Testicular Torsion Chief Resident Grand Rounds SUNY Downstate Medical Center Jacob Eisdorfer, DO February, 23 th 2012 Thank You Dr. McNeil! www.downsatesurgery.org
Testicular Torsion Chief Resident Grand Rounds
SUNY Downstate Medical Center
Jacob Eisdorfer, DO February, 23th 2012
Thank You Dr. McNeil!
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Agenda • Questions • Anatomy • Differential Diagnosis of Testicular Pain • Pathophysiology / Epidemiology • History • Physical • Diagnosis • Treatment
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Anatomy • Spermatic cord –testicular vessels,
lymph, vas deferens – Epididymis - sperm formed in testicle
and undergo maturation, stored in lower portion
– Vas Deferens –propels sperm up and out during ejaculation
• Gubernaculum – fixation point for testicle to tunica vaginalis
• Tunica Vaginalis – potential space – Encompasses anterior 2/3’s of testicle – Tunica albuginea is inner layer
opposing testis
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Differential
• Pain – Torsion of appendix testis – Epididymitis – Trauma – Orchitis – Others
• Swelling – Hydrocele – Varicocele – Spermatocele – Tumor
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Pathophysiology
• Inadequate fixation of testes to tunica vagnialis at gubernaculum – Torsion around spermatic cord in the Tunica Vaginalis – Lymphatic Compression Venous compression
edema ischemia
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Predisposing Anatomy
• Bell-clapper deformity – Testicle lacks
attachment at tunica vaginalis
– Increased mobility – Transverse lie of testes – Typically bilateral – Prevalence 1/125
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Epidemiology
• Accounts for 30% of all acute scrotal swelling • Bimodal ages
– neonatal (in utero) – 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
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History
• Acute onset of pain – usually testicular, can be lower abdominal, inguinal – May follow exercise or minor trauma – May awaken from sleep
• Cremasteric contraction with nocturnal stimulation in REM
– Up to 8% report testicular pain sometime in the in past
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Physical • Tender, Swollen • Elevated from shortened spermatic cord
– Horizontal lie common (80%) – Reactive hydrocele may be present
• Cremasteric reflex absent in nearly all (unreliable in <30mo old) (95%)
• Prehn’s sign = elevation relieves pain • (+) in epididymitis and • (-) in torsion • unreliable
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Diagnosis
• Imaging – Color doppler (Test of Choice) – 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 • Sens and spec 97-100%
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Imaging
Acute Late
“Rim Sign”
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Treatment • Time is Testicle • 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 present • Orchiectomy if non-viable testicle
• Never delay surgery on assumption of
nonviability as prolonged symptoms can represent periods of intermittent torsion
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Treatment
• Manual Detorsion – If presents before swelling – Appropriate sedation – In 2/3 of cases testes torses
medially, 1/3 lateral – Success if pain relief, & testes
lowers in scrotum – Still need surgical fixation
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References
• Ciftci, AO. Clinical Predictors for Diff. Diagnosis of Acute Scrotum, European J. of Ped. Surgery. Oct 2004.
• Blavis M., Emergency Evaluation of Patients Presenting with Acute Scrotum, Academy of Emergency Medicine. Jan 2001
• al Mufti RA, Ogedegbe AK, Lafferty K. The use of Doppler ultrasound in the clinical management of acute testicular pain. Br J Urol 1995; 76:625.
• Wampler SM, Llanes M. Common scrotal and testicular problems. Prim Care 2010; 37:613.
• Dunne PJ, O'Loughlin BS. Testicular torsion: time is the enemy. Aust N Z J Surg 2000; 70:441.
• Jarow JP, Sanzone JJ. Risk factors for male partner antisperm antibodies. J Urol 1992; 148:1805.
• Schmitz D, Safranek S. Clinical inquiries. How useful is a physical exam in diagnosing testicular torsion? J Fam Pract 2009; 58:433.
• Wilbert DM, Schaerfe CW, Stern WD, et al. Evaluation of the acute scrotum by color-coded Doppler ultrasonography. J Urol 1993; 149:1475.
