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Differential
Differential of a scrotal mass:
History: Time course, associated pain,
constitutional symptoms, exacerbating factors,
etc
Past medical history: undescended testis, h/o
contralateral tumor
Evaluation of Scrotal Mass
Physical exam:
Vitals
Pain, redness, heat, reducibility, orientation of testis
Phrens sign
Transillumination
Cremasteric reflex
UA, urine culture
Ultrasound
Differential: Hydrocele
Differential: Epididymo-orchitis
Epididymitis is most common
Usually an ascending infection thru vas
deferens
Age predicts causative organism
>35 yrs: coliform bacteria
12-35 yrs: chlamydia, gonorrhea
<12: coliform, ?viruses
Differential: Spermatocele/
Epididymal cyst
Differential: Varicocele
Differential: Testicular Torsion
Differential: Hernia
Reducible or incarcerated
Usually does not transilluminate
Swells with valsalva
Differential: benign testicular lesions
Very rare. Ultrasound may be suggestive
epidermoid cysts
fibromas
fibroadenomas
adenomatoid tumors
lipomas
Differential: testis tumor
Physical exam
?gynecomastia (found in 5%)
adenopathy
abdominal mass
Burden of Illness
Incidence rose from 3.5 to 6.5/100,000 over
30 years
About 6,000 cases/yr
Survival is > 90%
For all males, lifetime probability of dying of
testes cancer is 0.02%
Testicular Cancer: Is Screening
Accurate
Can screen via:
Testicular self exam: Low specificity: about 8% of
men with a lump found to have a tumor
Buetow J, Med Screen. 1996
Testicular ultrasound: Highly sensitive and
specific
Does Screening Improve Outcomes?
US Preventative Services Task Force 4/2004
Review
No evidence of decreased mortality
5 yr survival is >90% without screening
Risk of false positives with TSE
Cannot recommend screening
Diagnosis
Diagnosis
Diagnosis
Ultrasound is highly specific (hypoechoic lesion),
but diagnosis is made at radical orchiectomy
Microlithiasis- not a risk factor
Biopsy contraindicated
Histologic types
Germ cell tumors:
Seminoma versus Non seminomatous germ cell tumors
(NSGCT)
Non-germ cell tumors (rare, <5%)
Leydig cell tumors (precocious puberty)
Sertoli cell tumors
Mixed sex chord-stromal tumors
NSGCT
Choriocarcinoma
(elevated b-Hcg)
Embryonal cell
Teratoma (mature and immature)
Yolk sac
(elevated AFP)
Seminoma
Rarely make hcg
Generally favorable prognosis when seen in
older men
Tumor markers
AFP levels are elevated 50%-70% NSGCT
hCG levels are elevated in 40%-60%.
AFP has a half-life of 5-7 days
hCG has a half-life of 36 hours.
Important to follow response after
orchiectomy
LDH is non-specific measure of tumor burden
Treatment
Staging CT scan miss microscopic disease in 1
in 3 to 1 in 5 men
% embryonal cell, LV invasion, T stage can be
predictive or RP disease
Dilemma: overtreat or undertreat?
Treatment
Seminoma
Stage IA and B:
radiation therapy vs surveillance (? Chemo)
NSGCT
Stage IA
retroperitoneal lymph node dissection vs surveillance
Stage IB
retroperitoneal lymph node dissection vs surveillance vs
chemotherapy
Higher stages-chemo, f/b surgery as needed
Retroperitoneal Lymph Node
Dissection
chemotherapy
Usually 2 cycles of BEP
Well tolerated
? Late effects
Effects on fertility
Surveillance
NCCN guidelines
CT q 2-3 months for first year or two
Then q4, q6
Labs, CXR q month for year one, then q 2
months, etc
Issues are compliance, anxiety
Quality of Surveillance for Stage I Testis Cancer in the Community
401, 96, and 541 patients received surveillance, RPLND and XRT, respectively.
Mean follow up was 23, 24 mo, and 23 months, respectively.
100% of surveillance patients had at least one follow up test in the first year, but 8-16% of patients had no follow tests of any kind in years 2-5.
Compliance with recommended follow up was generally poor.
Compliance with follow up was higher in RPLND patients.
