disease after initial orchiectomy. Each tumor marker has a specific half-life, and time to normalization of elevated markers is highly predictable. Normalization of tumor markers within the expected time line implies absence of residual disease (in the scrotum/groin and lymph nodes). Persistently elevated tumor markers beyond the date of expected normalization portend a worse prognosis with presence of ongoing cancer (typically lymph node disease).

IMAGING CONSIDERATIONS

→ Ultrasonography: For clinically suspicious masses or when unsure of the diagnosis, ultrasonography is the imaging modality of choice for the majority of scrotal masses. It can differentiate solid from cystic masses and testicular from paratesticular masses.	$96
→ MRI: If the diagnosis is still uncertain, an MRI scan is appropriate and effective. MRI has been reported to have a negative predictive value of 100% and a positive predictive value of 71%.	$534
→ CT scan: If the mass is found to be malignant, the next step is to obtain a CT scan of the abdomen and pelvis (with IV contrast) and a chest radiograph (posteroanterior and lateral views) to evaluate for metastatic disease. In the event of a positive abdominal CT scan or an abnormal chest radiograph, a chest CT scan would be indicated. These images will differentiate clinical stages I, II, and III.	$334
Clinical stage I disease is confined to the testis. Clinical stage II disease is characterized by enlarged retroperitoneal lymph nodes. Clinical stage III disease involves metastatic disease to any viscera or any disease above the diaphragm.

Clinical Entities*

Medical Knowledge

Seminomas
Pφ	A seminoma is derived from spermatogonia/spermatocytes.
TP	A tumor may present as a solid, painless mass in the scrotum or along the cord structures within or above the scrotum. With hormone-producing tumors, precocious puberty ensues.
Dx	Testicular ultrasonography is indicated if the diagnosis is in question or a solid component is suspected (i.e., bilateral scrotal ultrasonography should be performed in every case of suspected tumor). A chest radiograph, CT of the abdomen and pelvis with IV contrast, and tumor markers (AFP, β-hCG, and LDH) should be obtained preoperatively if tumor is suspected.
Tx	Testicular tumors should be treated initially with radical inguinal orchiectomy and may require further medical treatment. Further treatment includes: • Clinical stage I seminomas: Active surveillance (in compliant patients) vs. radiation therapy (XRT) vs. one to two cycles of single-agent carboplatin. • Clinical stage II seminomas: XRT vs. etoposide and cisplatin (EP) for four cycles vs. bleomycin, etoposide, and cisplatin (BEP) for three cycles. • Clinical stage III seminomas: Good risk—EP for four cycles, BEP for three cycles. Intermediate risk—BEP for four cycles. See Cecil Essentials 72.
*Please note that only malignant diagnoses are presented in the Clinical Entities.

Nonseminomatous Germ Cell Tumors
Pφ	NSGCTs can be composed of one or more histologic subtypes that include embryonal carcinoma, yolk sac tumor, choriocarcinoma, and teratoma.
TP	A tumor may present as a solid, painless mass in the scrotum or along the cord structures within or above the scrotum. With hormone-producing tumors, precocious puberty ensues.
Dx	Testicular ultrasonography is indicated if the diagnosis is in question or a solid component is suspected (i.e., bilateral scrotal ultrasonography should be performed in every case of suspected tumor). A chest radiograph, a CT of the abdomen and pelvis with IV contrast, and tumor markers (AFP, β-hCG, and LDH) should be obtained preoperatively if tumor is suspected.
Tx	Testicular tumors should be treated initially by radical inguinal orchiectomy and may require further medical treatment. Further treatment includes: • Clinical stage I NSGCT: Stage IA: active surveillance (in a compliant patient) vs. retroperitoneal lymph node dissection (RPLN). Stage IB: rarely active surveillance (T2 lesion in a compliant patient) vs. XRT vs. BEP for two cycles. Stage IS (persistent elevation of tumor markers): EP for four cycles or BEP for three cycles. • Clinical Stage II NSGCT: EP for four cycles vs. BEP for three cycles. • Clinical Stage III NSGCT: Intermediate risk—BEP for four cycles. Poor risk—BEP for four cycles vs. etoposide, ifosfamide, cisplatin, and mesna (VIP) for four cycles (if patient cannot tolerate bleomycin). See Cecil Essentials 72.

a. Epididymo-orchitis: Although mumps is now rare in the United States because of the widespread use of the MMR vaccine, this viral cause of orchitis should be considered in a young man with scrotal swelling. Orchitis usually develops within 1 week of the onset of parotitis.

b. Hematocele: In addition to physical examination, a history of trauma to the testicles would be suggestive of a hematocele, an accumulation of blood within the scrotal space. Significant testicular trauma may also rupture the tunica, a condition referred to as testicular fracture. Hematoceles may be associated with testicular rupture and occur in as many as 50% of patients with blunt scrotal trauma. The definitive diagnosis of a ruptured testicle is made after surgical exploration. All cases of hematocele require surgical evacuation and exploration to preserve testicular function and fertility.

