Question 1

Case 1 I may have noticed a lump in my scrotum

I have noticed a lump in my scrotum. Have I got cancer?

Tom is a 28-year old male who presents with a swelling in the right testicle. He first became aware of the lesion a couple of weeks ago when he was playing with his 18-month old daughter who accidentally head-butted him. He has not felt any pain in the testicle. However, on closer questioning he says that he has noticed a dragging/ heavy sensation in the scrotum off and on over the last few months. He had attributed this symptom to the fact that he has recently taken to jogging to work. On examination he is found to have a non-tender, 2-cm rubbery mass at the apex of the right testicle. The lesion is ovoid. The left testicle is of normal size and consistency.

VINDICATEOTesticular Lump DdxVascularInflammationNeoplasmCongenitalAllergic AutoimmuneTraumaObstructionSkinCarbuncleCarcinomaUrticariaContusionSebaceous cystSubcutaneous TissueCellulitisDirect inguinal herniaTunica VaginalisIndirect inguinal herniaHaematocele, haematoma, hydrocoeleHydroceleVenous PlexusPhlebitisObstruction from renal carcinomaVaricoceleTestisOrchitisSeminomaTeratomaSyphilisNon seminoma: Embryonal carcinoma, Chorioepithelioma, Yolk sac, teratomaMixed germ cellNon germ cell: sex cord tumoursHydatid cyst of MorgagniEpididymisBacterial epididymitisCystSpermatoceleTuberculosisArteryTorsionTorsionVas DeferensSecondary to obstruction by carcinoma of prostateProstate diseaseLymphaticsFilariasisProbability DxSigns & Symptoms: Rubbery consistency, painless lump, dragging sensation for 2 months makes neoplasm or cyst (epididymal cyst, Hydatid cyst of Morgagni) likely.Age 27 excludes lymphoma, more likely to be seminoma but other types (non-seminoma, mixed germ cell, sex cord tumours and non-germ cell tumours) must be ruled out by biopsy.Trauma: head butt by daughter raises possibility of trauma causing haematoma, haematocele, hydrocele.Presence of fever, pain, malaise, nausea with a Hx of unsafe sexual practices, multiple partners, etc. would make bacterial infection more likely. Mumps is most common cause of orchitis but still need more history.

Other HxConfirm that the daughter did actually head butt him in the goolies. Did the lump appear soon after?The lump itself: has it since changed size, consistencyAssociated symptoms of malignancy: weight loss, night sweats, metastases: lung (cough, haemoptysis), back pain, enlarged cervical or inguinal nodesAny symptoms associated with infection: fever, malaise, nausea, penile discharge (puss, blood), dysuria, skin changes, arthropathiesPMH: cryptorchidism, UTIs, STIs, mumps, parotid swellingSocial Hx (O/S travel, sexual Hx)Family Hx: varicose veins (varicocele), cancersFurther clinical examination?TransilluminationAbdominal examLymph nodesNeuroAnkle edemaGynecomastiaThyroid

Investigations?UltrasoundMRI fetoprotein hCGLDHSperm countAJCC/UICC TNM stagingTreatment options?Sperm cryopreservationRadical inguinal orchiectomyTesticle sparing surgeryRetroperitoneal lymph node dissectionChemotherapyActive surveillanceRadiation therapy

SourcesUp to date:http://www.uptodate.com/contents/evaluation-of-nonacute-scrotal-pathology-in-adult-men