Chief Resident Grand Rounds SUNY Downstate Medical Center · Testicular Torsion Chief Resident...

Testicular Torsion Chief Resident Grand Rounds

SUNY Downstate Medical Center

Jacob Eisdorfer, DO February, 23th 2012

Thank You Dr. McNeil!

www.downsatesurgery.org

Agenda • Questions • Anatomy • Differential Diagnosis of Testicular Pain • Pathophysiology / Epidemiology • History • Physical • Diagnosis • Treatment


Question www.downsatesurgery.org

Anatomy • Spermatic cord –testicular vessels,

lymph, vas deferens – Epididymis - sperm formed in testicle

and undergo maturation, stored in lower portion

– Vas Deferens –propels sperm up and out during ejaculation

• Gubernaculum – fixation point for testicle to tunica vaginalis

• Tunica Vaginalis – potential space – Encompasses anterior 2/3’s of testicle – Tunica albuginea is inner layer

opposing testis


Differential

• Pain – Torsion of appendix testis – Epididymitis – Trauma – Orchitis – Others

• Swelling – Hydrocele – Varicocele – Spermatocele – Tumor


Pathophysiology

• Inadequate fixation of testes to tunica vagnialis at gubernaculum – Torsion around spermatic cord in the Tunica Vaginalis – Lymphatic Compression Venous compression

edema ischemia


Predisposing Anatomy

• Bell-clapper deformity – Testicle lacks

attachment at tunica vaginalis

– Increased mobility – Transverse lie of testes – Typically bilateral – Prevalence 1/125


Epidemiology

• Accounts for 30% of all acute scrotal swelling • Bimodal ages

– neonatal (in utero) – pubertal ages

• 65% occur in ages 12-18yo

• Incidence 1 in 4000 in males <25yo • Increased incidence in puberty due to inc weight

of testes


History

• Acute onset of pain – usually testicular, can be lower abdominal, inguinal – May follow exercise or minor trauma – May awaken from sleep

• Cremasteric contraction with nocturnal stimulation in REM

– Up to 8% report testicular pain sometime in the in past


Physical • Tender, Swollen • Elevated from shortened spermatic cord

– Horizontal lie common (80%) – Reactive hydrocele may be present

• Cremasteric reflex absent in nearly all (unreliable in <30mo old) (95%)

• Prehn’s sign = elevation relieves pain • (+) in epididymitis and • (-) in torsion • unreliable


Diagnosis

• Imaging – Color doppler (Test of Choice) – decreased

intratesticular flow • False (+) in large hydrocele, hematoma • Sens 69-100% and Spec 77-100% • Lower sensitivity in low flow pre-pubertal testes

– Nuclear Technetium-99 radioisotope scan • Show testicular perfusion • Sens and spec 97-100%


Imaging

Acute Late

“Rim Sign”


Treatment • Time is Testicle • Detorsion

– Within 6hr = 100% viability – Within 12-24 hrs. = 20% viability – After 24 hrs. = 0% viability

• Surgical detorsion and orchiopexy if viable – Contralateral exploration and fixation if bell-clapper

deformity present • Orchiectomy if non-viable testicle

• Never delay surgery on assumption of

nonviability as prolonged symptoms can represent periods of intermittent torsion


Treatment

• Manual Detorsion – If presents before swelling – Appropriate sedation – In 2/3 of cases testes torses

medially, 1/3 lateral – Success if pain relief, & testes

lowers in scrotum – Still need surgical fixation


References

• Ciftci, AO. Clinical Predictors for Diff. Diagnosis of Acute Scrotum, European J. of Ped. Surgery. Oct 2004.

• Blavis M., Emergency Evaluation of Patients Presenting with Acute Scrotum, Academy of Emergency Medicine. Jan 2001

• al Mufti RA, Ogedegbe AK, Lafferty K. The use of Doppler ultrasound in the clinical management of acute testicular pain. Br J Urol 1995; 76:625.

• Wampler SM, Llanes M. Common scrotal and testicular problems. Prim Care 2010; 37:613.

• Dunne PJ, O'Loughlin BS. Testicular torsion: time is the enemy. Aust N Z J Surg 2000; 70:441.

