Transcript Testicular Tumours and Disorders of External

TESTICULAR TUMORS &
DISORDERS OF
EXTERNAL GENITALIA
DEPARTMENT OF UROLOGY IAŞI – 2010
TESTICULAR TUMORS
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rare [0.8 (Japan) – 6.7 (Scandinavia) new cases/100,000 males/yr]
90-95% are germ cell tumors (seminoma & nonseminoma)
effective combination chemotherapy  overall 5-year survival
rate: 78% (1975) & 91% (1985)
1-2% are bilateral – 50% with history of cryptorchidism
risk factors
 congenital – cryptorchidism (7-10%)
 acquired – exogenous estrogen administration during
pregnancy, trauma & infection-related testicular atrophy (?)
tumor development – totipotential germ cell
 normal differentiation  spermatocyte
 abnormal development  seminoma or embryonal
carcinoma
TESTICULAR TUMORS
embryonal carcinoma (totipotential tumor cell)  teratoma
(intraembryonic diff.), choriocarcinoma or yolk sac tumor
(extraembryonic diff.)
PATHOLOGY
seminoma (35%) – 4th decade of life; grossly, coalescing gray
nodules; syncytiotrophoblastic elements (10-15%)  hCG
embryonal cell carcinoma (20%) – adult & infantile type (yolk sac
tumor = endodermal sinus tumor, most common in children);
microscopically, embryoid bodies
teratoma (5%) – mature: benign structures from ectoderm,
mesoderm and endoderm; imature: undifferentiated primitive
tissue
choriocarcinoma (<1%) – aggressive tumors, early hematogenous
spread; microscopically, syncytio- & cytotrophoblast
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TESTICULAR TUMORS
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mixed cell type (40%) – teratocarcinomas etc.
METASTATIC SPREAD & CLINICAL STAGING
stepwise lymphatic spread – regional lymph nodes at the level of
the renal hilum; for the right testis: interaortocaval area 
precaval  preaortic  right common iliac  right external iliac;
for the left testis: para-aortic area  preaortic  left common
iliac  left external iliac
no crossover metastases to the right side, but common right-toleft metastases (!)
choriocarcinoma – early hematogenous spread
visceral metastases: lung, liver, brain, bone, kidney, adrenal,
gastrointestinal tract, spleen
TNM classification for testicular cancer (UICC, 2002, 6th edition)
pTis Intratubular germ cell neoplasia (carcinoma in situ)
pT1 Tumour limited to testis and epididymis without vascular/lymphatic invasion: tumour
may invade tunica albuginea but not tunica vaginalis
pT2 Tumour limited to testis and epididymis with vascular/lymphatic invasion, or tumour
extending through tunica albuginea with involvement of tunica vaginalis
pT3 Tumour invades spermatic cord with or without vascular/lymphatic invasion
pT4 Tumour invades scrotum with or without vascular/lymphatic invasion
N1 Metastasis with a lymph node mass 2 cm or less in greatest dimension or multiple
lymph nodes, none more than 2 cm in greatest dimension
N2 Metastasis with a lymph node mass more than 2 cm but not more than 5 cm in
greatest dimension, or multiple lymph nodes, any one mass more than 2 cm but not
more than 5 cm in greatest dimension
N3 Metastasis with a lymph node mass more than 5 cm in greatest dimension
M1 Distant metastasis
M1a Non-regional lymph node(s) or lung
M1b Other sites
Sx Serum marker studies not available or not performed
S0 Serum marker study levels within normal limits
LDH (U/l) hCG (mIU/ml) AFP (ng/ml)
S1 < 1.5 x N and < 5,000 and < 1,000
S2 1.5-10 x N or 5,000-50,000 or 1,000-10,000
S3 > 10 x N or > 50,000 or > 10,000
STADIERE
TESTICULAR TUMORS
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CLINICAL FINDINGS
symptoms
 painless enlargement of the testis, testicular heaviness
 acute testicular pain (10%) – intratesticular hemorrhage or
infarction
 metastatic disease (10%) – back pain (retroperitoneal); cough
or dyspnea; anorexia, nausea or vomiting; bone pain; lower
extremity swelling (venacaval obstruction)
signs
 testicular mass (firm, nontender) or diffuse enlargement
 hydrocele may accompany the tumor
 palpation of the abdomen – bulky retroperitoneal disease
 supraclavicular or inguinal nodes
 gynecomastia (5%)
TESTICULAR TUMORS
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INVESTIGATIONS
elevated serum creatinine – ureteral obstruction
biochemical markers
 AFP – NSGCTs
 β-hCG – NSGCTs (choriocarcinoma – 100%) & seminomas (7%)
 LDH – NSGCTs & seminomas
imaging
 scrotal US
 chest x-ray
 CT scan (abdomen & pelvis)
inguinal orchiectomy
TESTICULAR TUMORS
AJCC (American Joint Committee on Cancer) STAGE GROUPING
0 Tis N0 M0 S0
I T1-4 N0 M0 SX
IA T1 N0 M0 S0
IB T2-4 N0 M0 S0
IS T1-4 N0 M0 S1-3
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II T1-4 N1-3 M0 SX
IIA T1-4 N1 M0 S0-1
IIB T1-4 N2 M0 S0-1
IIC T1-4 N3 M0 S0-1
III T1-4 N0-3 M1 SX
IIIA T1-4 N0-3 M1a S0-1
IIIB T1-4 N1-3 M0/M1a S2
IIIC T1-4 N1-3 M0/M1a S3 sau M1b S0-3
DIFFERENTIAL DIAGNOSIS
epididymitis or epididymoorchitis, granulomatous orchitis
hydrocele, spermatocele, hematocele, varicocele, epididymal
cysts
TESTICULAR TUMORS
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TREATMENT
radical orchiectomy
low-stage seminoma (I, II-A/B)  retroperitoneal irradiation (2530 Gy)
high-stage seminoma (II-C/III)  primary chemotherapy (PEB,
VAB-6, cisplatin + etoposide)
low-stage NSGCT (I, II-A/B)  RPLND or surveillance
high-stage NSGCT (II-C/III)  primary chemotherapy ± RPLND
PRIAPISM
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prolonged painful erection; no sexual excitement or desire
