Outpatient- Lump in Scrotum Flashcards
Mr Jones is a 24 year old plasterer. He found a lump in this scrotum; his GP has referred him urgently under the 2 week wait cancer pathway.
How would you assess this patient?
I would review this in a urgent outpatient clinic
Focussed history:
- duration
- change in size
- associated trauma
- previous lumps
- previous scrotal procedures
- hx of UTIs/ STIs
- Associated LUTs
- family hx
- hx of infertility, poor sperm count
- prev cancer in other testicle
- family planning
General PMH to assess performance status
Dhx- allergies, anticoagulants
Clinical assessment:
- chaperone present
- general assessment of body habitus, signs of cachexia
- genitalia examination: assessing size, texture and position.
- Assess for extrascrotal spread: groin lymphadenopathy, retroperitoneal mass, Supraclavicular nodes, Gynaecomastia [7% cases]
Mr Jones is a 24 year old plasterer. He found a lump in this scrotum; his GP has referred him urgently under the 2 week wait cancer pathway.
You find a hard irregular mass in the upper pole of the left testis. What investigations would you organise?
Tumour markers: LDH, AFP, HCG
Baseline bloods for pre-op assessment and further scans: FBC, Coag, U&Es
Imaging: USS testes and CXR, CTCAP for staging
Suspicious of infection: STI screen, urinalysis, infection markers [CRP, WCC]
Mr Jones is a 24 year old plasterer. He found a lump in this scrotum; his GP has referred him urgently under the 2 week wait cancer pathway.
USS showed a heterogenous irregular mass upper pole of left testis. Tumour markers are raised, CXR is clear, what are your next steps?
Update my consultant in clinic and provisionally plan a date for a inguinal orchidectomy, and next possible pre-op assessment appointment
Discuss diagnosis and break bad news
- ask if someone is there to support them
- nursing staff/ cancer nurse specialist to be present
- no distractions when giving news
Discuss the next steps:
- staging CTCAP
- need for inguinal orchidectomy
- if pt had previous orchidectomy of other testicle, history of subfertility or small contralateral testicle then counselling for sperm banking is needed
What information would you give about sperm banking?
Those patients with a history of subfertility and small contralateral testicle should be offered sperm banking. EUA recommends this to be done prior to the orchidectomy.
Pt would be referred to the local fertility unit and they need to provide 3 semen samples are required as well as 2-3 days of abstinence. Assessment of sperm is made under microscope and then the sample is frozen in -196c.
Patients need to be aware of the following:
-sperm quality is not guaranteed when thawed
-sperm quality may be affected due to illness, normally its ok to use sperm in the first week of chemo, as the sperm made prior to tx is viable
-maximum storage is 10 years, the first year is offered covered by the NHS but thereafter the average fees is £200 per year
-all men need to be tested for HIV, Hep B and C first. Those with HIV with have their sperm stored in a separate facility
What complications would you get from a scrotal prosthesis insertion?
Scrotal contraction and migration
Chronic pain
Haematuria
infection
Would you consider taking a biopsy of the contralateral side?
In our local service we do not perform this however I am aware that the EUA guidelines recommend performing a biopsy in those under 40 with a contralateral testis volume of <12ml as there is a 34% risk of intratubular germ cell neoplasia.
other considerations for biopsy are those with a history of undescended testes and subfertility.
What is the role of the tumour markers?
They are both diagnostic and prognostic. Measuring tumour markers after an orchidectomy and their half-life decline are useful in assessing the likelihood of retroperitoneal and metastatic disease.
Half-life of bHCG is 36 hours, AFP every 5 days
LDH is useful in determining tumour burden and assesses tumour volume and cell necrosis. LDH is often useful in seminomas and oncologists uses this to measure tumour response.
Do all patients have raised tumour markers at presentation?
No, approximately 51% of testicular tumours will have raised markers, which varies of the type of tumour present.
AFP- Raised in NSGCT- teratoma, yolk sac
HCG- Raised in SGCT- seminomas
LDH- can be raised in both, assesses tumour burden
Note: HCG has half life of 24-46hrs, so if still high after orchidectomy then it raises concerns for residual disease
What types of testicular cancers do you know?
I am aware of the WHO classification of testicular cancer which splits into 4 titles:
Germ Cell- Seminoma, Spermatocytic seminoma, Non-seminomatous germ cell tumour [teratoma, yolk sac tumour, choriocarcinoma, embryonal carcinoma]
Sex cord stromal tumours- Leydig, sertoli
Mixed Sex cord stromal tumour
Other- lymphoma, metastatic, adenocarcinoma
What staging do you know for testicular cancer?
I am aware of the TNM where it takes the primary tumour, Nodal status, evidence of metastatic disease and serum markers into consideration.
I am also aware of the American Joint Committee on Cancer staging classification, which splits into three stages.
Stage 1= Any pT N0 M0
Stage 2= Any pT N1-3 M0, serum markers not very high
Stage 3= Any pT Any N, M1, high serum markers
What are the mainstay treatment of testicular cancer?
Options after the inguinal orchidectomy would be surveillance, single dose adjuvant chemotherapy or adjuvant radiotherapy to the retroperitoneum.
Options would be dependent of factors such as stage of disease, patient age and performance status therefore the decision for further managements needs to be done via a MDT approach