• Jarow JP, Sanzone JJ. Risk factors for male partner antisperm antibodies. J Urol 1992; 148:1805.

• Schmitz D, Safranek S. Clinical inquiries. How useful is a physical exam in diagnosing testicular torsion? J Fam Pract 2009; 58:433.

• Wilbert DM, Schaerfe CW, Stern WD, et al. Evaluation of the acute scrotum by color-coded Doppler ultrasonography. J Urol 1993; 149:1475.


Testicular Cancer

Chief Resident Grand Rounds SUNY Downstate Medical Center

Jacob Eisdorfer, DO February, 23th 2012


Agenda

• Questions • Epidemiology • History • Physical • Work Up • Classification • Treatment


Question A 24 y/o M presents with a solid, painless right testicular mass confirmed by scrotal ultrasound. Serum Tumor Markers show a βHCG of 96mU/mL, and a AFP of 58. The most likely histologic finding in the right testis is: a. Pure Teratoma b. Pure Seminoma c. Pure Embryonal Carcinoma d. Pure Yolk Sac Tumor e. Choriocarcinoma


Some epidemiology

• Incidence 0.2% in United States • Most common malignancy in men in the

15 to 35 year age group. – Age - 3 peaks:

2 – 4 yrs. 20 – 40 yrs. above 60 yrs.


History

• Painless Swelling of One Testis

• Dull Ache or Heaviness in Lower Abdomen

• Acute Scrotal Pain (10%)

• Present with Metastasis (10%) – Neck Mass / Cough / Anorexia / Vomiting / Back Ache / Lower

limb swelling

• Gynecomastia (5%)

• Infertility (Rarely)


Physical

• Examine contralateral normal testis. • Firm to hard fixed area within tunica

albugenia is suspicious • Seminoma expand within the testis as a

painless, rubbery enlargement. • Embryonal carcinoma or Teratoma may

produce an irregular, rather than discrete mass.


Physical

• All patients with a solid, Firm Intratesticular Mass that cannot be Transilluminated should be regarded as Malignant until proven otherwise


Work Up

• Ultrasound - Hypoechoic area • Chest X-Ray - PA and lateral • CT Scan • Tumor Markers

– AFP (Trophoblastic Cells) – β HCG (Syncytiotrophoblastic Cells) – LDH (lactic acid dehydrogenase) – PLAP (placental alkaline phosphatase)


AFP

• Normal: Below 16 ngm / ml • Half Life: 5 to 7 days • Raised AFP :

– Pure embryonal carcinoma – Teratoma – Yolk sac Tumor – Combined tumors – AFP not raised in pure Choriocarcinoma or in

pure seminoma


β HCG

• Normal: < 1 ng / ml • Half Life: 24 to 36 hours • RAISED β HCG –

– 100 % - Choriocarcinoma – 60% - Embryonal carcinoma – 55% - Teratoma – 25% - Yolk Cell Tumor – 7%- Seminomas


Question

A 24 y/o M presents with a solid, painless right testicular mass confirmed by scrotal ultrasound. Serum Tumor Markers show a βHCG of 96mU/mL, and a AFP of 58. The most likely histologic finding in the right testis is: a. Pure Teratoma b. Pure Seminoma c. Pure Embryonal Carcinoma d. Pure Yolk Sac Tumor e. Choriocarcinoma


LDH & PLAP

• PLAP – Elevated in 50-72% of Seminomas • LDH

– Elevated in 60% of patients with nonseminomatous germ cell tumors

– Nonspecific tumor marker but is a useful prognostic indicator

– Indicator of tumor burden


How to Use Tumor Markers

• Diagnosis - – 80 to 85% have Positive Markers

• Helps with presurgical Identification of Tumor Histology – Only 10 to 15% Non-Seminomas have normal

marker level – If AFP elevated in Seminoma - Means Tumor has

Non-Seminomatous elements


How to Use Tumor Markers

• Elevated Markers After Orchiectomy if means Residual Disease

• Elevated Markers after Lymphadenectomy means a STAGE III Disease

• Degree of Marker Elevation Appears to be Directly Proportional to Tumor Burden

• Markers becoming positive on follow up usually indicates Recurrence

• Markers become Positive earlier than Imaging


Classification

• Primary Neoplasms of Testis – Germ Cell Tumor (90% to 95%) – Non-Germ Cell Tumor

• Secondary Neoplasms • Paratesticular Tumors.


