Testicular swelling and tumour simplified

1. DR. Muhammad Ahsan kaleem

2.  Embryology of testes
 Scrotal swelling
 Hydrocele
 Hematocele
 Varicocele
 Epididymal cyst
 Testicular torsion
 Testicular tumors

3.  Descent of testes at 32-40 wks gestation
 Descends within processes vaginalis
 Outpouching of peritoneal cavity
 Tunica vaginalis is potential space that remains
after closure of process vaginalis

4. Posterior
Anterior

6. Definition:-
A hydrocele is an abnormal collection of serous
fluid in a part of the processus vaginalis, usually the
tunica.

7. A hydrocele can be produced in four different ways:-
• by excessive production of fluid within the sac, e.g.
secondary hydrocele;
• by defective absorption of fluid; this appears to be
the explanation for most primary hydroceles although
the reason the fluid is not absorbed is obscure;
• by interference with lymphatic drainage of scrotal
structures;
• by connection with the peritoneal cavity via a patent
processus vaginalis (congenital).

8. Congenital
Acquired

9.  Vaginal hydrocele
 True Congenital hydrocele
 Infantile hydrocele
 Hydrocele of the cord

10.  Primary  Secondary
 Develop slowly
 Large
 Hard and tense
 No defined cause
 Over 40s
 Develops rapidly
 Small
 Secondary to
inflammation,trauma or
tumor of testes
 Younger age group(20-40)

11.  Symptoms
 Scrotal swelling
 Pain & discomfort if its
secondary
 Frequent &painful
micturition if secondary
to epididymo-orchitis
 Malaise & weight loss if
secondary to tumor with
distant metastases
 Don’t affect fertility
• Physical Examination
• Often bilateral
• Can get above the
swelling
• Testes cannot be felt
separately
• Fluid thrill
• Transilluminates
• Not tender if primary

14. Treatment

24. • This is twisting of the testis with interference to the
arterial blood supply.
the actual torsion is usually of the spermatic cord
• Possible mechanism; it is associated with:
1. Imperfectly descended testis
2. High investment of tunica vaginalis with a horizontal lie of
testis
3. Epididymis& testis are separated by a mesorchium, & twisting
occurs at the mesorchium.
• The incidence is highest between 10 & 20 years.

26.  Accounts for 30% of all acute scrotal swelling
 Bimodal ages – neonatal (in utero) and pubertal
ages
 65% occur in ages 12-18yo
 Incidence 1 in 4000 in males <25yo
 Increased incidence in puberty due to inc weight
of testes

27.  Bell-clapper deformity
 Testicle lacks normal
attachment at vaginalis
 Increased mobility
 Tranverse lie of testes
 Typically bilateral
 Prevalence 1/125

28. Clinical Presentation
 Abrupt onset of pain – usually testicular, can be
lower abdominal, inguinal
 Often < 12 hrs duration
 May follow exercise or minor trauma
 May awaken from sleep
 Cremasteric contraction with nocturnal stimulation in REM
 Up to 8% report testicular pain in past

29. Examination
 Edematous, tender, swollen
 Elevated from shortened spermatic cord
 Horizontal lie common (PPV 80%)
 Reactive hydrocele may be present
 Cremasteric reflex absent in nearly all (unreliable
in <30mo old) (PPV 95%)
 Prehn’s sign elevation relieves pain in epididymitis
and not torsion is unreliable

30.  Ideally -- prompt clinical diagnosis
 Imaging
 Color doppler – decreased intratesticular flow
 False + in large hydrocele, hematoma
 Sens 69-100% and Spec 77-100%
 Lower sensitivity in low flow pre-pubertal testes
 Nuclear Technetium-99 radioisotope scan
 Show testicular perfusion
 30 min procedure time
 Sens and spec 97-100%

31.  Acute torsion L testis
 Dec blood flow on L
 Late torsion on R
 Inc blood flow around
but dec flow w/in testis

32.  Decreased echogenicity
and size of right testicle
 Nuclear medicine scan
shows "rim sign“ =no flow
to testicle and swelling

33.  Detorsion within 6hr = 100% viability
 Within 12-24 hrs = 20% viability
 After 24 hrs = 0% viability
 Surgical detorsion and orchiopexy if viable
 Contralateral exploration and fixation if bell-clapper
deformity
 Orchiectomy if non-viable testicle
 Never delay surgery on assumption of nonviability
as prolonged symptoms can represent periods of
intermittent torsion

