Testicular cancers - The Royal Marsden

The Royal Marsden
Testicular cancers
Mr Erik Mayer
Consultant Urological surgeon,
The Royal Marsden
2
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Contents
− Referral Guidelines
− Diagnostics
− Common misdiagnosis – Differential Diagnosis
– The newly diagnosed cancer patient
– The awkward Scrotum
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Referral Guidelines
The Royal Marsden
Quiz
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Question 1
1. Testicular torsion
2. Torted hydatid of
Morgagni
3. Epididymal cyst(s)
4. Microlithiasis
5. Hydrocoele
6. Varicocoele
7. Epididymo-orchitis
8. Hernia
9. Testicular Rupture
10. Testicular Germ Cell
Tumour
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Question 1.
81%
9%
2%
re
0%
up
tu
oor
ch
i
co
e
tis
le
2%
ul
a
Te
st
ic
id
ym
Ep
id
cy
al
id
ym
2%
Hy
dr
o
io
n
or
s
rt
Ep
id
ul
a
st
ic
0%
st
(s)
0%
rR
4%
Te
1. Testicular torsion
2. Torted hydatid of
Morgagni
3. Epididymal cyst(s)
4. Microlithiasis
5. Hydrocoele
6. Varicocoele
7. Epididymo-orchitis
8. Hernia
9. Testicular Rupture
10. Testicular Germ Cell
Tumour
0%
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Question 2
1. Testicular torsion
2. Torted hydatid of Morgagni
3. Epididymal cyst(s)
4. Microlithiasis
5. Hydrocoele
6. Varicocoele
7. Epididymo-orchitis
8. Hernia
9. Testicular Rupture
10. Testicular Germ Cell Tumour
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Question 2
67%
10% 9%
9%
3%
1%
up
tu
tis
Te
st
ic
ul
a
rR
oor
ch
i
co
e
id
ym
Ep
id
1%
re
0%
le
0%
Hy
dr
o
cy
al
id
ym
Ep
id
st
ic
ul
a
rt
or
s
io
n
st
(s)
0%
Te
1. Testicular torsion
2. Torted hydatid of
Morgagni
3. Epididymal cyst(s)
4. Microlithiasis
5. Hydrocoele
6. Varicocoele
7. Epididymo-orchitis
8. Hernia
9. Testicular Rupture
10. Testicular Germ Cell
Tumour
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Question 3
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Testicular torsion
Torted hydatid of Morgagni
Epididymal cyst(s)
Microlithiasis
Hydrocoele
Varicocoele
Epididymo-orchitis
Hernia
Adenomatoid Tumour
Testicular Germ Cell Tumour
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Question 3
74%
11%
1%
id
Tu
m
ou
r
tis
Ad
en
om
at
o
oor
ch
i
co
e
Ep
id
cy
al
id
ym
Hy
dr
o
st
(s)
io
n
or
s
rt
Ep
id
ul
a
st
ic
5%
3%
0%
le
1%
id
ym
3%
0%
Te
1. Testicular torsion
2. Torted hydatid of
Morgagni
3. Epididymal cyst(s)
4. Microlithiasis
5. Hydrocoele
6. Varicocoele
7. Epididymo-orchitis
8. Hernia
9. Adenomatoid Tumour
10. Testicular Germ Cell
Tumour
3%
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Question 4
1. Testicular torsion
2. Torted hydatid of Morgagni
3. Epididymal cyst(s)
4. Microlithiasis
5. Hydrocoele
6. Varicocoele
7. Epididymo-orchitis
8. Hernia
9. Testicular Rupture
10. Testicular Germ Cell Tumour
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Question 4
72%
23%
0%
up
tu
tis
Te
st
ic
ul
a
rR
oor
ch
i
co
e
2%
re
0%
le
0%
id
ym
Ep
id
cy
al
id
ym
0%
Hy
dr
o
io
n
or
s
rt
Ep
id
ul
a
st
ic
2%
st
(s)
2%
Te
1. Testicular torsion
2. Torted hydatid of
Morgagni
3. Epididymal cyst(s)
4. Microlithiasis
5. Hydrocoele
6. Varicocoele
7. Epididymo-orchitis
8. Hernia
9. Testicular Rupture
10. Testicular Germ Cell
Tumour
0%
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Question 5
1. Testicular torsion
2. Torted hydatid of Morgagni
3. Epididymal cyst(s)
4. Microlithiasis
5. Hydrocoele
6. Varicocoele
7. Epididymo-orchitis
8. Hernia
9. Testicular Rupture
10. Testicular Germ Cell Tumour
Question 5
The Royal Marsden
92%
up
tu
tis
ch
i
Te
st
ic
ul
a
rR
oor
0%
0%
re
0%
le
0%
co
e
Ep
id
cy
al
id
ym
3%
Hy
dr
o
st
(s)
io
n
or
s
rt
Ep
id
ul
a
0%
id
