Ecase #9-C

Karen Wang, M.D.

April 15- 19, 2002

HPI: A 33 y.o. Male comes in for a routine physical. He feels well, offers no complaints.

PMH: benign leukopenia found on routine CBC 2 years ago. Work up included normal bone marrow biopsy, normal CT scan of chest/abdomen and pelvis, negative HIV screen.

SH: loves to exercise, non-smoker, social alcohol use.

FH: mother with type 2 DM, asthma

Meds: none

PE: very fit young man, exam normal except left testicle is enlarged compared to the right.  Consistency is firm, no nodules felt.  No inguinal adenopathy.  Normal abdomen.

In retrospect, during the exam, patient believes this testicle has been enlarged for several months. It has never been painful. Denies trauma.

Questions

What is the differential diagnosis of a scrotal mass, and what is the appropriate work up?

Who gets testicular cancer, what types are there, and how do patients do (general prognosis)?

What is the treatment for seminoma, a common germ cell testicular tumor, and how might you as a PCP play an important role in follow up care of the patient?

Discussion

Some characteristics of scrotal mass are as follows:

• Epididymitis/orchitis-usually tender, history of fever, urethral discharge, irritative voiding symptoms.

• Torsion-severe pain in one testicle, swelling, redness, lower abdominal pain, nausea and vomiting. A true urologic emergency!

• Hydrocele-usually non-tender cystic intrascrotal mass, history of mass that gets larger and more tense at night (communicating hydrocele).

• Varicocele-in 10% of young men, dilation of the pampinoform plexus, left side most common.  Examination of a man upright reveals a mass of dilated, tortuous veins lying posterior to and above the testicle. Increased dilation with Valsalva, decreases with recumbent position.

• Spermatocele-cystic mass sitting on the head of the epididymitis. Should be painless, freely mobile, and separated from the testes.  Usually less than 1 cm.

• Hematocele-associated with trauma.

• Tumor-usually painless enlargement of one or both testicles.

When uncertain about a scrotal mass, ultrasound can give a rapid and accurate assessment of whether the mass is intratesticular or epididymal, and whether it appears cystic or solid.  All solid masses are neoplasm until proven otherwise.

Serum tumor markers such as AFP, b-HcG, and LDH can be helpful.

Histological evaluation of a tumor requires a radical orchiectomy.  Scrotal violation or biopsy at the time of surgery should be avoided due to poorer outcomes.

Staging involves results from above, plus a CT scan of the chest/abdomen/pelvis to look for any evidence of spread to the retro peritoneum or mediastinum.

Malignant testicular cancers are rare, approx. 3 cases per 100,000 per year. Most common in young men, ages 30-40.  Higher rates in Scandinavian countries, and higher rates in white males compared to black males. Strongest association is with cryptorchid testis.  95% of testicular tumors are germ cell tumors (seminoma, and nonseminoma), the rest are nongerminal (Leydig cell, Sertoli cell, gonadoblastoma, lymphoma).

Overall, the survival rates of testicular cancer are good, with excellent prognosis for early stage seminoma (5 year survival rates >95%).

Pure seminomas usually present with localized disease since they are so indolent. They are exquisitely radiosensitive, rarely do they spread hematogenously to liver, bone, lungs, brain. Seminomas are not consistently associated with elevated tumor markers, so tumor markers are NOT a reliable indicator of disease recurrence or prognosis.

Treatment options for patients with stage 1 disease after orchiectomy are initial radiation, or surveillance. Radiation therapy today offers excellent results (almost 100% five year survival).  The greatest concerns are risks of impaired fertility and the observation that there is a small increase in second malignancies.  However, it is thought that 50% of men with testicular cancer already have impaired spermatogenesis, as well as a genetic predisposition towards malignancy, so these outcomes are difficult to attribute to the radiation alone.

As a PCP, you can start the discussion of possible sperm banking with cryopreservation if future fertility is a concern.  It is also important to keep close follow up on those patients who chose surveillance as an option, since those with small tumors need CT scans every 3 months for about 3 years to assess disease activity.  These patients have been shown to have the same survival as those who chose initial radiation, but they must be highly motivated to comply with these 3 month follow ups.  Most urologists stop routine imaging after 3-4 years, but relapses can occur as late as 7 years. Generally after 10 years with no recurrence, the patient is home free.

References

Up to date 2001

Smith's General Urology, 13th edition.