Germ Cell tumor

• Arise from pluripotential cells • More than half contain more than one cell

type and are therefore known as mixed


Germ Cell Tumors • Seminomas - 40%

– Typical (82-85%) • Slow growth

– Anaplastic (5-10%) • More aggressive • Greater metastatic potential

– Spermatocytic (2-12 %) – Cells resemble different phases of maturing

spermatogonia – B/L tumors have been reported – Extremely low metastatic potential


Germ Cell Tumors

• Embryonal Carcinoma - 20 - 25% – Discovered as a small, rounded but irregular

mass invading the tunica vaginalis – Highly malignant

• Teratoma - 25 - 35% – Multiple germ cell layers in various stages of

maturation and differentiation – Large, lobulated, heterogeneous tumors – Microscopically, cystic & solid components – Classified as Mature & Immature


Germ Cell Tumors • Choriocarcinoma - 1%

– May occur as palpable nodule or normal testis

– Central hemorrhage – High metastatic potential

• Yolk Sac Tumor – most common testicular tumor in infants &

children – A.K.A. endodermal sinus tumor,

adenocarcinoma of infantile testis, orchioblastoma


Sex cord / gonadal stromal tumors

• Specialized gonadal stromal tumor – Leydig cell tumor – Sertoli cell tumor

• Gonadoblastoma • Miscellaneous Neoplasms

– Carcinoid – Tumors of ovarian epithelial sub types


Lymphatic Drainage • The primary drainage of the

right testis is within the interaortocaval region.

• Left testis drainage , the Para-aortic region in the compartment bounded by the left ureter, the left renal vein, the aorta, and the origin of the inferior mesenteric artery.

• Cross over from right to left is possible.


Lymphatic Drainage

• Inguinal node metastasis may result from – scrotal involvement by the primary tumor – prior inguinal or scrotal surgery – retrograde lymphatic spread secondary to

massive retroperitoneal lymph node deposits.


Clinical Staging

• Stage A or I -Tumor confined to testis. • Stage B or II- Spread to Regional nodes.

– IIA - Nodes <2 cm in size or < 6 Positive Nodes

– IIB - 2 to 5 cm in size or > 6 Positive Nodes – IIC - Large, Bulky, abdominal mass usually >

5 to 10 cm • Stage C or III- Spread beyond

retroperitoneal Nodes or Above the Diaphragm or visceral disease


TNMS Staging

• Primary Tumor (T) pTX - Primary tumor cannot be assessed (if no radical orchiectomy has been performed, TX is used)

• pT0 = No evidence of Tumor (e.g., histologic scar in testis) • pTis = Intratubular, pre invasive (carcinoma in situ) • pT1 = Confined to Testis and epididymis, no vascular/lymphatic invasion • pT2 = Limited to testis and epididymis with vascular/ lymphatic

invasion or tumor extending through Tunica Albuginea with involvement of tunica vaginalis • pT3 = Invades Spermatic Cord with/without vascular/ lymphatic

invasion • pT4 = Invades Scrotum with/without vascular/ lymphatic invasion Nodal staging: • N1 = Single or multiple < 2 cm • N2 = Multiple < 5 cm / Single 2-5 cm • N3 = Any node > 5 cm


TNMS Staging

Distant metastasis:

M0 = No distant metastasis

M1 = Distant metastasis

M1a = Nonregional nodal or pulmonary metastasis

M1b = Distant metastasis other than to nonregional lymph nodes and lung


TNMS Staging

LDH HCG AFP

S0 ≤Normal ≤Normal ≤Normal

S1 <1.5 x Normal <5,000 <5,000

S2 1.5-10 X Normal 5,000 – 50,000 1,000 – 10,000

S3 >10 X Normal >50,000 >10,000

Serum Tumor Markers


TNMS Staging Stage T N M S

0 pTis N0 M0 S0 I pT1-4 N0 M0 SX IA pT1 N0 M0 S0 IB pT2-4 N0 M0 S0 IS Any pT/Tx N0 M0 S1-3 II Any pT/Tx N1-3 M0 SX

