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Malignant Disease of the Testicle
THE JOURNAL OF UROLOGY
Vol. 65, No. 4, April 1951 Printed 1·n U.S.A.
MALIGNANT DISEASE OF THE TESTICLE JAMES C. KIJ\IBROUGH,
CoL.,
:\!IC
AND
JOSEPH C. DENSLOW,
MAJ.,
MC
From the Surgical Service, Walter Reed General Hospital, Washington, D. C.
It is the scope of this paper to discuss the diagnostic difficulties encounternd in 32 patients admitted to Walter Reed General Hospital because of malignant diseases of the testicles during the 3½ year period ending December 31, 1949. Although tumors of the testis are rare, they occur ·with sufficient frequency and early diagnosis is of such great importance that every physical examination should include a careful eyaluation of the scrotal contents. These tumors occur most frequently in the ages 20~40 years. Because of this age factor a high incidence is noted in recruits during a general mobilization. Before the mobilization in 1940, a series of more than 50 testicular tumors was rarely reported. In a short time after mobilization, Lowry, et al. reported 100 cases at the Lawson General Hospital, Lewis reported 250 at Vi/ alter Reed General Hospital, and Friedman and J\foore reported 922 at the Army Institute of Pathology. ETIOLOGY
~ othing more is known of the active etiologic factors than is knmvn of the cause of the malignant tumors in general. Trauma as an etiologic factor is uncertain since the trauma in almost all the cases was merely accidental and did not influence the origin of the disease. Trauma ·was noted in 20 per cent of the cases reported Gordon-Taylor and Till. The incidence in undescended testes has been estimated to be 20 to 40 times as great as in normally organs. The clinical types usually seen are 1) tumors with slmv, insidious, painless, but relentless onset; 2) the "hurricane" type with an incredibly rapid onset; 3) tumors of slmv growth, as in Ko. 1, but with sudden increase in size; and 4) the unobtrnsi,·e first recognized by metastases. In considering the differential diagnosis it is important to keep these types in mind. The structural patterns as classified by Friedman and lVIoore are 1) seminoma, 2) embryonal carcinoma, 3) teratocarcinoma, 4) teratoma, and 5) miscellaneous. This simplified classification giyes the clinician a better Yrnrking basis than the more elaborate nomenclature. Early diagnosis followed by the proper treatment is the most important factor in the prognosis of tumor of the testis. The differential diagnosis is not difficult. Every mass in the scrotum should be considered malignant until proved to be otherwise. Bimanual examination is imperative. In the case of painful lesions, not often found in malignancy, general anesthesia may be necessary in order that the condition of the scrotal contents may be properly evaluated. Epididymitis, thick-,rnlled hydroceles, and hematoceles are the most difficult to differentiate. Hydroceles that haye been tapped frequently are
Read at the annual meeting, Western Section, American Urological Association, Yosem· ite ValleY, Calif., Ma)· 10, 1950. 611
612
JAMES C. KIMBROUGH AND JOSEPH C. DENSLOW
very confusing. Careful estimation of the size, contour, and weight of the testis should be made. A malignant tumor of the testis feels heavier than other masses on bimanual palpation. The clinical recognition is a matter of exclusion. Early diagnosis is life saving. The Aschheim-Zondek hormone test offers little in establishing an early diagnosis, and may even be confusing because the usually negative response may give a sense of false security and cause loss of valuable time in beginning proper treatment. It is important that the diagnosis be established and treatment be initiated before metastases take place. In Lewis' series, metastatic lesions were present in 43 per cent on admission to the hospital and metastases developed in 28 per cent soon after admission, a total of 71 per cent metastases, caused by delay in diagnosis and treatment. TREATMENT
Orchiectomy and resection of the spermatic vessels and the iliac and retroperitoneal lymph glands to the renal pedicle has been the treatment for all cases. Postoperative x-ray treatment has been carried out in case of tumors sensitive to radiation therapy. ANALYSIS OF CASES
