Inguinoscrotal mass Case Presentation

Objectives To present the history and physical examination of a patient presenting with inguinoscrotal mass To present the differential diagnosis for a patient with inguinoscrotal mass To present the approach to diagnosis and management of a patient with inguinoscrotal mass

Patient data J.F 40/M Feb Single Filipino, Roman Catholic San Miguel, Pasig

"luslos" (inguinoscrotal mass) Chief complaint

History of Present Illness round palpable inguinal mass (quail egg size), right More apparent when lifting heavy objects Reducible No pain, swelling No urinary symptoms 4 years PTC

History of Present Illness Gradual increase in size (chicken egg) Involving the scrotum Irreducible No pain Consult at a hospital, advised surgery, deferred 2 years PTC

History of Present Illness Persistence of symptoms Still increasing in size, palm size Still no pain No discoloration Consult at hospital, referred to this institution 2 weeks PTC

Past Medical History (+) Bilaterally undescended testes (-) HTN (-) DM (+) allergy to shrimps No previous hospitalization No previous surgeries

Family history (-) undescended testes in brother (+) HTN (-) DM

Personal & Social History Construction worker Lives in apartment-type house with 2 families Previous smoker, 7 pack years, quit 10 yrs ago Occasional alcohol drinker Denies drug use Water comes from MWSS Garbage collected regularly

Patient has no children, no wife Heterosexual, does not use protection, Currently not sexually active

Review of Systems No recent weight loss No fever No cough and colds, no dyspnea No abdominal pain No changes in bowel movement No changes in urination

Physical examination

BP 130/80 T 37 C PR 88 bpm, regular RR 16 bpm BMI 23.3 VAS 0/10

General: Conscious, coherent, not in cardiorespiratory distress, not in pain Skin: warm to touch, no active lesions Head and Neck: Anicteric sclerae, pink conjunctiva, (-)TPC, (-) CLAD Cardiovascular:Adynamic precordium, PMI at 5th ICS along L MCL, normal rate and rhythm, good S1, S2, no murmurs Respiratory: symmetric chest expansion, clear breath sounds, no rales/crackles

Gastrointestinal: Flat, normoactive bowel sounds, soft, non-tender Urogenital: (+) scrotal mass, R 8 x 10 x 6 cm, firm, smooth borders, non- nodular (-) Transillumination No palpable testis and masses in Left scrotum Extremities: Full and equal pulses, Full ROM

Incarcerated inguinal hernia, R Primary Impression

Differential Diagnoses Testicular neoplasia Undescended testes, 36 yo, painless firm testicular mass Hydrocoele Painless scrotal mass (-) transillumination, usually soft mass Varicocoele Painless scrotal mass Usually soft mass, not round

Diagnostics Ultrasound of the scrotum Tumor serum markers AFP B HCG LDH

Discussion Testicular cancer

Most common malignancy in yo men 95% are Germ Cell tumors Cell types: seminoma (50%), embryonal cell carcinoma, yolk sac tumor, teratoma, choriocarcinoma Seminoma and non-seminoma

Seminoma Classic, anaplastic, spermatocytic Typical/classic % of all seminomas, mostly in 30s, may occur in 40s-50s Syncyciotrophoblasts - b HCG production Anaplastic % 30% mortality Lethal- greater mitotic activity, higher rate of local invasion, inc metastatic spread, higher b HCG production

Spermatocytic Seminoma 2-12% Cells closely resemble different phases of maturing spermatogonia Low metastatic potential

Non-seminoma Embryonal carcinoma - irregular mass cut surface: variegated, grayish white, fleshy tumor often with areas of necrosis or hemorrhage and poorly defined capsule Choriocarcinoma - hemorrhagic Teratoma- derived from ectoderm, mesoderm, endoderm Yolk sac tumor- most common in infants and children

Mixed tumors 60% have more than 1 histologic pattern Usual combination

Risk factors: GCT yo American blacks Family history

Risk factors: (testicular CIS) Cryptorchidism (3%) Family history of testicular carcinoma (5-6%) Contralateral testis with unilateral testicular cancer (5-6%) Atrophic contralateral testis with testiculat cancer (30%) Somatosexual ambiguity (25-100%) Infertility ( %) Harland et. al 1998

Approach to a patient with testicular mass CBC, creatine, electrolytes, liver enzymes Serum tumor markers – diagnosis, staging, prognosis; before and after orchiectomy Chest X-ray Testicular ultrasound Biopsy may be considered Sperm banking

Chest CT indicated if the abdominopelvic CT shows retroperitoneal adenopathy or abnormal Chest X-ray

Management Inguinal orchiectomy – primary treatment Open inguinal biopsy of contralateral testis usually not done, may be considered for cryptochidism

Definition of stage and risk classification – American Joint Committee on Cancer (AJCC) an International Germ Cell Cancer Consensus Group (IGCCCG) Extent of disease Levels of serum tumor markers post- orchiectomy

Pure Seminoma IA and IB Inguinal orchiectomy Surveillance Radiotherapy Chemotherapy (1-2 cycles of carboplatin) Survival 99% Relapse rate 99% in 5 years Follow-up every 3-4 months, for 1-2 years Then every 6-12 months for 3-4 years, then annuallu

Campbell et al Urology NCCN Guidelines on Testicular Cancer