Stage I Testis Cancer Compliance With Surveillance Follow Up Guidelines for Seminoma
N*
COMPLIANCE
Abdominal Imaging
Chest Imaging
Labs / Tumor Markers
100%
50%
0%
100%
50%
0%
100%
50%
0%
Surveillance
For
Seminoma
1
397
39.5%
14.9%
22.4%
56.7%
17.4%
25.9%
41.8%
10.3%
27.5%
2
227
15.9%
17.2%
39.6%
40.1%
20.3%
39.6%
30.4%
11.9%
34.8%
3
110
3.6%
19.1%
45.5%
21.8%
30.9%
47.3%
25.5%
17.3%
39.1%
4
61
6.6%
31.1%
62.3%
42.6%
NA
57.4%
27.9%
23.0%
49.2%
5
19
0%
36.8%
63.2%
42.1%
NA
57.9%
21.1%
21.1%
57.9%
Surveillance
For NSGCT
1
397
23.7%
30.7%
22.4%
12.3%
28.5%
25.9%
21.4%
20.4%
27.5%
2
227
5.3%
27.8%
39.6%
3.1%
20.3%
39.6%
13.2%
17.2%
34.8%
3
110
3.6%
19.1%
45.5%
3.6%
18.2%
47.3%
13.6%
29.1%
39.1%
4
61
6.6%
31.1%
62.3%
3.3%
8.2%
57.4%
11.5%
16.4%
49.2%
5
19
36.8%
NA
63.2%
10.5%
31.6%
57.9%
21.1%
21.1%
57.9%
Post -
RPLND
1
96
68.8%
22.9%
8.3%
60.4%
33.3%
0%
57.3%
16.7%
14.6%
2
61
62.3%
NA
37.7%
27.9%
37.7%
14.8%
23.0%
29.5%
26.2%
3
28
60.7%
NA
39.3%
17.9%
28.6%
28.6%
25.0%
14.3%
32.1%
4
14
50.0%
NA
50.0%
14.3%
28.6%
14.3%
14.3%
21.4%
42.9%
5
7
28.6%
NA
71.4%
0%
14.3%
85.7%
28.6%
42.9%
28.6%
Post - XRT
1
541
19.8%
30.1%
11.8%
28.8%
27.2%
15.3%
43.6%
16.5%
23.3%
2
309
19.7%
38.5%
41.7%
32.7%
36.2%
31.1%
41.1%
27.2%
31.7%
3
155
45.2%
NA
54.8%
59.4%
NA
40.6%
59.4%
NA
40.6%
4
76
35.5%
NA
64.5%
51.3%
NA
48.7%
57.9%
NA
42.1%
5
23
13.0%
NA
87.0%
30.4%
NA
69.6%
60.9%
NA
39.1%
FOLLOW
UP YEAR
N*
COMPLIANCE
Abdominal Imaging
Chest Imaging
Labs / Tumor Markers
100%
50%
0%
100%
50%
0%
100%
50%
0%
1
397
39.5%
14.9%
22.4%
56.7%
17.4%
25.9%
41.8%
10.3%
27.5%
2
227
15.9%
17.2%
39.6%
40.1%
20.3%
39.6%
30.4%
11.9%
34.8%
3
110
3.6%
19.1%
45.5%
21.8%
30.9%
47.3%
25.5%
17.3%
39.1%
4
61
6.6%
31.1%
62.3%
42.6%
NA
57.4%
27.9%
23.0%
49.2%
5
19
0%
36.8%
63.2%
42.1%
NA
57.9%
21.1%
21.1%
57.9%
Quality of Surveillance for Stage I Testis Cancer in the Community
The use of surveillance for testis cancer is widely accepted in the community.
Compliance rates with recommended follow up care are poor .
Compliance among RPLND patients appear to be superior, possibly due to
greater selection for motivated patients.
Surveillance protocols developed at referral centers are not being followed in
the community; further work is needed to understand the impact of this
apparent quality of care problem on oncologic outcomes in men treated in the
community with surveillance protocols.
Testicular Cancer outcomes
5 year survival for stage I is >95%
Focus is on reducing treatment side effects (e.g.
retrograde ejaculation)
Concern over late effects of treatment