A 47-year-old man presents with scrotal swelling and lumbar back pain for one year. He has a history of an inguinal “hernia,” and the pain is exacerbated with lifting and twisting.
He denies IV drug use, sexually transmitted disease, penile lesions, rash, dysuria, frequency, night sweats, weight loss, chest pain, shortness of breath, abdominal pain, paresthesias, weakness, and change in bladder or bowel habits.
On examination, he has a grapefruit-sized testicular mass. The photograph shows his testicular ultrasound.
What condition could be causing his back pain? See p. 6.
Diagnosis: Testicular Cancer
Testicular cancer is the most common solid tumor in post-puberty and young adult men with a lifetime risk of approximately one in 250. It accounts for only one percent of all-cause cancers in men (CA Cancer J Clin 2011;61:212), but has excellent cure rates.(Urology 2011;78[4 Suppl]:S427.) This is an unlikely primary presentation in the ED, but the EP should be familiar with the presentation and evaluation because its incidence appears to be on the rise. (Int J Cancer 2006;118:3099.) Almost all (95%) testicular cancers are germ cell tumors (GCTs), classified as seminomas or nonseminomas, with the remaining identified as Leydig or Sertoli cell tumors. The etiology of the increased incidence is unknown, but risk factors include a premalignant condition for GCTs (carcinoma in situ), a family or personal history of testicular cancer, a personal history of extragonadal germ cell tumors, Down syndrome, impaired fertility, hypospadias, Peutz-Jeghers syndrome (Sertoli cell tumors), and HIV infection. Undescended testes, particularly intraabdominal rather than infrainguinal, also significantly predispose the patient to testicular cancer. The risk of exposure to intrauterine estrogens, pesticides, elevated cholesterol levels, and ethnicity have yet to be determined.
GCTs present most often after puberty as a painless testicular mass. (Urology 2006;68:402.) Leydig cell tumors present differently from GCTs, with precocious puberty or symptoms related to excess estrogen and decreased testosterone production in young adults. (Cancer 1975;35:1184.) Some patients may complain of “heaviness or fullness” in the lower abdominal, perineal, or scrotal area, but acute pain is atypical, occurring in less than 10 percent of patients. Patients who present with symptoms resulting from metastasis (10%) are equally rare. Metastasis can occur in the lungs, in the gastrointestinal system including the liver, in bone, in the central and peripheral nervous systems, and in the lymphatic system. It can present with myriad findings. Lower extremity or pelvic venous thromboses are also complications of metastatic disease, and as many as 10 percent of patients will have gynecomastia (up to 30% in patients with Leydig cell tumors) from a testicular malignancy.
Patients with asymmetric firm testicular swelling, hard or fixed areas in the tunica albuginea, and inguinal adenopathy on physical examination are concerning for testicular cancer, and warrant further evaluation with ultrasound. The differential diagnosis of testicular cancer includes testicular torsion, epididymitis, hematoma, spermatocele, hydrocele, varicocele, and hernia.
Ultrasound can identify the location of any masses and characterize tumors as small as 1 mm in diameter. The ultrasonic findings of testicular malignancy include hypoechoic lesions, cystic lesions, calcifications, and regular or irregular margins. Ultrasound is unable to stage or fully characterize and diagnose the cell type of a testicular tumor appropriately, however. (Urol Int 1990;45:237.) Surgical tissue diagnosis by radical inguinal orchiectomy and staging by regional lymph node dissection is therefore required. (Urol Clin North Am 2011;38:439.)
Testicular biopsy and scrotal violation procedures prior to radical inguinal orchiectomy are not typically recommended. (J Urol 1995;153[3 Pt 2]:981.) Patients with testicular cancer tend to be pre- or reproductive age so fertility-sparing treatments including partial orchiectomy can occur but are less common and depend on patient clinical factors.(Urology 2004;63:421.) Semen cryopreservation is an option, but as many as half of patients with testicular cancer may have some form of baseline sperm impairment. (Semin Urol Oncol 1996;14:36; J Urol; 1987;137:420.)
CT of the abdomen is recommended to characterize possible metastases as is a screening chest x-ray. (N Engl J Med 1997;337:242.) Baseline complete blood count, chemistries, and serum tumor markers (alpha fetoprotein, beta-HCG, and lactate dehydrogenase) are also part of the evaluation. Tumor markers are insufficient to rule out testicular cancer, and are used primarily for trending response to disease management therapies.
How much of this staging evaluation and patient disposition occurs in the ED for a patient with a newly diagnosed possible malignant testicular mass depends on local practice, access to outpatient care, the patient's clinical condition in the ED, and provider and patient preference. Once the diagnosis of possible malignant testicular tumor is made in the ED, the patient must be counseled about the need for prompt outpatient follow-up and the need for further characterization because prognosis depends on early detection and treatment.
Early detection and surgical, radiation, and chemotherapeutic treatments have raised the five-year survival rate for most testicular cancers to 95 percent, a significant improvement from under 65 percent in the 1960s. (J Clin Oncol 1990;8:1777; SEER Cancer Statistics Review, 1975–2001. Bethesda, MD: National Cancer Institute, 2004.)
This patient had significant retroperitoneal metastatic disease that resulted in obstructive renal failure, lung metastasis, and large pelvic thromboses. He had a complicated a hospital course including sepsis, large malignant pleural effusions, and a pneumothorax.
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