Hydrocele surgery is a painful process

Further information and differential diagnostics for the certified case report "Schmzerlose enlargement of the scrotal content"

scientifically assessed by Professor Dr. Malte Ludwig, Head of the Angiology and Phlebology Department of the Internal Clinic Dr. Argirov, mountain.

by Mirko Müller

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Symptoms and findings

Differential diagnosis of testicular tumor

Literature and Links


Symptoms and findings

In this specific case, a stromal tumor of the testicle - a malignant Sertoli cell tumor - was diagnosed. The majority of testicular tumors occur between the ages of 30 and 40 years. There is another peak in incidence for seminomas around the age of 60. Stromal tumors make up less than 10 percent of all testicular tumors. The Sertoli cell tumor belonging to this group is a rarity, with around 250 reported cases worldwide. A malignant form only occurs in around 10 to 20 percent of cases, so that there are 25 to 50 cases worldwide.

The symptoms described - unclear increases in temperature, unwanted weight loss and syncope - are atypical for testicular cancer patients and explain, among other things, the long way to diagnosis. Apart from the syncope, the symptoms speak for the classic B symptoms, as can be found, for example, in the context of other malignant or chronic inflammatory diseases. The patient's medical history indicated that he was often abroad due to work (chauffeur). Therefore, an infectious disease was initially thought of.

Although the presence of a malignant disease, e.g. haematological or gastrointestinal origin, was taken into account in the differential diagnosis, the pioneering tactile findings of the testicle had remained hidden for a long time due to a lack of examination of the external genitalia. In this context, it should be mentioned here that our own surveys of medical students have shown that the examination of the external genitals, including the rectal examination, is not carried out during the admission examination, mostly due to misunderstood feelings of shame.

Since the laboratory analyzes, with the exception of the anemia and the increase in CRP, were normal and also in the imaging procedures (conventional chest x-ray, computed tomography of the thorax and abdomen, skeletal scintigraphy), there was suspicion if the symptoms persisted on an infectious disease admission to the infection ward of the University Hospital Düsseldorf. During the survey there, the patient stated that an increase in the PSA value (most recently to 9.52 ng / ml) had been noticed in the course of previous routine examinations. Therefore, a total of four prostate biopsies had been performed in the past four years, each with no evidence of malignancy. Instead, the histological picture of chronic prostatitis had emerged. At no time was any noticeable palpable finding of the testicle reported. Not least because of the now existing suspicion of prostate cancer on the part of colleagues, a consultation was presented to our clinic. During the clinical-urological examination, the contents of the right scrotum felt significantly enlarged and suspicious.

In terms of differential diagnosis, epididymitis with involvement of the testicle was initially thought. This was supported by obstructive micturition problems with anamnestic residual urine formation, the histological picture of prostatitis and the condition after several prostate punch biopsies. Furthermore, both the elevated temperatures and the anemia - albeit not to the same extent - and the increase in CRP values ​​matched it. The lack of leukocytosis was not an exclusion criterion. However, this would not have clarified the weight loss. Ultimately, in the specific case, the tactile findings in conjunction with the sonographic findings were groundbreaking for a malignant process of the testicle. The indications for inguinal testicular exposure, which inevitably resulted from this suspicion, confirmed the suspicion both intraoperatively and later histopathologically.

 

Differential diagnosis of testicular tumor

Testicular tumors

Testicular tumors can usually be diagnosed relatively reliably by palpation even by non-urologists. In the majority of cases, the patient reports a painless (in about 20-30 percent also painful) enlargement of the scrotal contents. This is mostly "rock-hard" and occasionally with an irregular surface. In the specific case, the patient did not notice the enlargement of his scrotal organs - which led to the long latency period before the diagnosis was made. Accompanying symptoms such as weight loss, night sweats, back pain and fatigue mostly characterize advanced, metastatic cases. At the time of diagnosis, this is the case in 10 to 30 percent of cases.

 

Tumor markers

If a testicular tumor is suspected, the pre-operative determination of the tumor markers is mandatory.

The "classic testicular tumor markers" include alpha-fetoprotein (AFP), human chorionic gonadotropin (beta-HCG), placental alkaline phosphatase (PLAP) and non-specific lactate dehydrogenase (LDH). Although the markers mentioned cannot be used for screening purposes, they serve as progress parameters during and after therapy in the event of a pathological increase.