34.  If presents before swelling
 Appropriate sedation
 In 2/3rds of cases testes
torses medially, 1/3rd lateral
 Success if pain relief, testes
lowers in scrotum
 Still need surgical fixation

35. Testicular tumour
 Comprise a morphologically and clinically diverse
group of tumors
 +1-2% of all malignancies
 95% are Germ Cell Tumours (GCTs)
 Predominantly affects young males

36. 1. Cryptochordism
2. Positive family history
3. Positive personal history
4. Intratubular germ cell neoplasia
5. Trauma
6. Hormonal factors
7. Exposure to environmental oestrogen and
contaminations

37. Classified according to predominant cell type:
1. Germ Cell tumors (95%)
a) Seminoma
b) Embyonal cell carcinoma
c) Choriocarcinoma
d) Yolk sac tumor
e) Teratoma

38. Classified according to predominant cell type:
2. Non Germ Cell tomors
a) Interstitial Cell Tumors / Sex Cord / Stromal Tumors
 Leydig cell tumors
 Sertoli Cell Tumors
 Gonadoblastoma
 Granulosa Cell tumors
b) Miscellaneous Testicular Neoplasms
 Epidermoid cyst
 Adenocarcinoma of rete testis
c) Secondary Tumors
 Lymphoma
 Leukemic Infiltration
 Metastases

39. Classified according to predominant cell type:
3. Tumors of the testicular adnexa
a) Adenamatoid Tumor
b) Cystadenoma
c) Mesothelioma

41.  The commonest variety of testicular tumour
 Adults are the usual target (4th and 5th decade);
never seen in infancy
 Right > Left Testis
 Starts in the mediastinum: compresses the
surrounding structure.
 Patients present with painless testicular mass
 30 % have metastases at presentation, but only
3% have symptoms related to metastases

42.  Serum alpha fetoprotein is normal
 Beta HCG is elevated in 30% of patients with
Seminoma
 Classification (of no clinical significance)
a) Typical
b) Anaplastic
c) Spermatocytic

43.  Macroscopically:
Characterized by a
circumscribed
lobular gray white
fleshy tumor that
have areas of
necrosis &
hemorrhage
Cut surface in
homogenous and
greyish white or
pinkish in colour

44.  Microscopically:
 Typical seminoma Cells have round to oval
nuclei with one to several nucleoli & clear to
eosinophillic cytoplasm.
 Cell borders are well defined arranged in solid
nests separated by fibrous septa.
 Active lymphocytic infiltration in 80% cases.
 Strongly positive for placental Alkaline
phosphatase (PLAP)

45.  Microscopically:

46.  2nd most common germ cell tumor
 Present in majority of mixed germ cell tumors
 Most men present in their 20s to 30s with a
testicular mass
 Highly malignant tumours; may invade the
cord stuctures
 High degree of metastasis
 Serum AFP is normal , & beta HCG is elevated
in 60 % of cases

47.  Macroscopically:
Tan to yellow neoplasms (fleshy tumor) that exhibit
large areas of hemorrhage and necrosis.
 Microscopically:
Undifferentiated malignant cells with crowded
pleomorphic nuclei
Solid sheets,
Papillary
Glandular
Tubular arrangement of cells
• Most undifferentiated; capacity to differentiate to
other NSGCT within primary or mets

50.  A rare and aggressive
tumour (5yrs survival is 5%)
 Typically elevated hCG
• Microscopically:
Consists of both
syncitiotrophoblast and
cytotrophoblast
Prominent areas of
hemorrhage and necrosis.

51.  Most common germ cell tumor ( & most
common testicular tumor ) in children, where
it occurs in its pure form.
 In adults, it is unusual in pure form, but is
found approx. 50 % of mixed germ cell tumors.
 Testicular mass the most usual presentation.
 Always produce AFP, never hCG
 Easily detectable, lower relapse

52.  Most common germ cell tumor ( & most common
testicular tumor ) in children, where it occurs in its
pure form.
 In adults, it is unusual in pure form, but is found
approx. 50 % of mixed germ cell tumors.
 Testicular mass the most usual presentation.
 Always produce AFP, never hCG
 Easily detectable, lower relapse