In the 3½ years ending December 31, 1949, thirty-two patients were admitted to Walter Reed General Hospital who had malignancy of the testis. The patients ranged from 18 to 43 years of age, the average being 26 years. The initial symptom in all cases except one was painless swelling of the testis. In only 1 case was pain described by the patient at the onset and he did not seek medical attention for 9 months. In several others intermittent, vague, dull pain was noted later, at times associated with moderate pains in the lower abdomen. This is of interest since 9 of the patients were treated for epididymitis because of pain and tenderness in the testis, although they all described painless swelling that antedated the pain. On physical examination the testis was enlarged and firm in 25 of the cases. In only 7 were nodules described. This was probably caused by failure of the examiner to palpate the testis carefully. The initial diagnosis in 18 cases (56 per cent) was tumor. In the other 14 the diagnoses were: epididymitis, 9; hydrocele, 2; varicocele, 1; and no diagnosis, 2. The last 2 patients, were, however, treated for epididymitis. The interval from the onset of symptoms until medical advice was sought was from 1 day to 2 years. The average interval was 3.5 months, but 37 per cent of the patients sought attention within 2 weeks. One patient with symptoms for 7 years is disregarded. Of the patients with metastases the interval was from 1 day to 11 months. The average interval was 4.2 months. Thirty per cent of the patients sought attention within 2 weeks. In the patients in whom the original diagnosis was erroneous, the interval from the onset of symptoms until a correct diagnosis was from 3 days to 4 years (average 4.6 months). The interval from the date of diagnosis of tumor until operation was 1 to 60 days (average 10). In only 7 patients was this over 25 days. This indicates that these patients should be treated as emergencies and given definitive treatment as soon as possible.
r
613
MALIGNANT DISEASE OF THE TESTICLE
The pathologic diagnoses following operation arc shown in table 1. Fourteen patients, or 44 per had metastases, at the time of retroperitoneal gland dissection. No metastases were found to develop following this surgical procedure; however, this series is too small and too recent for proper evaluation of that factor. Nine, or 28 per cent of the patients, died and all of these had metastases at the time of operation. The hormone test was performed on 27 patients and was positive in 3. Two of these had choriocarcinoma and one teratocarcinoma. This indicates that history and physical examination are paramount and that treatment should not await the results of the hormone test. The transfer of one patient to another hospital was delayed 3 weeks a,vaiting the report from a regional laboratory, and when reported the test was negative. There was a history of trauma in 4 patients, but this was either vague or the injury had occurred some years prior to the onset of symptoms. TABLE
1. Pathologic diagnoses and rnetastatic involvement in 32 patients with testicular
tumor TUMOR
Seminoma. Terntocarcinoma. Embryonal carcinoma. Choriocarcinoma. Chorio-epithelioma. Sarcoma, epididymis. Carcinoma, epididyrnis. Total ..
J,.IETASTi-\SES PRESE:JT
10
2
8
3
7
"±
4
4
1 1 1
()
0
32
14
l
REPORT OF CASES
Case 1. A 22 year old man was admitted to an overseas hospital June 7, 1946 complaining of painless swelling and firmness of the left testis of 5 months' duration. This had increased rapidly in size in the 3 months preceding admission. Two weeks prior to admission he had been hospitalized for hepatitis and had undergone a physical examination in which no testicular abnormality had been noted. Examination on admission revealed the left testis to be twice the normal size, smooth and hard in consistency. On June 8 a simple orchiectomy was performed. The hormone test was negative. He was transferred to 'Walter Reed General Hospital and on August 1 a retroperitoneal gland dissection was performed. The pathologic diagnosis was teratocarcinoma, and no metastases were found. He received postoperative radiation. Case 2. A 22 year old man first noted painless swelling of the left testis on October 13, 1948. On December 24 he noted a gna,Ying suprapubic He was admitted to an overseas station hospital with a diagnosis of epididymitis, treated with penicillin and heat, and discharged as cured. Because of continued swelling he ·was readmitted January 25, 1949 and transferred to a general hospital, where an orehiectomy wa8 performed. The hormone test was positive. He was transferred to \V alter Reed General Hospital and on February 8 a radical retroperitoneal gland dissection was performed. Postoperative radiation
614
JA.MES C. KIMBROUGH AND JOSEPH C. DENSLOW