The ultrasound examination has become an indispensable part of diagnostics today. Depending on the underlying tumor entity, the sonographic picture is very multifaceted. What they all have in common is that an intratesticular mass can be delimited from the unaffected testicular parenchyma. If the tumor is already very large, it may well be that no intact testicular parenchyma can be seen.

A urinalysis is not obligatory in suspected testicular tumors, but is performed as part of general urological diagnostics. A transcrotal biopsy is prohibited in any case if a tumor is suspected because of the risk of tumor cell spilling. If there is even the slightest suspicion of a testicular tumor, inguinal exposure is mandatory.

A malignant testicular tumor can usually be identified macroscopically without any problems after surgical exposure. The histological typing is of outstanding relevance for the prognosis and therapy. If the diagnosis of "malignant testicular tumor" has been confirmed histologically, the extent of the disease is diagnosed using computed tomography (CT) of the thorax and abdomen. If the patient has neurological symptoms, a CT skull must be performed. Conventional X-rays play practically no role in the assessment of metastases from the testicular tumor. Magnetic resonance tomography is reserved for special indications and, like skeletal scintigraphy and positron emission tomography (PET), is not one of the standard procedures. The latter is only of interest in the course of chemotherapy of a testicular tumor with regard to the dignity of vital tumor tissue, whereby teratomas cannot be diagnosed by PET.

 

Hydrocele

A hydrocele is a pool of water in the tunica vaginalis testis. The latter fuses after the descent of the testicle. If the closure does not take place, the result is an open vaginal process. As a result of trauma or inflammation, increased fluid production in the tunica vaginalis testis can occur, resulting in a hydrocele.

Clinically, a hydrocele is characterized by a slowly increasing enlargement of the scrotal contents. This process often develops over months and years. During the examination, the hydrocele is felt as a resilient, non-painful resistance. This can be very easily diagnosed sonographically as an anechoic mass around the testicles or epididymis. Not infrequently this is also chambered.

Evidence of a hydrocele does not rule out the presence of a testicular tumor or epididymitis. It can be coincident or arise as a follow-up reaction to the inflammation (so-called accompanying hydrocele).

Diaphanoscopy, i.e. the examination of the contents of the scrotum, is no longer important today. Before sonography was introduced, it was a simple method of diagnosing a hydrocele through its translucent effect. Occasionally, mostly older colleagues perform a transscrotal puncture for a hydrocele testis. This is associated with an increased risk of infection and, moreover, only of temporary success. A symptomatic hydrocele is surgically repaired.

 

Epididymitis

An epididymitis (epididymitis) can be well delineated based on the history and the almost invariable constellation of infections in the blood. The following predisposing factors speak for the presence of epididymitis: obstructive micturition problems, possibly with residual urine and status after endoscopic and / or surgical measures on the prostate or urinary bladder.

Symptoms of a urinary tract infection that precede epididymitis are often described. These include pollakiuria and dysuria. Clinically, an increasing painfulness of the affected epididymis, later also of the entire scrotal contents, a reddening of the affected scrotal half and the elimination of the scrotal skin folds, an increase in the size of the scrotal contents and an increase in temperature indicate this.

In advanced cases, the scrotal skin over the testicle can no longer be moved because the adherence of the testicle sheaths is caused by inflammation. The enlarged epididymis can be visualized well with ultrasound. It is not uncommon for the texture to appear inhomogeneous, occasionally with calcifications as an indirect sign of past inflammation. An accompanying hydrocele is common.

The duplex sonography of the scrotal contents helps to determine the V. a. to harden an epididymis. The affected epididymis is hypervascularized on duplex ultrasound. In contrast to a testicular tumor or a hydrocele, in the case of a suspected epididymitis, the detection or exclusion of a urinary tract infection is obligatory, since especially in older men it is almost exclusively an ascending urinary tract infection. The latter are usually understood as a consequence of a subvesical obstruction with residual urine and secondary infection. It is therefore imperative to determine the residual urine.

If there is residual urine formation, a suprapubic urinary drainage takes place. The insertion of a transurethral catheter is forbidden due to the risk of causing further germ ascension and worsening of symptoms due to the mechanical stress on the prostatic urethra and simultaneous infection.

In contrast to younger patients, in whom chlamydia and ureaplasma infections are most common, the germ spectrum includes the group of enterobacteria.