ym
3%
0%
st
ic
1. Testicular torsion
2. Torted hydatid of
Morgagni
3. Epididymal cyst(s)
4. Microlithiasis
5. Hydrocoele
6. Varicocoele
7. Epididymo-orchitis
8. Hernia
9. Testicular Rupture
10. Testicular Germ Cell
Tumour
Te
14
2%
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Question 6
1. Testicular torsion
2. Torted hydatid of Morgagni
3. Epididymal cyst(s)
4. Microlithiasis
5. Hydrocoele
6. Varicocoele
7. Epididymo-orchitis
8. Hernia
9. Testicular Germ Cell Tumour
10. Testicular Rupture
The Royal Marsden
Question 6
58%
11%
11%
8%
6%
5%
0%
0%
d
Te
hy stic
da ul
tid ar
o to
Ep f M rsio
id
id org n
ym ag
a ni
M l cy
icr st
ol (s)
it
Hy hia
dr sis
Ep V oco
id ari ele
id
Te
ym coc
st
ic u
o- oel
or e
la
rG
ch
it i
er
s
m
H
Ce er
n
ll
T u ia
m
ou
r
2%
rte
1. Testicular torsion
2. Torted hydatid of
Morgagni
3. Epididymal cyst(s)
4. Microlithiasis
5. Hydrocoele
6. Varicocoele
7. Epididymo-orchitis
8. Hernia
9. Testicular Germ Cell
Tumour
10. Testicular rupture
To
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Diagnostics
– History
– Clinical Examination
– Genitals
– Abdomen
– Supraclavicular Lymphadenopathy
– Urine Dipstick & Pregnancy Test
– Tumour Markers
– Ultrasound
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History
Symptoms
•
Hard, painless lump
- Partner detection
•
5-10% scrotal pain
•
- Intra-tumoural haemorrhage
- Trauma brings attention to abnormality
•
Metastatic
- Weight loss
- Shortness of Breath
- Back/abdominal pain
- Neck lumps
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Key Points in a Scrotal Mass History
– The Lump
– How was it detected (in the bath etc.)?
– How long has it been there?
– Is it changing in size?
– Painful or painless
– Sexual history – Any recent STIs
– Any lower urinary tract symptoms
– Any recent testicular trauma
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Key points continued
− Any abdominal or neck lumps (lymphadenopathy)
− Any SOB or abdominal pain
− PMH
− Previous orchidopexy/maldescent of testicle
− Have they had testicular US scan before/been
encouraged to regularly self examine
− FH of testicular Cancer
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Clinical Examination
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Which tumour markers might be raised in
testicular cancer?
71%
CA 19-9, CA 125
CEA, B-HCG
AFP, B-HCG, LDH
CA 125, AFP
None of the above
23%
6%
of
th
e
ab
o
ve
FP
12
5,
A
No
ne
CA
BAF
P,
,B
CE
A
HC
G,
LD
H
0%
-H
CG
12
5
0%
19
-9
,C
A
1.
2.
3.
4.
5.
CA
22
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Tumour Markers
AFP - raised in 50-70% of NSGCT
– May be elevated with:
– hepatic dysfunction, cirrhosis, and
– drug or alcohol abuse
- normal <10ng/mL
–
–
–
Useful in diagnosis, risk
stratification & monitoring
βhCG - raised in:
• 100% Choriocarcinoma
• 60% Embryonal carcinoma
• 55% Teratocarcinoma
• 25% Yolk Cell Tumour
• 7% Seminomas
- normal <5mIU/mL
False positive elevations - marijuana use
LDH- ↑in 30% to 80% of pure seminoma and 60% of
nonseminomas.
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Ultrasound
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What I discuss with the patient
− Diagnosis
− Prognosis
− CxR/CT scan/tumour markers
− Need for Surgery as first line treatment
− Testicular Prosthesis
− Fertility/Sperm Storage
− Possible further treatment
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Headline Statistics
–
–
–
–
–
Affects 7 in 100,000 men
Most common solid cancer in men 20-45
Rare below 15 and above 60
Responsible for just over 1% of all male cancers.
Estimated that the lifetime risk of developing testicular cancer in
2012 is 1 in 195 for men in the UK.
