Genitourinary and vascular Flashcards
For treatment purposes how are testicular tumours broadly divided
Pure seminoma vs non seminomatous germ cell tumours (NSGCT)
- Pure Seminomas contain no other tumour element
- NSGCT may contain seminoma elements or not
What is the overall 5 year survival rate for testicular cancers now
Over 95%
- Until the 1970s it was as low as 65%
Presenting symptoms of testicular cancer
chronic discomfort/pain in perineum and low abdomen is common
acute pain in ~10%
Palpable mass or testicular enlargement is the usual
Symptoms of metastatic disease in ~10%
Gynaeomastia
- 5% of testicular cancers
- Usually from BhCG production by choriocarcinoma elements
BhCG producing tumours can have what systemic hormonal and paraneoplastic effects
Gynaecomastia
- Although not all testicular tumour associated gynaecomastia is caused by hCG
Hyperthyroidism
- hCG and TSH are structurally similar and hCG has a weak thyroid stimulating effect
Limbic encephalitis
- Rare paraneoplastic phenomenon
Physical examination of the suspected testicular cancer
Testicular exam
- examine normal side first
- between thumb and 2 fingers
- examine for cryptochidism and scars from orchidopexy
Cord exam
- assess for spread
Nodal exam
- supraclavicular nodes
- groin nodes
- The testis drains to the iliacs and thus groin involvement might suggest invasion through tunica albuginea (which is rare because it is tough)
Systemic
- abdomen for masses
- gynaecomastia
- lung exam
- signs of hyperthyroidism
Diagnostic evaluation of men with suspected testicular cancer
Scrotal ultrasound
SPERM BANKING
- By cryopreservation
- baseline sperm count also
Radiology
- CT CAP
- MRI adds little
- PET is not warranted
Serum tumor markers
- AFP
- BhCG
- LDH
Radical inguinal orchiectomy
In some cases retroperitoneal lymph node dissection (RPLND) may be necessary while still in the diagnostic process
If a question is on:
Breast cancer in a young woman
or
Testicular cancer in a young man
FERTILITY preservation!!!!
Testicular ultrasound findings in malignancy
Classically:
- seminomas are homogenous hypoechoic
- NSGCTs are mixed solid/cystic, heterogenous
USS can detect even very small lesions with excellent accuracy
- but cannot assess breach of the tunica well
- cannot be used for staging
Microlithiasis
- associated with testical tumours
- doesn’t appear to convey an ongoing risk if no other USS concerns
- surveillance is not warranted
- doesn’t appear to convey an ongoing risk if no other USS concerns
What tumour markers are useful in testicular cancers
How are they useful
Three serum tumor markers have established roles in testicular cancer:
- Alpha-fetoprotein (AFP),
- Lactate dehydrogenase (LDH).
- Beta subunit of human chorionic gonadotrophin (BHCG)
The primary purpose of tumour marker testing is for post treatment monitoring
If AFP and HCG are elevated it is likely an NSGCT
- Serum levels of AFP and/or beta-hCG are elevated in 80 to 85 percent of men with NSGCTs, even when nonmetastatic.
Serum beta-hCG is elevated in less than 20 percent of testicular seminomas
If AFP is normal it is likely a pure seminoma
- AFP is not elevated in pure seminomas
Name at least 5 testicular neoplasms
Seminoma
Nonseminomatous germ cell tumors
- Embryonal carcinoma
- Choriocarcinoma
- Yolk sac tumor (endodermal sinus tumor)
- Teratoma
- Teratoma with malignant/somatic transformation
- Mixed germ cell tumor
- Spermatocytic Tumor
Sex cord-stromal tumors
- Sertoli cell tumor
- Leydig cell tumor
- Granulosa cell tumor
- Mixed types (eg, Sertoli-Leydig cell tumor)
- Unclassified
Mixed germ cell and stromal tumors
- Gonadoblastoma
Adnexal and paratesticular tumors
- Adenocarcinoma of rete testis
- Adenocarcinoma of the epididymis
- Mesothelioma
- Malignant mesothelioma
- Adenomatoid tumor
Miscellaneous tumors
- Carcinoid
- Lymphoma
- Metastatic tumors
Treatment options in varicose veins
Endovenous techniques appear to be at least as good (esp laser) as surgery
- lower pain scores, earlier return to work are also favourable outcomes
- vein closure rates on 88% seen in both for laser and surgery, 72% for sclerotherapy at 1 year
What are the layers of the scrotum and testis
From superficial to deep
- skin
- superficial (dartos) fascia
- external spermatic fascia
- cremasteric fascia
- internal spermatic fascia
- parietal layer of tunica vaginalis
- visceral layer of tunica vaginalis
- tunica albuginea
What are the components of the spermatic cord
3 coverings
- internal spermatic fascia (from transversalis)
- cremasteric muscle and fascia (from internal oblique)
- external spermatic fascia (from external oblique)
6 contents
- ductus deferens
- pampiniform venous plexus
- arteries
- testicular
- cremasteric
- lymphatics
- testicular to aortics (follow artery)
- coverings to iliacs (follow veins)
- nerves
- genital branch of genitofemoral
- counted as a cord constituent buyt not as running seprately though the canal as joins in the canal
- sympathetics
- genital branch of genitofemoral
- processus vaginalis
- obliterated remnant
What is the embrylogic origin of the appendix testis
A remnant of the obliterated paramesonephric duct
how many seminiferous tubules is each testis comprised of
15-20