Practice-Based Learning and Improvement: Evidence-Based Medicine

Title
Improved chemotherapy in disseminated testicular cancer

Authors
Einhorn LH, Donohue JP

Institution
Indiana University Medical Center

Reference
Einhorn LH, Donohue JP. Improved chemotherapy in disseminated testicular cancer. J Urol 117:65–69, 1977

Problem
Patient mortality from testicular cancer was greater than 50% before 1970.

Intervention
Addition of platinum-based drugs to chemotherapy regimens

Comparison/control (quality of evidence)
This study compared the then standard chemotherapy regimen of adriamycin, bleomycin, and vincristine against platinum, vinblastine, and bleomycin.

Outcome/effect
The adriamycin, bleomycin, and vincristine group had an 87.5% overall response rate with a 50% partial remission rate and a 37.5% complete remission rate. The group receiving platinum, vinblastine, and bleomycin (which ultimately became known as the Einhorn regimen) had a 100% overall response rate with a 20% partial remission rate and an 80% complete remission rate.

Historical significance/comments
Testicular cancer has become one of the most curable cancers in the United States. In 1997, there was less than 5% patient mortality.

Interpersonal and Communication Skills

Communicate Effectively about Potential Diagnoses

In the setting of a testicular mass, this patient is already concerned that he may have cancer. During the examination, describe your impression of the testicular exam and explain the implications of this to the patient (who is often accompanied by a parent, given the relatively young age at diagnosis). It is preferable to be direct about the concern for a testicular tumor, if the examination warrants this concern. Communicate to the patient that an ultrasonogram should be performed to obtain further information. As testicular cancer has a very rapid doubling time and surgery should be performed expeditiously, the patient must be given a clear understanding of the likely diagnosis so that he can cooperate with immediate testing. Throughout this time, support the patient and family by answering any questions and by explaining that should this be diagnosed as a testicular malignancy, it has a very high cure rate.

Professionalism

Maintain Appropriate Patient Relations in Performing a Testicular Exam

In a time when female medical students constitute approximately 50% of medical school classes, many testicular exams will be performed by female physicians. Before approaching the male patient for a genital exam, a female physician should always be accompanied by a chaperone (male or female is acceptable). Privacy and confidentiality should be respected at all times. Great care and professionalism must be conveyed when approaching the patient so as to gain the patient’s confidence and establish a level of comfort that will facilitate both a thorough physical exam and a nontraumatic experience for the patient. The female physician might also explain that care of the male patient is what she does on a daily basis and that she is very comfortable in that role. A patient’s genitalia should be covered during all parts of the physical exam until the time for the genital exam. Verbalize to your patient what you plan to do and what you are doing throughout the exam. Often this simple “warning” of what is to come will facilitate the exam. If a patient is still uneasy despite your efforts, it is often helpful to emphasize both your role as the physician and the importance of the exam for diagnostic purposes. The most important aspect of this encounter is demeanor; if you convey a sense of serious and confident professionalism, the patient will respond to you appropriately.

Systems-Based Practice

Effective Use of Health Information Resources on Patient Options and Patient Care

In certain clinical circumstances, namely stage IA and IB seminomas and nonseminomas, the patient has the option of aggressive surveillance in lieu of systemic therapy. Surveillance as a management option for early-stage testicular cancer requires a series of regimented studies over several years to monitor disease, so this option is historically reserved only for compliant patients. Reports have indicated that 21% of seminoma patients on surveillance were lost to follow-up after approximately 5 years. One tool that has been instrumental in facilitating compliance with follow-up is the electronic medical record (EMR). EMR has the capacity to organize surveillance schedules and enhance patient compliance with follow-up care. Additionally, it has been suggested that providing effective access to EMR data as a reference source for patients with early-stage testicular cancer contributes to patient reassurance and to enhanced compliance with surveillance.