therapy was given. The pathologic examination showed choriocarcinoma, probably chorio-epithelioma, with lymphatic and vascular extension. He died of metastases June 18, 1949. Case 3. A 19 year old man noted a firm, nontender enlargement of the right testis early in March 1947. About the end of March he was admitted to an overseas hospital where he was treated for 3 weeks with penicillin and ice bags. The scrotum was tapped but no fluid was obtained. He was discharged to duty and returned to the "United States for separation. While on terminal leave he reported to an Army hospital where a diagnosis of tumor, hydrocele and organized hematoma was considered. After 6 weeks he was transferred to Walter Reed General Hospital where he was admitted on June 27. A radical orchiectomy performed on July 1 revealed retroperitoneal metastases, which necessitated a right nephrectomy. After a course of postoperative radiation he was discharged January 24, 1948. On November 2 he was readmitted with chest pain, hemoptysis and weakness of 1 month's duration. He died on K ovember 26 with multiple pulmonary metastases. SUMMARY
In a series of 32 cases of tumor of the testis, the initial diagnosis of tumor was made in 18. Fourteen patients had metastases on admission. The average time interval from onset to medical attention was 3.8 months. The average time from first medical attention to definitive treatment was 2 months. The average interval from tumor diagnosis to treatment was 10 days. In those patients in whom the initial diagnosis was incorrect an average of 4.6 months elapsed before proper treatment was instituted. The hormone test was rarely a useful factor in making a proper diagnosis. The results of this test were often confusing and even caused delay in beginning the treatment. Early diagnosis and immediate treatment will greatly reduce the mortality in malignancy of the testis. All scrotal masses should be considered malignant until proved otherwise by adequate examination or operation. REFERE~CES FRIEDMAN, N. B. AND MooRE, R. A.: Tumors of the testis: Report on nine hundred twentytwo cases. Military Surg., 99: 573, 1946. GORDON-TAYLOR, C. AND TILL, A. S.: Malignant disease of testicle with special references to neoplasm of undescended organ. Brit. J. Urol., 10: 1-45, 1938. LEWIS, L. G.: Testis tumors: Report on 250 cases. J. Urol., 59: 763, 1948. Lo WRY, E. C., BEARD, D. E., HEWIT, L. W. AXD BARNER, J. L. : Tumor of the testicle: Analysis of one hundred cases: A preliminary report. J. Urol., 55: 373, 1946.
Vol. 65, No. 4, April 1951 Printed 1·n U.S.A.
MALIGNANT DISEASE OF THE TESTICLE JAMES C. KIJ\IBROUGH,
CoL.,
:\!IC
AND
JOSEPH C. DENSLOW,
MAJ.,
MC
From the Surgical Service, Walter Reed General Hospital, Washington, D. C.
It is the scope of this paper to discuss the diagnostic difficulties encounternd in 32 patients admitted to Walter Reed General Hospital because of malignant diseases of the testicles during the 3½ year period ending December 31, 1949. Although tumors of the testis are rare, they occur ·with sufficient frequency and early diagnosis is of such great importance that every physical examination should include a careful eyaluation of the scrotal contents. These tumors occur most frequently in the ages 20~40 years. Because of this age factor a high incidence is noted in recruits during a general mobilization. Before the mobilization in 1940, a series of more than 50 testicular tumors was rarely reported. In a short time after mobilization, Lowry, et al. reported 100 cases at the Lawson General Hospital, Lewis reported 250 at Vi/ alter Reed General Hospital, and Friedman and J\foore reported 922 at the Army Institute of Pathology. ETIOLOGY
~ othing more is known of the active etiologic factors than is knmvn of the cause of the malignant tumors in general. Trauma as an etiologic factor is uncertain since the trauma in almost all the cases was merely accidental and did not influence the origin of the disease. Trauma ·was noted in 20 per cent of the cases reported Gordon-Taylor and Till. The incidence in undescended testes has been estimated to be 20 to 40 times as great as in normally organs. The clinical types usually seen are 1) tumors with slmv, insidious, painless, but relentless onset; 2) the "hurricane" type with an incredibly rapid onset; 3) tumors of slmv growth, as in Ko. 1, but with sudden increase in size; and 4) the unobtrnsi,·e first recognized by metastases. In considering the differential diagnosis it is important to keep these types in mind. The structural patterns as classified by Friedman and lVIoore are 1) seminoma, 2) embryonal carcinoma, 3) teratocarcinoma, 4) teratoma, and 5) miscellaneous. This simplified classification giyes the clinician a better Yrnrking basis than the more elaborate nomenclature. Early diagnosis followed by the proper treatment is the most important factor in the prognosis of tumor of the testis. The differential diagnosis is not difficult. Every mass in the scrotum should be considered malignant until proved to be otherwise. Bimanual examination is imperative. In the case of painful lesions, not often found in malignancy, general anesthesia may be necessary in order that the condition of the scrotal contents may be properly evaluated. Epididymitis, thick-,rnlled hydroceles, and hematoceles are the most difficult to differentiate. Hydroceles that haye been tapped frequently are
