inguinoscrotal mass case presentation. objectives to present the history and physical examination of...
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Inguinoscrotal massCase Presentation
Patient data
J.F
40/M
Feb 9 1972
Single
Filipino, Roman Catholic
San Miguel, Pasig
"luslos" (inguinoscrotal mass)
Chief complaint
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
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
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
Past Medical History
(+) Bilaterally undescended testes
(-) HTN
(-) DM
(+) allergy to shrimps
No previous hospitalization
No previous surgeries
Family history
(-) undescended testes in brother
(+) HTN
(-) DM
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
Patient has no children, no wife
Heterosexual, does not use protection,
Currently not sexually active
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
Physical examination
BP 130/80
T 37 C
PR 88 bpm, regular
RR 16 bpm
BMI 23.3
VAS 0/10
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
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
Incarcerated inguinal hernia, R
Primary Impression
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
DiagnosticsUltrasound of the scrotum
Tumor serum markers
AFP
B HCG
LDH
DiscussionTesticular cancer
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
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
Spermatocytic Seminoma
2-12%
Cells closely resemble different phases of maturing spermatogonia
Low metastatic potential
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
Mixed tumors
60% have more than 1 histologic pattern
Usual combination
Risk factors: GCT
20-34 yo
American blacks
Family history
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
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
Chest CT indicated if the abdominopelvic CT shows retroperitoneal adenopathy or abnormal Chest X-ray
Management
Inguinal orchiectomy – primary treatment
Open inguinal biopsy of contralateral testis usually not done, may be considered for cryptochidism
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
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
Campbell et al Urology
NCCN Guidelines on Testicular Cancer
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