53.  Teratoma in greek means “monster tumor”
 Occurs in its pure form with a mean age of
diagnosis at 20 months
 In adults, occur as a component of mixed germ
cell tumor & is identified in > 47 % of mixed
tumors.
 Pure teratomas are uncommon.
 Normal serum markers.
◦ Mildly elevated AFP levels

54.  Histologically benign, but found at metastatic
sites in NSGCT
 Perhaps metastatised as Embryonal cell ca
 They are resistant to chemotherapy1
 Surgical resection required post chemotherapy
in 40-50% cases

56. 1. Due to primary tumor
a) Painless testicular lump
b) Sensation of heaviness if size > than 2-3 times
c) Rarely dragging pain is complained of (1/3rd cases)
d) May mimic epidedymo-orchitis
e) Sudden pain and enlargement due to hemorrhage
mimicking torsion
f) History of trauma (co-incidental)

57. 2. Due to metastasis
 Abdominal or lumbar pain (lymphatic spread)
 Mass in epigastrium
 Dyspnoea, hemoptysis and chest pain with lung
mets
 Jaundice with liver mets
 Hydronephrosis by para-aortic lymph nodes
enlargement
 Pedal oedema by IVC obstruction
 Troiser’s sign

58. 3. Clinical examination:
a) Enlarged testis (except choriocarcinoma)
b) Nodular testis
c) Firm to hard in consistency
d) Loss of testicular sensation (be gentle)
e) Secondary hydrocele
f) Flat and difficult to feel epidedymis
g) Sign of Vas negetive
h) General examination for mets

59. 3. Clinical examination:
a) Enlarged testis (except choriocarcinoma)
b) Nodular testis
c) Firm to hard in consistency
d) Loss of testicular sensation (be gentle)
e) Secondary hydrocele
f) Flat and difficult to feel epidedymis
g) Sign of Vas negetive
h) General examination for mets

60. 1. USG testes: gold standard
2. Tumor markers/ hormones
a) AFP
b) Beta hCG
3. Chest radiography
4. USG abdomen
5. CT abdomen
6. MRI: intra-abdominal and intra-thoracic
secondaries
7. IVP and RFT : obstruction on ureters

61.  Stage I – Tumor confined to the testis
 Stage II – Nodal disease present but confined to
below the diaphragm
 Stage III – Nodal disease above the diaphragm
 Stage IV – Nonlymphatic metastatic disease

62.  Primary Tumor (pT)
pTx: Primary tumor cannot be assessed
pT0: No evidence of primary tumor
pTis: ITGCN
pT1: Tumor confined to testicle; may invade into
the albuginea but not the tunica vaginalis
pT2: Tumor extending thru tunica albuginea with
involvement of tunica vaginalis or the presence of
angiolymphatic invasion.
pT3: Spermatic cord involvement.
pT4: Scortal involvement

63.  Regional Lymph nodes (by non-invasive
assessment)
 Nx: nodal status unknown.
 N0: No regional lymph node metastasis.
 N1:single or multiple lymph node involved, < 2 cm
 N2: single node, 2-5 cm or multiple nodes < 5 cm
 N3:any nodes > 5 cm

64.  Distant metastasis (M)
 Mx: status of metastases unknown
 M0: no distant metastasis
 M1: Distant metastasis

65. 1. Inguinal orchidectomy as soon as the diagnosis
is confirmed
2. Then the treatment differs as per the
histological type: seminoma or NSGCT

66. 1. Scrotal exploration and orchidectomy for
suspected testicular tumor
 Orchidectomy undertaken by the inguinal incision
 Spermatic cords are displayed
 A soft clamp applied across the cord
 Mobilise testis to the wound
 If neseccary, bisect the testes along the anterior
convexity to examine
 Take biopsy, send for frozen section
 In case of tumor, double transfix and divide at the
level of the deep ring
 Some advice hemi-scrotectomy along with
orchidectomy

67. 2. Radio/Chemotherapy
A. Stage I tumor:
 Seminomas:
 Radio-sensitive and chemo sensitive (platinum based
regimen)
 Current protocol: radiotherapy is the mainstay of
treatment with CT and tumor marker based surveillance
 In men who demonstrate relapse, chemotherapy to be
applied
 NSGCT
 Not radio-sensitive
 Subjected to BEP (Bleomycin, etoposide and cis-
platinum)

