3) Painless & Solid Scrotal Swellings (Reviewed)
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Transcript of 3) Painless & Solid Scrotal Swellings (Reviewed)
04/07/2023Urology Posting, 5th Rotation, 6th Batch1
Painless & Solid Scrotal Swelling
By: Hakimah Khani Binti Suhaimi
Supervised by: Dr Mular Paw
04/07/20232
Testicular Tumors
Benign testicular tumors are rare.
Hence, classification of testicular tumors are based on the cell of origin, instead of benign vs malignant in other tumors.
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Testicular Tumors Commonest
malignancy in young men.
90% arise from germ cells and are either seminomas (40%) or teratomas (30%) or mixed (10%)
10% are non-germ cells; lymphomas (7%), sertoli cell tumors or leydig cell tumors
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Germ-cell Testicular Tumors Seminomas in 35 – 45y. Teratomas in 20 – 35y. Maldescent testis predisposes to seminomas.
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Germ-cell Testicular Tumors Symptoms
Painless swelling of the testis Early stage – usually
chance discovery Many present late when
the whole scrotum is preoccupied w/ tumors
May have dull, aching and dragging pain in the scrotum and groin if significantly enlarged
Heaviness in the scrotum Almost diagnostic
Constitutional symptoms Malaise, LoA, LoW
Symptoms of metastasis Metastasizes via lymphatic
spread to paraaortic lymph nodes
Abdominal discomfort / swelling, dyspnea
Hematogenous spread - Uncommon
Signs Position
Localized scrotal swelling which you can get above it, normal epididymis, vas deferens and spermatic cord
Sensation
LOSS OF NORMAL TESTICULAR SENSATION (Normally, testicles are very sensitive to touch, whatmore to palpation)
Heavier as compared to the unaffected testis Tenderness Non-tender Temperature & color
Normal (unless if the tumor mets to the skin and skin becomes ulcerated – very unlikely and rare because testicular tumors mets via lymphatics and lymphatic drainage for testicles are to paraaortic lymph nodes, whereas scrotal skin – inguinal lymph nodes)
Shape & size Variable, but usu. spherical Surface Smooth / craggy (if nodes
present) Consistency Firm-hard, dull on percussion Fluctuancy Non-fluctuant Transillumination Does not transillumate Association Maybe assoc. with hydrocele
(secondary)
Signs of mets – Paraaortic, supraclavicular nodes
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Non Germ-cell Testicular Tumors Arise from intersticial cells of the testis (1.5%) Additional characteristics:
Sertoli cell tumor – Feminizes (Estrogen) Usually postpuberty Loss of libido Gynecomastia Aspermia
Leydig cell tumor – Masculinizes (Androgen) Usualy prepuberty Sexual precocity Extreme muscular development
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Ix Scrotal US Tumor markers
(AFP, ß-hCG and LDH) CXR CT Scan
Staging Stage 1 : Localized tumor, no spread Stage 2 : Nodes below diaphragm Stage 3 : Nodes above diaphragm Stage 4 : Pulmonary or Hepato mets
Color and power Doppler shows increased vascularity in the testicular mass.
The testis is mostly replaced by a solid mass with poorly defined margins and heterogeneous echo pattern with infiltrating aspect. A rim of normal testicular parenchyma surrounds the mass.
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Rx Orchidectomy
Removal of testis In other dz like orchitis, incision is done at the lesion, but in tumors, incision is
done at the inguinal (as in hernia) to prevent hematogenous spread to the skin.
Spermatic cord is clamped prior to removal of testis to ensure no introduction of tumor cells into the spermatic cord
Adjuvants Radiotherapy - Seminoma Chemotherapy - Teratoma
Prognosis Seminoma
No mets : 95% 5-year survival rate Mets : 75% 5-year survival rate
Teratoma Stage 1, 2 : 85% 5-year survival rate Stage 3,4 : 60% 5-year survival rate
Seminomas – microscopic - sheets of cells resembling spermatocytes, pinkish on macroscopic appearance
Teratomas – microscopic – totipotent cells in the rete testis, yellowish on macroscopic appearance
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Image 3a (left): Orchidectomy specimen showing complete replacement of the normal testicular parenchyma with the classical "cut-potato" appearance of a seminoma. The tunica albuginea is intact.
Image 4a (right): Orchidectomy specimen showing a teratoma with areas of cyst formation and haemorrhage.
http://www.imagingpathways.health.wa.gov.au/includes/dipmenu/a_scrot/image.html
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Histological section of a seminoma showing groups of malignant cells with large nuclei and prominent nucleoli. There are also intervening fibrous bands with an infiltrate of lymphocytes and plasma cells.
Histological section of a teratoma (non-seminomatous germ cell tumour) showing hyaline cartilage and islands of columnar epithelium.http://www.imagingpathways.health.
wa.gov.au/includes/dipmenu/a_scrot/image.html
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DDx for PAINLESS, SOLID Scrotal Swelling Chronic haematocele
Initially in acute haematocele (blood collection in the tunica vaginalis due to trauma), it is painful. But if the blood is not drained, it will form clots, which is hard, and painless.
Gumma Congenital syphilis causes testicular atrophy But in adults inflammation in the interstitial spaces
round, hard, insensitive mass over the testis = ‘biliard ball testis’
Tuberculous epididymis Infection develops slowly – rarely has acute pain Differ from tumors in the sense that;
Epididymis – Hard, knobbly Spermatic cord – Thickened Vas deferens – Irregular
Lymphedema (Filariasis / Elephantiasis) Thickened skin Can hardly palpate the testis
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Quiz What is the peak age incidence of
seminomas? What is the peak age incidence of non-
seminomatous germ cell tumors (NSGCT)? What is the S&S of a testicular tumor? What investigations are required? What surgery is usually necessary? What other therapeutic options exist for
seminomas and NSGCTs?http://www.storyq.net/slide_boxes/16700