idiopathic (60%)
secondary (40%) – leukemia, sickle cell disease, pelvic tumors,
pelvic infections, penile trauma, spinal cord trauma or use of
medications (intracavernous injection)
obstruction of the venous drainage  highly viscous, poorly
oxigenated blood within the corpora cavernosa  interstitial
edema and fibrosis of the corpora cavernosa  impotence
epidural or spinal anesthesia, evacuation of sludged blood from
the corpora cavernosa through a large needle, intracavernous
adrenergic agents (norepinephrine, Levophed), shunt between
the glans penis and corpora cavernosa (biopsy needle),
anastomosing the superficial dorsal vein to the corpora cavernosa,
corpora cavernosa to corpus spongiosum and saphenous vein to
corpora cavernosa
PEYRONIE DISEASE
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plastic induration of the penis – painful erection, curvature of the
penis and poor erection distal to the involved area
examination – palpable dense, fibrous plaque, usually near the
dorsal midline, involving the tunica albuginea of the penile shaft
spontaneous remission ≈ 50% of cases
p-aminobenzoic acid (powder or tablets) or vitamin E (tablets) for
several months
refractory cases – excision of the plaque with replacement with a
dermal graft, the use of tunica vaginalis grafts after plaque
incision and incision of the plaque with insertion of penile
prostheses in the corpora cavernosa
additional methods – radiation therapy and injection of steroids,
dimethyl sulfoxide or parathyroid hormone into the plaque
PHIMOSIS
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the contracted foreskin cannot be retracted over the glans
cause - chronic infection (balanoposthitis) from poor local hygiene
calculi and squamous cell carcinoma may develop under the
foreskin
signs – edema, erythema and tenderness of the prepuce, purulent
discharge
incision of the dorsal foreskin
circumcision (posthectomy), after the infection is controlled
PARAPHIMOSIS
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the foreskin, once retracted over the glans, cannot be replaced in
its normal position
cause – chronic inflammation under the redundant foreskin 
contracture of the preputial opening (phimosis)
tight ring behind the glans  venous congestion  edema and
enlargement of the glans  arterial occlusion and necrosis of the
glans
squeeze of the glans for 5 min, then reduction (phimosis)
incision of the constricting ring, under local anesthesia
circumcision – after inflammation has subsided
VARICOCELE
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10% of young men
dilatation of the pampiniform plexus above the testis (left side
most commonly affected !)
! sudden development of a varicocele in an older man ≈ late sign
of renal tumor, that has invaded the renal vein, occluding the
spermatic vein
examination – mass of dilated, tortuous veins lying posterior to
and above the testis; degree of dilatation can be increased by the
Valsalva maneuver; testicular atrophy (impaired circulation);
sperm concentration and motility are significantly decreased (6575%)  infertility
ligation of the internal spermatic veins; percutaneous methods
(balloon catheter, sclerosing fluids) to occlude the veins, following
percutaneous spermatic venography
HYDROCELE
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collection of fluid within the tunica or processus vaginalis
may develop rapidly secondary to local injury, radiotherapy, acute
nonspecific or tuberculous epididymitis or orchitis and testicular
neoplasm !
diagnosis – rounded cystic intrascrotal mass, that is not tender;
the mass transilluminates
differential diagnosis – testicular tumor – US
indications for treatment – tense hydrocele that embarrass
circulation to the testicle or large, bulky mass, uncomfortable for
the patient
hydrocele sac is opened and stitched together to collapse the wall
(Lord’s procedure)
SPERMATIC CORD - TORSION
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most often seen in adolescent males
congenital abnormality (voluminous tunica vaginalis, that inserts
well up on the cord and allows the testis to rotate) + contraction
of the cremaster muscle  left testis rotate counterclockwise and
right testis clockwise  vascular occlusion  ischemic death of
the testis and epididymis
diagnosis – young boy suddenly develops severe pain in one
testicle, followed by swelling of the organ, reddening of the
scrotal skin, lower abdominal pain, nausea and vomiting
examination – swollen, tender organ, that is retracted upward
(shortening of the cord by volvulus); pain may be increased by
lifting the testicle up (pain from epididymitis is usually alleviated)
– Prehn’s maneuver
SPERMATIC CORD - TORSION
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differential diagnosis – acute epididymitis, acute orchitis and
trauma – color Doppler US (absence of arterial flow in torsion,
hypervascularity in inflammatory lesions); scintillation scan
(99mTc-pertechnetate) – avascular (torsion), increased vascularity
(testicular tumor) or decreased vascularity (trauma)
manual detorsion may be attempted (the right testis should be
“unscrewed” and the left one “screwed up”) after local
anesthesia; ! surgical fixation of both testes should be done within
the next few days
if manual detorsion fails  immediate surgical detorsion &
orchydopexy
detorsion within 6 h of onset – good result; delayed beyond 24 h –
orchiectomy