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Testicular Cancer
Chief Resident Grand Rounds SUNY Downstate Medical Center
Jacob Eisdorfer, DO February, 23th 2012
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Agenda
• Questions • Epidemiology • History • Physical • Work Up • Classification • Treatment
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Question A 24 y/o M presents with a solid, painless right testicular mass confirmed by scrotal ultrasound. Serum Tumor Markers show a βHCG of 96mU/mL, and a AFP of 58. The most likely histologic finding in the right testis is: a. Pure Teratoma b. Pure Seminoma c. Pure Embryonal Carcinoma d. Pure Yolk Sac Tumor e. Choriocarcinoma
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Some epidemiology
• Incidence 0.2% in United States • Most common malignancy in men in the
15 to 35 year age group. – Age - 3 peaks:
2 – 4 yrs. 20 – 40 yrs. above 60 yrs.
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History
• Painless Swelling of One Testis
• Dull Ache or Heaviness in Lower Abdomen
• Acute Scrotal Pain (10%)
• Present with Metastasis (10%) – Neck Mass / Cough / Anorexia / Vomiting / Back Ache / Lower
limb swelling
• Gynecomastia (5%)
• Infertility (Rarely)
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Physical
• Examine contralateral normal testis. • Firm to hard fixed area within tunica
albugenia is suspicious • Seminoma expand within the testis as a
painless, rubbery enlargement. • Embryonal carcinoma or Teratoma may
produce an irregular, rather than discrete mass.
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Physical
• All patients with a solid, Firm Intratesticular Mass that cannot be Transilluminated should be regarded as Malignant until proven otherwise
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Work Up
• Ultrasound - Hypoechoic area • Chest X-Ray - PA and lateral • CT Scan • Tumor Markers
– AFP (Trophoblastic Cells) – β HCG (Syncytiotrophoblastic Cells) – LDH (lactic acid dehydrogenase) – PLAP (placental alkaline phosphatase)
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AFP
• Normal: Below 16 ngm / ml • Half Life: 5 to 7 days • Raised AFP :
– Pure embryonal carcinoma – Teratoma – Yolk sac Tumor – Combined tumors – AFP not raised in pure Choriocarcinoma or in
pure seminoma
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β HCG
• Normal: < 1 ng / ml • Half Life: 24 to 36 hours • RAISED β HCG –
– 100 % - Choriocarcinoma – 60% - Embryonal carcinoma – 55% - Teratoma – 25% - Yolk Cell Tumor – 7%- Seminomas
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Question
A 24 y/o M presents with a solid, painless right testicular mass confirmed by scrotal ultrasound. Serum Tumor Markers show a βHCG of 96mU/mL, and a AFP of 58. The most likely histologic finding in the right testis is: a. Pure Teratoma b. Pure Seminoma c. Pure Embryonal Carcinoma d. Pure Yolk Sac Tumor e. Choriocarcinoma
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LDH & PLAP
• PLAP – Elevated in 50-72% of Seminomas • LDH
– Elevated in 60% of patients with nonseminomatous germ cell tumors
– Nonspecific tumor marker but is a useful prognostic indicator
– Indicator of tumor burden
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How to Use Tumor Markers
• Diagnosis - – 80 to 85% have Positive Markers
• Helps with presurgical Identification of Tumor Histology – Only 10 to 15% Non-Seminomas have normal
marker level – If AFP elevated in Seminoma - Means Tumor has
Non-Seminomatous elements
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How to Use Tumor Markers
• Elevated Markers After Orchiectomy if means Residual Disease
• Elevated Markers after Lymphadenectomy means a STAGE III Disease
• Degree of Marker Elevation Appears to be Directly Proportional to Tumor Burden
• Markers becoming positive on follow up usually indicates Recurrence
• Markers become Positive earlier than Imaging
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Classification
• Primary Neoplasms of Testis – Germ Cell Tumor (90% to 95%) – Non-Germ Cell Tumor
• Secondary Neoplasms • Paratesticular Tumors.