68. 2. Radio/Chemotherapy
B. Stage II- IV
 Combination chemotherapy for seminoma and NSGCT
 RPLND needed in some cases for post chemotherapy
masses in the retroperitoneum

69.  Radiotherapy:
 Given to para-aortic and ipsilateral lymph nodes,
field extending from D10-11interspace to the
lower border of the obturator foramen
 Anterior and posterior fields are given
alternatively
 Laterally to the hila of the kidneys
 Contralateral testis being protected by thick lead
cups
 High enery Xrays- 6-8MeV with linear accilerator
 3000 rads delivered in 3-4 wks

70.  Lymph node dissection:

71. 1. Leydig cell tumors
Considered a pre-ubertal tumor
May affect 20-60yrs of age
A masculinising tumor, produces androgens
No association with crytochordism
Presents with painless testicular mass
Precocious puberty
 Prominent external genitalia
 Deep masculinised voice
 Pubic hair
Gynacomastia and decreased libodo due to
oestrogen production by perpheral conversion

72. 1. Leydig cell tumors
 10% are malignant
 Orchidectomy is te treatment of choice
 Regression of symptoms after orchidectomy may
not be complete
 Metastasize by blood to lungs and
retroperitoneum
 Abdominopelvic CT, chest Xray, RPLND
 Insensitive to radiotherapy and chemtherapy

73. 2. Sertoli Cell Tumor
 Considered a post pubertal tumor
 But can occur in any age group including infants
 No association with crytochordism
 Gynacomastia in 1/3rd of cases
 10 % are malignant
 Inguinal orchidectomy is the treatment
 RPLND
 Radiotherapy and chemotherapy are ineffective

74. 3. Gonadoblastoma
 Mixed germ cell/sex cord/stromal tumor
 Composed of seminoma like germ cells and
Sertoli differentiation
 Exclusively in patients with dysgenic gonads and
intersex syndromes
 80% are phenotype females with primary
amenorrhoea
 20% are males with crytochordism and dysgenic
gonads and hypospadias

75. 3. Gonadoblastoma
 Considered in-situ malignant form of GCT
 Bilateral orchidectomy because of risk of
bilateral tumours

76. 1. Epidermoid Cyst
 A rare benign neoplasm
 Mondermally differentiated teratoam
 Resemmbles Dermoid cyst
 Enucleation or orchidectomy
 HPR is must

77. 2. Adeno-carcinoma of rete testis
 A rare but highly malignant neoplasm
 Arises from collecting system of testis
 Usual presentation: painless swellinng with
hydrocoele
 More than 50% present with mets
 Mean survival period is 1 yr
 Radiotherapy and chemotherapy are ineffective
 RPLND in cases of limited retroperitoneal mets

78. 1. Lymphoma
 Primary testicular Non-Hodgekin’s lymphoma is
rare
 Mostly involvement of testes by dissemination
from other sites
 Bilateral involvement in 35 % cases
 Presents as painless testicular mass
 25% have systemic symptoms (fever, night sweats
and weight loss)
 10% CNS involvement
 Radical inguinal orchidectomy
 Refer to heamto-oncologist for staging and
subsequent therapy

79. 2. Leukemic Infiltration
 Relapse of ALL in testes
 Diagnosis by biopsy
 No orchidectomy
 Local control with low dose radiotherapy (20Gy)
 Should include the contralateral testis: Bilateral
involvement

80. 3. Metastases
 Metastases from prostate cancer
 Lung cancer
 Melanoma
 Colon cancer
 Kidney malignancy
 Presents as diffuse metastatic disease

81. 1. Adenomatoid
 Most cmmon paratesticular tumour
 Involving the epidedymis mostly
 May arise from spermatic cord
 Presents as small (0.5 to 5cm) painless
paratesticular mass detected on routine
examination
 3rd to 4th decade of life
 Benign
 Excision by inguinal route

82. 2. Cystadenoma
 Cystadenoma is benign epithelial hyperplasia of epidedymis
 Multicystic
 Glandular or pappillary configuration
3. Mesothelioma
 Arises from tunica vaginalis
 Painless scrotal mass with hydrocele
 Older adults
 Both Benign and malignant varieties have been identified
 Malignant cases ralted to asbestos exposure
 Radical orchidectomy
 RPLND in malignant cases

83. Other causes of testicular swelling
Torsion of appendix
testis
Epididymitis
Trauma
Orchitis
Mumps orichitis