Haematogenic infections are mainly seen in children or adolescents after respiratory diseases with a latency period of 14 days. Physical rest, elevating the scrotum with a testicle rests or a jockstrap and local cooling are complementary conservative measures to the obligatory antibiotic therapy. In the case of acute, melting epididymitis at the time of the initial diagnosis or during ongoing antibiotic therapy, surgical treatment in the sense of splitting the abscess is required. This procedure is mainly carried out transcrotally.

If chronic epididymitis persists, the presence of urogenital tuberculosis must also be considered in the differential diagnosis.

 

Testicular torsion

Testicular torsion is always a highly acute event initially. The patients report the most severe pain, which suddenly began shooting in. This event can occur during exercise, for example during sport or sexual intercourse, but also at rest, practically from sleep. Testicular torsion can occur at any age, but adolescents are more likely to be affected.

Sonographically, a change in the testicular parenchyma texture can only be seen in advanced cases - but then it is difficult to differentiate it from the tumor. In duplex ultrasound, the perfusion of the affected testicle is often reduced or completely eliminated in a lateral comparison. But: the derivation of a flow signal does not rule out testicular torsion. For example, a perfusion can often be detected in the case of a partial torsion - an obstruction of the venous blood flow results in a hemorrhagic infarction depending on the time of the event. This can be suspected sonographically from an inhomogeneous representation of the parenchyma.

Due to the short ischemia tolerance time of the testicle of a maximum of six hours after the torsion, the principle always applies in cases of doubt that the testicles must be exposed for final clarification. A fresh or old testicular torsion can be recognized by a bluish blackish discoloration - mostly of the entire testicle. This is the result of the more or less pronounced hemorrhagic infarction. If there is no spontaneous improvement in testicular perfusion after re-torquing the twisted testicle, only the orchiectomy remains. A hemorrhagic testicular tumor or a hematoma can often be clearly differentiated using the differential diagnosis.

 

Hematoma

An intrascrotal or intratesticular hematoma is practically always associated with trauma, which should be inquired about based on anamnestic. Sonographically, this can be both homogeneous and inhomogeneous. In the case of the organization of the hematoma, liquid parts can also be represented. In terms of differential diagnosis, the presence of an abscess must also be considered in these cases.

 

Lymphoma

Primary malignant lymphoma of the testicle is rare and accounts for approximately 5 percent of all testicular tumors. In men over 60 years of age, however, it is the most common testicular tumor, so that in the present case it definitely had to be considered in terms of differential diagnosis. Primarily malignant lymphoma of the testicle is associated with a poor prognosis. The 5-year survival rate is between 16 and 50 percent. Orchiectomy alone is rarely curative. In the event of therapy failure, there is often an extranodal relapse, mostly in the central nervous system and / or in the contralateral testes.

 

Sertoli cell tumor

As a stromal tumor of the spermatic cord, a Sertoli cell tumor is one of the rare tumor entities. It accounts for about 0.4 to 1.5 percent of all primary testicular tumors and 17 percent of non-germ cell tumors. The low incidence does not allow sufficient conclusions to be drawn regarding the symptoms, the natural course and therapy of the disease (around 260 cases have been published worldwide). In the cases published so far, gynecomastia was occasionally present. In these cases, estrogen production was increased. Testicular tumor markers were negative in each case. Testosterone deficiency due to testicular atrophy has often been described.

The vast majority of Sertoli cell tumors are benign (90 percent). In the case of a primarily metastatic Sertoli cell tumor, the prognosis is very poor (maximum two years). The metastasis is probably primarily lymphogenic. So far it is unclear how and when a hematogenous metastasis takes place. Of the published cases, metastases mostly occurred within the first five months after diagnosis. In one single case, the tumor metastasized only 15 years after primary therapy.

The only reliable criterion for malignancy is evidence of metastasis. Tumor size (over 5 cm), cellular atypia with a tendency to necrosis, lymphovascular invasion, a high mitotic rate and tumor spread beyond the testes predispose to a malignant course. If these factors are present, a modified retroperitoneal lymphadenectomy (RLA) based on the treatment of non-seminomatous testicular tumors is recommended. As with all testicular tumors, primary therapy is inguinal orchiectomy.

Histologically, three subtypes are distinguished:

  1. the classic one
  2. the large-cell calcifying and
  3. the sclerosing Sertoli cell tumor.