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Germ Cell tumor
• Arise from pluripotential cells • More than half contain more than one cell
type and are therefore known as mixed
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Germ Cell Tumors • Seminomas - 40%
– Typical (82-85%) • Slow growth
– Anaplastic (5-10%) • More aggressive • Greater metastatic potential
– Spermatocytic (2-12 %) – Cells resemble different phases of maturing
spermatogonia – B/L tumors have been reported – Extremely low metastatic potential
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Germ Cell Tumors
• Embryonal Carcinoma - 20 - 25% – Discovered as a small, rounded but irregular
mass invading the tunica vaginalis – Highly malignant
• Teratoma - 25 - 35% – Multiple germ cell layers in various stages of
maturation and differentiation – Large, lobulated, heterogeneous tumors – Microscopically, cystic & solid components – Classified as Mature & Immature
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Germ Cell Tumors • Choriocarcinoma - 1%
– May occur as palpable nodule or normal testis
– Central hemorrhage – High metastatic potential
• Yolk Sac Tumor – most common testicular tumor in infants &
children – A.K.A. endodermal sinus tumor,
adenocarcinoma of infantile testis, orchioblastoma
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Sex cord / gonadal stromal tumors
• Specialized gonadal stromal tumor – Leydig cell tumor – Sertoli cell tumor
• Gonadoblastoma • Miscellaneous Neoplasms
– Carcinoid – Tumors of ovarian epithelial sub types
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Lymphatic Drainage • The primary drainage of the
right testis is within the interaortocaval region.
• Left testis drainage , the Para-aortic region in the compartment bounded by the left ureter, the left renal vein, the aorta, and the origin of the inferior mesenteric artery.
• Cross over from right to left is possible.
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Lymphatic Drainage
• Inguinal node metastasis may result from – scrotal involvement by the primary tumor – prior inguinal or scrotal surgery – retrograde lymphatic spread secondary to
massive retroperitoneal lymph node deposits.
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Clinical Staging
• Stage A or I -Tumor confined to testis. • Stage B or II- Spread to Regional nodes.
– IIA - Nodes <2 cm in size or < 6 Positive Nodes
– IIB - 2 to 5 cm in size or > 6 Positive Nodes – IIC - Large, Bulky, abdominal mass usually >
5 to 10 cm • Stage C or III- Spread beyond
retroperitoneal Nodes or Above the Diaphragm or visceral disease
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TNMS Staging
• Primary Tumor (T) pTX - Primary tumor cannot be assessed (if no radical orchiectomy has been performed, TX is used)
• pT0 = No evidence of Tumor (e.g., histologic scar in testis) • pTis = Intratubular, pre invasive (carcinoma in situ) • pT1 = Confined to Testis and epididymis, no vascular/lymphatic invasion • pT2 = Limited to testis and epididymis with vascular/ lymphatic
invasion or tumor extending through Tunica Albuginea with involvement of tunica vaginalis • pT3 = Invades Spermatic Cord with/without vascular/ lymphatic
invasion • pT4 = Invades Scrotum with/without vascular/ lymphatic invasion Nodal staging: • N1 = Single or multiple < 2 cm • N2 = Multiple < 5 cm / Single 2-5 cm • N3 = Any node > 5 cm
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TNMS Staging
Distant metastasis:
M0 = No distant metastasis
M1 = Distant metastasis
M1a = Nonregional nodal or pulmonary metastasis
M1b = Distant metastasis other than to nonregional lymph nodes and lung
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TNMS Staging
LDH HCG AFP
S0 ≤Normal ≤Normal ≤Normal
S1 <1.5 x Normal <5,000 <5,000
S2 1.5-10 X Normal 5,000 – 50,000 1,000 – 10,000
S3 >10 X Normal >50,000 >10,000
Serum Tumor Markers
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TNMS Staging Stage T N M S
0 pTis N0 M0 S0 I pT1-4 N0 M0 SX IA pT1 N0 M0 S0 IB pT2-4 N0 M0 S0 IS Any pT/Tx N0 M0 S1-3 II Any pT/Tx N1-3 M0 SX
IIA Any pT/Tx N1 M0 S0 Any pT/Tx N1 M0 S1
IIB Any pT/Tx N2 M0 S0-S1 IIC Any pT/Tx N3 M0 S0-S1 III Any pT/Tx Any N M1 SX IIIA Any pT/Tx Any N M1a S0 or S1
IIIB Any pT/Tx N1-3 M0 S2 Any pT/Tx Any N M1a S2
IIIC Any pT/Tx N1-3 M0 S3 Any pT/Tx Any N M1a S3 Any pT/Tx Any N M1b Any S
AJCC Cancer Staging Manual, Seventh Edition (2010) published by Springer New York, Inc.
