Medical Professionals Version - National Cancer Centre Singapore

PAGE C4
Spotlight
SALUBRIS
July / August 2009
RATIONAL APPROACH TO
TESTICULAR SWELLING
Continued from page C3.
Some 90% of testicular torsions occur in
men younger than 30 years old. A teenager
with sudden onset scrotal pain and a normal
urinalysis most likely has testicular torsion.
Unrelieved torsion (longer than six hours)
leads to testicular ischemia and atrophy. A
delay in diagnosis longer than 12 hours will
result in irreversible damage.
Testicular torsion can be confirmed by
Doppler ultrasound (greater than 90%
sensitivity, 70% specificity). However, if in
doubt, scrotal exploration and detorsion
should always be performed. The common
anatomical defect is high “investment” of the
tunica vaginalis – the so called bell-clapper
deformity. This inherent defect is usually
bilateral, and detorsion should always be
followed by testicular fixation (orchiopexy)
of both gonads.
If epididymitis or epididymo-orchitis is
diagnosed especially with the finding of
pus cells and bacteria on urine microscopy,
the patient can be treated with a course of
bactrim and doxycycline for two weeks. The
etiology is commonly bacterial infection of
the urinary tract.
In sexually active young adults especially
when associated with urethritis, chlamydial
and neisseria gonorrhoeae infection must be
considered. It is prudent to review the patients
after treatment for resolution of symptoms
and signs. If in doubt, an ultrasound scrotum
should be ordered. An underlying testicular
malignancy must still be a consideration.
Testicular cancer is the most frequent cancer
in young men (15 to 35 years of age).
Cryptorchidism is a well-known risk factor
even after orchiopexy. Testicular tumours
usually present as painless lumps, but some
men (20-25%) develop scrotal pain as a result
of bleeding caused by rapid tumour growth
and necrosis. Most tumours are discovered
as hard testicular lumps detected on self
examination. Reactive hydrocele may make
appreciation of a testicular lesion difficult.
Scrotal ultrasound is an excellent modality for the assessment of testicular
mass. Testicular cancers are typically non-homogenous with hypoechoic
areas. Testicular microcalcifications are associated with a high propensity for
developing seminomas and warrants regular ultrasound surveillance.
More than 95% of testicular tumours originate from germ cells. Germ cell
tumours can be seminomas or nonseminomatous germ cell tumours. Seminomas
are more likely to be confined to the testis (stage I) and are exquisitely
radiosensitive. Nonseminomatous germ cell tumours consist of embryonal cell
carcinomas, yolk sac tumours, or teratomas, alone or mixed with other elements.
Sertoli cell tumours, Leydig cell tumours, and lymphomas are the most-common
non-germ cell tumours. In men older than 60 years, most tumours are non-
Hodgkin’s lymphoma, with a predilection for bilateral involvement.
Tumour markers are helpful in the diagnosis, staging and management of malignant
testicular tumours. α-fetoprotein (AFP) is often associated with embryonal
carcinoma, whereas β-subunit of human chorionic gonadotropin (β-hCG)
elevations occur with choriocarcinomas. However, many testicular cancers are
mixed germ cell in origin and tumour marker elevation is variable. Persistent
elevation of tumour markers post orchiectomy suggests the presence of metastatic
disease. However, there is a 25% false-negative marker elevation rate.
Avoidance of scrotal skin violation is mandatory when obtaining histological
diagnosis. The lymphatics of the testes drain primarily into the retroperitoneal
para-aortic and inter-aortocaval lymph nodes while the scrotal skin lymphatics
drain into the inguinal nodes. Trans-scrotal needle biopsy or orchiectomy is
therefore contraindicated. Suspected testicular tumours should be explored via
an inguinal incision with early control of the spermatic cord to prevent vascular
or lymphatic dissemination.
Further treatment is based on histological
assessment of the tumour and staging
consisting of computed tomography (CT)
scanning and chest x-ray. A false-negative
rate on 20 to 25% occurs in the presence
of non-enlarged (smaller than 1.5cm) but
microscopically involved retroperitoneal
lymph nodes. Treatment modalities include
retroperitoneal lymphadenectomy, external
beam radiation to the retroperitoneum and
chemotherapy, alone or in combination.