The classic Sertoli cell tumor (classic sertoli cell tumor, SCT) was observed in every age group, but on average around the age of 45. It is a slowly growing, well-defined mass in the testicle that causes pain in less than 8.5 percent of cases. A bilateral occurrence and an inheritable variant have not been described. Occasionally elevated levels of estrogen resulted in gynecomastia and / or accelerated bone growth in adolescents. Malignant forms are described in 10 to 20 percent of these cases. However, if the tumor occurs in adulthood, up to 30 percent malignant courses are reported. The malignant courses were characterized by survival times of less than two years and premature metastasis in the lymph nodes, lungs and liver.

The mean age of onset of large-cell calcifying Sertoli cell tumor (large cell calcifying sertoli cell tumor, LCCSCT) is 34 years old; Occasionally, very early manifestations were also reported: from 2 to 51 years of age. This entity is often observed bilaterally; 28 percent of the reported cases were unilaterally multifocal. Inherited cases have been reported. Very often (36 percent) an association with complex dysplastic syndromes, for example Peutz-Jeghers syndrome, Bourneville's syndrome or, most often, with Carney's complex, was seen.The testosterone levels tend to be elevated in these cases; on the other hand, estrogen production is rarely increased and when it is, it is associated with Peutz-Jeghers syndrome. With regard to the age of onset, a distinction is made between an "early onset" and a "late onset" group. In addition to the mean age of onset, 17 vs. 37 years, these also differ in therapy and course. While in the first case a malignant course is rather rare, in the second group malignant degeneration occurs in around 20 to 30 percent of the cases.

The third group, the sclerosing sertoli cell tumor (sclerosing sertoli cell tumor, SSCT), occurs on average at 37 years of age (18 to 80 years of age). So far, only 13 cases have been described worldwide. An increased hormone production or a hereditary course were not observed. Malignant courses have not yet been described.

A uniform therapy regime for malignant Sertoli cell tumors does not exist due to the rarity of the findings. The apparently lack of sensitivity to chemotherapy and / or radiation therapy drastically reduces the therapeutic options. Some authors have therefore recommended performing a retroperitoneal lymphadenectomy based on metastatic non-seminomatous testicular tumors as an effective means for exact staging and treatment of the disease. Since the prognosis is poor in the case of metastasis, surgical therapy is the only available option.

 

Literature and Links

  1. Guideline for the diagnosis and treatment of testicular tumors on the basis of evidence-based medicine (EBM), Deutsche Krebsgesellschaft e.V., 2002
    www.uni-duesseldorf.de/AWMF/ll/032-043.pdf
  2. European Germ Cell Cancer Consensus Group. European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG). Ann Oncol. 2004 Sep; 15 (9): 1377-99
    www.hodenkrebs.de/arzt/Konsensus_Annals_2004.pdf
  3. Interdisciplinary consensus on diagnosis and treatment of trouser tumors Results of an update conference on the basis of evidence-based medicine (EBM) Published in "Radiation therapy and oncology" by Urban & Vogel Verlag (2000),
    www.hodenkrebs.de/arzt/konsensus2000.pdf
  4. Yoon GH, Stein JP, Skinner DG. Retroperitoneal lymph node dissection in the treatment of low-stage nonseminomatous germ cell tumors of the testicle: an update. Urol Oncol. 2005 May-Jun; 23 (3): 168-77.
  5. Hahn NM, Sweeney CJ. Germ cell tumors: an update of recent data and review of active protocols in stage I and metastatic disease. Urol Oncol. 2005 Jul-Aug; 23 (4): 293-302.
  6. Giglio M, Medica M, De Rose AF, Germinale F, Ravetti JL, Carmignani G. Testicular sertoli cell tumors and relative sub-types. Analysis of clinical and prognostic features. Urol Int. 2003; 70 (3): 205-10.
  7. Chang B, Borer JG, Tan PE, Diamond DA. Large-cell calcifying Sertoli cell tumor of the testis: case report and review of the literature. Urology. 1998 Sep; 52 (3): 520-2; discussion 522-3.
  8. Henley JD, Young RH, Ulbright ™. Malignant Sertoli cell tumors of the testis: a study of 13 examples of a neoplasm frequently misinterpreted as seminoma. At J Surg Pathol. 2002 May; 26 (5): 541-50.
  9. Mikuz G. [WHO classification of testicular tumors] Verh Dtsch Ges Pathol. 2002; 86: 67-75.
  10. Young RH, Koelliker DD, Scully RE. Sertoli cell tumors of the testis, not otherwise specified: a clinicopathologic analysis of 60 cases. At J Surg Pathol. 1998 Jun; 22 (6): 709-21.