inguinoscrotal mass case presentation. objectives to present the history and physical examination of...
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Inguinoscrotal massCase Presentation
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Patient data
J.F
40/M
Feb 9 1972
Single
Filipino, Roman Catholic
San Miguel, Pasig
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"luslos" (inguinoscrotal mass)
Chief complaint
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History of Present Illness
round palpable inguinal mass (quail egg size), right
More apparent when lifting heavy objects
Reducible
No pain, swelling
No urinary symptoms
4 years PTC
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History of Present IllnessGradual increase in
size (chicken egg)
Involving the scrotum
Irreducible
No pain
Consult at a hospital, advised surgery, deferred
2 years PTC
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History of Present Illness
Persistence of symptoms
Still increasing in size, palm size
Still no pain
No discoloration
Consult at hospital, referred to this institution
2 weeks PTC
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Past Medical History
(+) Bilaterally undescended testes
(-) HTN
(-) DM
(+) allergy to shrimps
No previous hospitalization
No previous surgeries
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Family history
(-) undescended testes in brother
(+) HTN
(-) DM
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Personal & Social History
Construction worker
Lives in apartment-type house with 2 families
Previous smoker, 7 pack years, quit 10 yrs ago
Occasional alcohol drinker
Denies drug use
Water comes from MWSS
Garbage collected regularly
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Patient has no children, no wife
Heterosexual, does not use protection,
Currently not sexually active
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Review of Systems
No recent weight loss
No fever
No cough and colds, no dyspnea
No abdominal pain
No changes in bowel movement
No changes in urination
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Physical examination
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BP 130/80
T 37 C
PR 88 bpm, regular
RR 16 bpm
BMI 23.3
VAS 0/10
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General: Conscious, coherent, not in cardiorespiratory distress, not in pain
Skin: warm to touch, no active lesions
Head and Neck: Anicteric sclerae, pink conjunctiva, (-)TPC, (-) CLAD
Cardiovascular:Adynamic precordium, PMI at 5th ICS along L MCL, normal rate and rhythm, good S1, S2, no murmurs
Respiratory: symmetric chest expansion, clear breath sounds, no rales/crackles
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Gastrointestinal: Flat, normoactive bowel sounds, soft, non-tender
Urogenital: (+) scrotal mass, R
8 x 10 x 6 cm, firm, smooth borders, non-nodular
(-) Transillumination
No palpable testis and masses in Left scrotum
Extremities: Full and equal pulses, Full ROM
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Incarcerated inguinal hernia, R
Primary Impression
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Differential Diagnoses
Testicular Testicular neoplasianeoplasia
Undescended Undescended testes, 36 yo, testes, 36 yo, painless firm painless firm
testicular masstesticular mass
HydrocoeleHydrocoele Painless scrotal Painless scrotal massmass
(-) (-) transilluminatiotransillumination, usually soft n, usually soft
massmass
VaricocoeleVaricocoele Painless scrotal Painless scrotal massmass
Usually soft Usually soft mass, not roundmass, not round
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DiagnosticsUltrasound of the scrotum
Tumor serum markers
AFP
B HCG
LDH
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DiscussionTesticular cancer
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Testicular cancer
Most common malignancy in 15-35 yo men
95% are Germ Cell tumors
Cell types: seminoma (50%) , embryonal cell carcinoma, yolk sac tumor, teratoma, choriocarcinoma
Seminoma and non-seminoma
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SeminomaClassic, anaplastic, spermatocytic
Typical/classic - 82-85% of all seminomas, mostly in 30s, may occur in 40s-50s
Syncyciotrophoblasts - b HCG production
Anaplastic - 5-10%
30% mortality
Lethal- greater mitotic activity, higher rate of local invasion, inc metastatic spread, higher b HCG production
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Spermatocytic Seminoma
2-12%
Cells closely resemble different phases of maturing spermatogonia
Low metastatic potential
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Non-seminomaEmbryonal carcinoma - irregular mass
cut surface: variegated, grayish white, fleshy tumor often with areas of necrosis or hemorrhage and poorly defined capsule
Choriocarcinoma - hemorrhagic
Teratoma- derived from ectoderm, mesoderm, endoderm
Yolk sac tumor- most common in infants and children
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Mixed tumors
60% have more than 1 histologic pattern
Usual combination
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Risk factors: GCT
20-34 yo
American blacks
Family history
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Risk factors: (testicular CIS)
Cryptorchidism (3%)
Family history of testicular carcinoma (5-6%)
Contralateral testis with unilateral testicular cancer (5-6%)
Atrophic contralateral testis with testiculat cancer (30%)
Somatosexual ambiguity (25-100%)
Infertility (0.4-1.1%)Harland et. al 1998
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Approach to a patient with testicular massCBC, creatine, electrolytes, liver enzymes
Serum tumor markers – diagnosis, staging, prognosis; before and after orchiectomy
Chest X-ray
Testicular ultrasound
Biopsy may be considered
Sperm banking
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Chest CT indicated if the abdominopelvic CT shows retroperitoneal adenopathy or abnormal Chest X-ray
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Management
Inguinal orchiectomy – primary treatment
Open inguinal biopsy of contralateral testis usually not done, may be considered for cryptochidism
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Definition of stage and risk classification – American Joint Committee on Cancer (AJCC) an International Germ Cell Cancer Consensus Group (IGCCCG)
Extent of disease
Levels of serum tumor markers post-orchiectomy
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Pure Seminoma IA and IB
Inguinal orchiectomy
Surveillance
Radiotherapy
Chemotherapy (1-2 cycles of carboplatin)
Survival 99%
Relapse rate 99% in 5 years
Follow-up every 3-4 months, for 1-2 years
Then every 6-12 months for 3-4 years, then annuallu
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Campbell et al Urology
NCCN Guidelines on Testicular Cancer