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Headline Statistics
European Age-Standardised Incidence Rates per 100,000
Population, Males, Great Britain
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Headline Statistics
European Age-Standardised Mortality Rates per
100,000 Population, Males, UK
One-, Five- and Ten-Year Net Survival (%), Adults Aged 15-99, England & Wales
1-Year
5-Year
10-Year
Survival (%) Survival (%) Survival (%)
Men
Net Survival
99.1
98.3
98.2
95% LCL
99.1
98.3
98.2
95% UCL
99.1
98.3
98.2
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Operating is not always best for the patient
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Orchidectomy: Inguinal vs. Scrotal approach
– Meta-analysis
– Scrotal violation → ↑ local recurrence
from 0.4 – 2.9%
Capelouto et al., 1995
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Prosthesis
–
–
–
–
–
Infection risk
Think Chemotherapy
Long-term safety
Cosmesis/Migration
About 25% uptake
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Sperm Storage
– Andrology Lab - Hammersmith
– Hep B/C, HIV & CMV screening
– No desperate need to do pre-op although is recommended in
EAU guidelines (3 samples/3 day abstinence)
– Cost associated after year one
– Collecting and freezing the samples can cost between £200
and £400. Then you pay about £300 a year to store them
– Standard storage period 10 years
– Quality of the sperm not guaranteed
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Further Treatment
– Oncological outcomes – overall survival
– Reducing burden of follow-up
– Minimising ‘overtreatment’ and treatment related
morbidity
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So it’s NOT Cancer
Most testicular lumps are NOT cancer. At a testicular
clinic at the Queen Elizabeth Hospital in Birmingham,
only 76 cancers were found out of 2,000 men seen with
a testicular lump. This means that fewer than 4 in every
100 testicular lumps (4%) are cancer
The awkward Scrotum
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Differential Diagnosis
–
Any cause of scrotal
lump/pain
–
Testicular torsion
–
Torted hydatid of Morgagni
–
Epididymal cyst(s)
–
Hydrocoele
–
Varicocoele
–
Epididymitis (orchitis)
–
Hernia
–
Adenomatoid Tumour
Other findings on Ultrasound
Microlithiasis
Varicocoele
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Microlithiasis
– Common – up to 10% men referred for Ultrasound
– Increasingly detected with higher frequency US
– Is it Premalignant?
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Varicocele
– Abnormal dilatation of the testicular
veins in the pampiniform plexus
– 2-22% incidence of normal men, and
25% of infertile men
– Typically pain coming on when standing/
ambulating
– No pain at night
– 90% Left and 10% bilateral
o 10 cms longer and into renal vein.
o ‘nutcracker effect’ left renal vein
between the aorta and SMA.
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Varicocoele
–
–
–
–
Grade 0:
– subclinical varicocoele.
Grade 1:
– palpable only with
valsalva.
Grade 2:
– Clinically palpable in
upright position.
Grade 3:
– Gross varicocoele with
‘bag of worms’ visible
through skin.
–
Consider underlying cause if:
• Sudden onset of varicocoele
• Right sided varicocoele
• Does not collapse on being
supine
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Varicocoeles and fertility
– Varicocoeles do not cause infertility
– Routine testing of semen parameters not
required
– Do not require treatment unless associated
with abnormal semen parameters and low
testicular volume in the context of infertility
– Always consider female infertility factors
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Treatment
– Treatment Conservative/embolisation/ ligation
– Be guarded about outcome
– Natural History may demonstrate improvement
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Torsion
– Testicular torsion
– Torsion of a testicular appendage
(appendix testis, Hydatid of
Morgagni)
– Torsion
– Acute testicular pain (unilateral)
– Radiation to lower abdomen
– Nausea & vomiting
– Negative urine dipstick
– Main investigation is scrotal
exploration
– (Ultrasound)
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Testicular Torsion
Torsion of Hydatid
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Torsion
− Immediate referral to A&E
− No investigation needed
− Scrotal exploration, untwisting of testicle and bilateral 3-point
fixation with non-absorbable sutures in adult, dartos pouch in
children
− Warm ischaemia time 6 hours
− Torted Hydatid of Morgagni – conservative treatment an option
if diagnosis clear
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Infection
–Acute epididymitis/Epididymo-orchitis
– Bacterial
– In older men, UTI organisms
– In younger men, Chlamydia and Gonococcus
History
– Examination; tender swelling of epididymis +/- secondary
hydrocoele
– 21 days of appropriate antibiotic but warn patient that swelling
may persist >6 weeks
– Scrotal support
– Patient typically ends up with repeat ultrasound
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Follow-up Ultrasound
– Epididymal/Testicular abscess
– Testicular infarction
– Underlying tumour
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Infection
–Orchitis
Can be extension of epididymorchitis
Viral
• Mumps, ?other viruses
• History of parotitis
• Supportive measures – analgesia, bed rest
• Steroids? Tunical incision
If bilateral, mumps orchitis post-puberty may lead to
atrophy and subfertility
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Epididymal cysts and hydroceles
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Aetiology
Hydrocoele
-Excess fluid production
Inflammation
Tumours
-Decreased fluid absorption
Post treatment for varicocoele
-Congenital
Patent Processus Vaginalis
Epididymal Cyst
– Possible results from
epididymal tube
obstruction
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Clinical Appearance
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Epididymal Cyst
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Management
Epididymal Cyst
– Conservative
- Why not to operate:
– Pain does not improve
– Pain can be made worse
– Recurrence
– Epididymal obstruction
Hydrocoele
– Conservative
– Aspiration
– Aspiration + Sclerotherapy
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Inguino-scrotal Hernia
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Take Home Messages
− Scrotal Lumps and Bumps can be difficult to confidently
diagnose
− Always get an Ultrasound (urgent vs. routine)
− If in doubt 2WW referral
− Elements of managing new testicular cancer patient
− Benign scrotal pathology can generally be managed
conservatively
− Except torsion