IIA Any pT/Tx N1 M0 S0 Any pT/Tx N1 M0 S1

IIB Any pT/Tx N2 M0 S0-S1 IIC Any pT/Tx N3 M0 S0-S1 III Any pT/Tx Any N M1 SX IIIA Any pT/Tx Any N M1a S0 or S1

IIIB Any pT/Tx N1-3 M0 S2 Any pT/Tx Any N M1a S2

IIIC Any pT/Tx N1-3 M0 S3 Any pT/Tx Any N M1a S3 Any pT/Tx Any N M1b Any S

AJCC Cancer Staging Manual, Seventh Edition (2010) published by Springer New York, Inc.


Prognosis

• Seminoma (5 yr. Survival) – I: 98% – IIA: 92-94% – IIB-III: 33-75%

• NSGT (5 yr. Survival) – I: 96-100% – IIA: >90% – IIB-III: 55-80%


Prognosis www.downsatesurgery.org

Treatment Principles

• Seminomas – Radio-Sensitive. Treat with Radiation.

• Non-Seminomas – Radio-Resistant and best treated by Surgery

• Advanced Disease or Metastasis - Responds well to Chemotherapy


Treatment Principles • Radical INGUINAL ORCHIECTOMY is

Standard first line of therapy – NEVER TRANS-SCROTAL BIOPSY


Radical Orchiectomy

• Inguinal approach • Testicle and spermatic cord are excised. • If a transscrotal orchiectomy was done

– Will have to go back and excise the ipsilateral hemi-scrotum and spermatic cord

– Biopsy inguinal nodes if palpable or enlarged on CT –> if they are positive will need chemo

• Trans-scrotal orchiectomy disrupts lymphatics therefore changing metastatic pattern (pelvic)


Seminoma Treatment Flow Chart www.downsatesurgery.org

Seminoma Treatment • Stage I, IIA, IIB

– Radical Inguinal Orchiectomy R – Radiation to Ipsilateral Retroperitonium & Ipsilateral Iliac

group Lymph nodes (2500-3500 rads)

• Bulky stage II and III Seminomas - – Radical Inguinal Orchiectomy is followed by

Chemotherapy


Non-Seminoma Treatment Flow Chart www.downsatesurgery.org

Non-Seminoma Treatment • Stage I and IIA:

– Radical Orchiectomy followed by Retroperitoneal Lymph Node Dissection

• Stage IIB

– RPLND with possible Adjuvant Chemotherapy

• Stage IIC and Stage III Disease – Initial chemotherapy followed by surgery for

Residual Disease


Retroperitoneal Lymph Node Dissection

• Primary treatment for NSGCTs • Remove abdominal lymph nodes • Problems mainly occur with the nerve: infertility,

ejaculation problems


Chemotherapy • BEP: (Bleomycin, Etoposide, Cisplatin)

– 2-4 cycles 21d intervals (4 most common) • EP: (Etoposide, Platinol)

– 4 cycles 21d intervals • Toxicity

– Bleomycin = Pulmonary fibrosis – Etoposide = Myelosuppression, Alopecia, Renal

insufficiency (mild), Secondary leukemia – Cis-platin = Renal insufficiency, Nausea, vomiting,

Neuropathy


References

• Einhorn LH. Treatment of testicular cancer: a new and improved model. J Clin Oncol 1990; 8:1777.

• Ries LA, Eisner MP, Kosary CL, et al. SEER Cancer Statistics Review, 1975-2001, National Cancer Institute, Bethesda, MD, 2004 http://seer.cancer.gov/csr/1975_2007/index.html (Accessed on April 11, 2011).

• Stephenson AJ, Gilligan TD . Neoplasms of the Testis. In: McDougal WS, Wein AJ, eds. Campbell-Walsh Urology Review. 10th ed. Philadelphia, PA: Elsevier-Saunders; 2012:150.

• Barthold JS. Abnormalities of the Testis and Scrotum and Their Surgical Management. In: McDougal WS, Wein AJ, eds. Campbell-Walsh Urology Review. 10th ed. Philadelphia, PA: Elsevier-Saunders; 2012:642.


Chief Resident Grand Rounds SUNY Downstate Medical Center · Testicular Torsion Chief Resident...

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