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Case History

Image not available. A 26-year-old man with no significant past medical or sexual history presents to his general practitioner with a 1-week history of a painful swollen left testicle. He is initially treated for epididymo-orchitis with a course of antibiotics, but his symptoms do not resolve. He is referred urgently to a urologist. Clinical assessment and a scrotal ultrasound scan reveal a highly suspicious lesion in the left testicle, and he proceeds to a radical inguinal orchidectomy. This confirms a germ cell tumour invading the rete testis but not the spermatic cord. Lymphovascular invasion is also seen. Postoperative staging is negative.

What is the initial differential diagnosis?

What pre- and postoperative tests are essential to fully stage this patient and what is his stage?

What adjuvant treatment should be considered if the histological examination revealed a non-seminomatous germ cell tumour (NSGCT)?

What adjuvant treatment should be considered if the histological examination revealed a seminoma?

Background

What is the initial differential diagnosis?

Image not available. Testicular tumours usually present as a painless testicular nodule or swelling of the whole testicle, with acute pain being a feature in only 10%. The differential diagnosis of a testicular mass include epididymitis/epididymo-orchitis, testicular torsion, varicocele, hydrocoele and haematoma. Up to 40% of patients may present with a sensation of heaviness or a dull ache in the scrotum or perianal region.

What pre- and postoperative tests are essential to fully stage this patient and what is his stage?

The baseline tumour markers (β-human chorionic gonadotrophin [hCG], α-fetoprotein [AFP] and lactate dehydrogenase [LDH]) are vital prognostic indicators, used to stratify patients into prognostic groups according to the International Germ Cell Cancer Collaborative Group (IGCCCG) guidelines,1 if they have metastatic disease. These markers are not specific for germ cell tumours and may occasionally be falsely raised (e.g. marijuana use and liver damage may raise β-hCG and AFP levels, respectively). In 25% of patients with NSGCTs they are not raised; only up to 35% of seminomas produce β-hCG, with pure seminomas not producing AFP at all. Postoperatively the tumour markers should be repeated if they were raised preoperatively. Serial weekly measurements are required until normal values are reached to ensure the levels are falling according to the serum half life of the markers (18–36 hours for β-hCG, and 4–5 days for AFP). Failure to do so implies metastatic disease.

Postoperative imaging consists of a computed tomography (CT) scan of the chest, abdomen and pelvis to fully stage the patient. Positron emission tomography (PET) has not been shown to be useful in confirming stage 1 disease.

The stage of this patient is stage 1B,2 which equates to pT2 N0 M0 S0. Invasion of the rete testis, although prognostic for seminomas, is not part of the staging system; tunica vaginalis invasion, however, will upstage it to pT2, as does the presence of ...

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