Ch. 53 - Scrotal Mass Flashcards
Cause(s) of scrotal masses found involving the skin (2):
Differential dx of scrotal masses involving spermatic cord?
Differential dx of scrotal masses involving epididymis?
Differential dx of scrotal masses founding involving the testes?
What features on H&P favor dx of testicular cancer?
Any painless mass is highly suggestive of metastatic testicular cancer
Sx: back/abdominal pain, weight loss, nausea suggest retroperitoneal lymph node metastasis… whereas cough and SOB suggest pulmonary metastasis
Major risk factor for testicular cancer?
Cryptorchidism (undescended testicle)
Family hx of testicular cancer, Klinefelter’s syndrome, white race
What are the main diagnoses to consider in the presence of a very painful scrotal mass?
Epididymitis and/or orchitis would be highest on the differential
During pubescence, testicular torsion and torsion of appendix testis = high on list
What benign processes are typically painless?
Spermatocele, varicocele, hydrocele
What physical exam maneuver can help identify a varicocele?
Patients with varicoceles will often have the mass disappear upon lying down and reappear when the patient stands up.
A varicocele feels like a spongy bag of worms.
Major association with varicocele?
Infertility :(
Does cryptorchidism increase the risk of developing testicular cancer in the undescended testicle, contralateral descended testicle, or both?
It is more likely to occur in undescended testicle. However, in nearly 25% of these cases, testicular cancer develops in contralateral descended testicle. This suggests that an undescended testicle may not play a direct role in the development of testicular cancer, but rather, there is some other phenomenon that leads to both testicular cancer and abnormal descent of the testicles during embryologic development.
Most common subtype of testicular tumor? Is it malignant?
Seminoma, germ cell tumor = most common subtype, malignant
What are the major pathologic subtypes of testicular cancers?
What causes gynecomastia in patients with testicular cancers?
Choriocarcinoma, germ cell tumor = associated with ectopic hCG production
Elevated levels of hCG –> stimulate breast development –> gynecomastia
Alpha subunit of hCG similar to TSH so these patients also present with sx suggestive of hyperthyroidism but w/o goiter
Organisms causing epididymitis
Why does a varicocele form?
Why is it more often on the Left?
Why does it affect fertility?
Impaired venous drainage
Veins in pampiniform plexus slowly and progressively dilate and enlarge over time as a result of impaired drainage –> occurs more commonly on left as venous drainage is less optimal (left testicular vein enters left renal vein at a right angle) than right (which drains into larger IVC at more favorable angle)
Stasis of venous blood appears to increase testicular temperature, increase seminal oxidative stress, and damage sperm DNA
WATCH OUT: sudden onset of L-sided varicocele!
May be precipitated by thrombosis of L renal vein (think of RCC)
Work Up:
Key imaging modalities for a patient with testicular cancer
Relevant blood tests?
Demonstration on U/S of a solid mass –> makes likelihood of cancer very high
Pts with dx of testicular cancer should be staged with a CT scan of the abdomen and pelvis (look for retroperitoneal lymph node metastasis) + CXR (to look for pulmonary metastasis)
**BIOPSY C/I = may seed cancerous cells
Blood test:
- bhCG (some seminomatous cancers and in most nonseminomatous ones)
- AFP (elevated in nonseminomatous cancer)
- LDH (useful for prognostic purposes… suggests large tumor bulk, but not for dx)
Mgmt:
How is pathologic confirmation of testicular cancer determined?
What other treatment modalities are utilized after initial surgery for testicular cancer?
Radical inguinal orchiectomy –> performed via inguinal (NOT scrotal.. higher rate of local recurrence) incision and consists of removal of testicle and spermatic cord up to the point where it exists from internal ring
Radiation, chemo, retroperitoneal lymph node dissection (RPLND) = additional tx strategies
- Seminoma = highly radiosensitive
Nonseminomas = RPLND
What are the key differences between a seminoma and nonseminoma?
Incidence
Elevated AFP levels
Elevated BCG levels
Radical inguinal orchiectomy
Radiation therapy
Chemotherapy
RLND