Read at the annual meeting, Western Section, American Urological Association, Yosem· ite ValleY, Calif., Ma)· 10, 1950. 611
612
JAMES C. KIMBROUGH AND JOSEPH C. DENSLOW
very confusing. Careful estimation of the size, contour, and weight of the testis should be made. A malignant tumor of the testis feels heavier than other masses on bimanual palpation. The clinical recognition is a matter of exclusion. Early diagnosis is life saving. The Aschheim-Zondek hormone test offers little in establishing an early diagnosis, and may even be confusing because the usually negative response may give a sense of false security and cause loss of valuable time in beginning proper treatment. It is important that the diagnosis be established and treatment be initiated before metastases take place. In Lewis' series, metastatic lesions were present in 43 per cent on admission to the hospital and metastases developed in 28 per cent soon after admission, a total of 71 per cent metastases, caused by delay in diagnosis and treatment. TREATMENT
Orchiectomy and resection of the spermatic vessels and the iliac and retroperitoneal lymph glands to the renal pedicle has been the treatment for all cases. Postoperative x-ray treatment has been carried out in case of tumors sensitive to radiation therapy. ANALYSIS OF CASES
In the 3½ years ending December 31, 1949, thirty-two patients were admitted to Walter Reed General Hospital who had malignancy of the testis. The patients ranged from 18 to 43 years of age, the average being 26 years. The initial symptom in all cases except one was painless swelling of the testis. In only 1 case was pain described by the patient at the onset and he did not seek medical attention for 9 months. In several others intermittent, vague, dull pain was noted later, at times associated with moderate pains in the lower abdomen. This is of interest since 9 of the patients were treated for epididymitis because of pain and tenderness in the testis, although they all described painless swelling that antedated the pain. On physical examination the testis was enlarged and firm in 25 of the cases. In only 7 were nodules described. This was probably caused by failure of the examiner to palpate the testis carefully. The initial diagnosis in 18 cases (56 per cent) was tumor. In the other 14 the diagnoses were: epididymitis, 9; hydrocele, 2; varicocele, 1; and no diagnosis, 2. The last 2 patients, were, however, treated for epididymitis. The interval from the onset of symptoms until medical advice was sought was from 1 day to 2 years. The average interval was 3.5 months, but 37 per cent of the patients sought attention within 2 weeks. One patient with symptoms for 7 years is disregarded. Of the patients with metastases the interval was from 1 day to 11 months. The average interval was 4.2 months. Thirty per cent of the patients sought attention within 2 weeks. In the patients in whom the original diagnosis was erroneous, the interval from the onset of symptoms until a correct diagnosis was from 3 days to 4 years (average 4.6 months). The interval from the date of diagnosis of tumor until operation was 1 to 60 days (average 10). In only 7 patients was this over 25 days. This indicates that these patients should be treated as emergencies and given definitive treatment as soon as possible.
r
613
MALIGNANT DISEASE OF THE TESTICLE
The pathologic diagnoses following operation arc shown in table 1. Fourteen patients, or 44 per had metastases, at the time of retroperitoneal gland dissection. No metastases were found to develop following this surgical procedure; however, this series is too small and too recent for proper evaluation of that factor. Nine, or 28 per cent of the patients, died and all of these had metastases at the time of operation. The hormone test was performed on 27 patients and was positive in 3. Two of these had choriocarcinoma and one teratocarcinoma. This indicates that history and physical examination are paramount and that treatment should not await the results of the hormone test. The transfer of one patient to another hospital was delayed 3 weeks a,vaiting the report from a regional laboratory, and when reported the test was negative. There was a history of trauma in 4 patients, but this was either vague or the injury had occurred some years prior to the onset of symptoms. TABLE
1. Pathologic diagnoses and rnetastatic involvement in 32 patients with testicular
tumor TUMOR
Seminoma. Terntocarcinoma. Embryonal carcinoma. Choriocarcinoma. Chorio-epithelioma. Sarcoma, epididymis. Carcinoma, epididyrnis. Total ..