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Prognosis
• Seminoma (5 yr. Survival) – I: 98% – IIA: 92-94% – IIB-III: 33-75%
• NSGT (5 yr. Survival) – I: 96-100% – IIA: >90% – IIB-III: 55-80%
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Prognosis www.downsatesurgery.org
Treatment Principles
• Seminomas – Radio-Sensitive. Treat with Radiation.
• Non-Seminomas – Radio-Resistant and best treated by Surgery
• Advanced Disease or Metastasis - Responds well to Chemotherapy
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Treatment Principles • Radical INGUINAL ORCHIECTOMY is
Standard first line of therapy – NEVER TRANS-SCROTAL BIOPSY
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Radical Orchiectomy
• Inguinal approach • Testicle and spermatic cord are excised. • If a transscrotal orchiectomy was done
– Will have to go back and excise the ipsilateral hemi-scrotum and spermatic cord
– Biopsy inguinal nodes if palpable or enlarged on CT –> if they are positive will need chemo
• Trans-scrotal orchiectomy disrupts lymphatics therefore changing metastatic pattern (pelvic)
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Seminoma Treatment Flow Chart www.downsatesurgery.org
Seminoma Treatment • Stage I, IIA, IIB
– Radical Inguinal Orchiectomy R – Radiation to Ipsilateral Retroperitonium & Ipsilateral Iliac
group Lymph nodes (2500-3500 rads)
• Bulky stage II and III Seminomas - – Radical Inguinal Orchiectomy is followed by
Chemotherapy
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Non-Seminoma Treatment Flow Chart www.downsatesurgery.org
Non-Seminoma Treatment • Stage I and IIA:
– Radical Orchiectomy followed by Retroperitoneal Lymph Node Dissection
• Stage IIB
– RPLND with possible Adjuvant Chemotherapy
• Stage IIC and Stage III Disease – Initial chemotherapy followed by surgery for
Residual Disease
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Retroperitoneal Lymph Node Dissection
• Primary treatment for NSGCTs • Remove abdominal lymph nodes • Problems mainly occur with the nerve: infertility,
ejaculation problems
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Chemotherapy • BEP: (Bleomycin, Etoposide, Cisplatin)
– 2-4 cycles 21d intervals (4 most common) • EP: (Etoposide, Platinol)
– 4 cycles 21d intervals • Toxicity
– Bleomycin = Pulmonary fibrosis – Etoposide = Myelosuppression, Alopecia, Renal
insufficiency (mild), Secondary leukemia – Cis-platin = Renal insufficiency, Nausea, vomiting,
Neuropathy
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References
• Einhorn LH. Treatment of testicular cancer: a new and improved model. J Clin Oncol 1990; 8:1777.
• Ries LA, Eisner MP, Kosary CL, et al. SEER Cancer Statistics Review, 1975-2001, National Cancer Institute, Bethesda, MD, 2004 http://seer.cancer.gov/csr/1975_2007/index.html (Accessed on April 11, 2011).
• Stephenson AJ, Gilligan TD . Neoplasms of the Testis. In: McDougal WS, Wein AJ, eds. Campbell-Walsh Urology Review. 10th ed. Philadelphia, PA: Elsevier-Saunders; 2012:150.
• Barthold JS. Abnormalities of the Testis and Scrotum and Their Surgical Management. In: McDougal WS, Wein AJ, eds. Campbell-Walsh Urology Review. 10th ed. Philadelphia, PA: Elsevier-Saunders; 2012:642.
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