J,.IETASTi-\SES PRESE:JT
10
2
8
3
7
"±
4
4
1 1 1
()
0
32
14
l
REPORT OF CASES
Case 1. A 22 year old man was admitted to an overseas hospital June 7, 1946 complaining of painless swelling and firmness of the left testis of 5 months' duration. This had increased rapidly in size in the 3 months preceding admission. Two weeks prior to admission he had been hospitalized for hepatitis and had undergone a physical examination in which no testicular abnormality had been noted. Examination on admission revealed the left testis to be twice the normal size, smooth and hard in consistency. On June 8 a simple orchiectomy was performed. The hormone test was negative. He was transferred to 'Walter Reed General Hospital and on August 1 a retroperitoneal gland dissection was performed. The pathologic diagnosis was teratocarcinoma, and no metastases were found. He received postoperative radiation. Case 2. A 22 year old man first noted painless swelling of the left testis on October 13, 1948. On December 24 he noted a gna,Ying suprapubic He was admitted to an overseas station hospital with a diagnosis of epididymitis, treated with penicillin and heat, and discharged as cured. Because of continued swelling he ·was readmitted January 25, 1949 and transferred to a general hospital, where an orehiectomy wa8 performed. The hormone test was positive. He was transferred to \V alter Reed General Hospital and on February 8 a radical retroperitoneal gland dissection was performed. Postoperative radiation
614
JA.MES C. KIMBROUGH AND JOSEPH C. DENSLOW
therapy was given. The pathologic examination showed choriocarcinoma, probably chorio-epithelioma, with lymphatic and vascular extension. He died of metastases June 18, 1949. Case 3. A 19 year old man noted a firm, nontender enlargement of the right testis early in March 1947. About the end of March he was admitted to an overseas hospital where he was treated for 3 weeks with penicillin and ice bags. The scrotum was tapped but no fluid was obtained. He was discharged to duty and returned to the "United States for separation. While on terminal leave he reported to an Army hospital where a diagnosis of tumor, hydrocele and organized hematoma was considered. After 6 weeks he was transferred to Walter Reed General Hospital where he was admitted on June 27. A radical orchiectomy performed on July 1 revealed retroperitoneal metastases, which necessitated a right nephrectomy. After a course of postoperative radiation he was discharged January 24, 1948. On November 2 he was readmitted with chest pain, hemoptysis and weakness of 1 month's duration. He died on K ovember 26 with multiple pulmonary metastases. SUMMARY
In a series of 32 cases of tumor of the testis, the initial diagnosis of tumor was made in 18. Fourteen patients had metastases on admission. The average time interval from onset to medical attention was 3.8 months. The average time from first medical attention to definitive treatment was 2 months. The average interval from tumor diagnosis to treatment was 10 days. In those patients in whom the initial diagnosis was incorrect an average of 4.6 months elapsed before proper treatment was instituted. The hormone test was rarely a useful factor in making a proper diagnosis. The results of this test were often confusing and even caused delay in beginning the treatment. Early diagnosis and immediate treatment will greatly reduce the mortality in malignancy of the testis. All scrotal masses should be considered malignant until proved otherwise by adequate examination or operation. REFERE~CES FRIEDMAN, N. B. AND MooRE, R. A.: Tumors of the testis: Report on nine hundred twentytwo cases. Military Surg., 99: 573, 1946. GORDON-TAYLOR, C. AND TILL, A. S.: Malignant disease of testicle with special references to neoplasm of undescended organ. Brit. J. Urol., 10: 1-45, 1938. LEWIS, L. G.: Testis tumors: Report on 250 cases. J. Urol., 59: 763, 1948. Lo WRY, E. C., BEARD, D. E., HEWIT, L. W. AXD BARNER, J. L. : Tumor of the testicle: Analysis of one hundred cases: A preliminary report. J. Urol., 55: 373, 1946.