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Primary Carcinoma of the Epididymis
PRIMARY CARCINOMA OF THE EPIDIDYMIS G. A. WILLIAMSON, JR.
AND
TOM R. BARRY
Primary carcinoma of the epididymis occurs so rarely that its existence is more of academic than clinical interest. Ferrier and Foord, in 1934, reviewed the literature and summarized 14 previously reported cases. To these they added one of their own. Thompson has recently reported 7 cases seen at the Mayo Clinic, and also one reported by DeVincentis. To this number we wish to add an additional case, bringing the total to 24 authentic cases thus far published. Case report. H. T. M., a white male, grocery store clerk, aged 26 years, was first seen June, 1934. His chief and only complaint was a severe pain in the right lower quadrant and right testicle of two weeks' duration. This was first noticed after lifting a heavy crate. Prior to this he was not conscious of any discomfort or scrotal enlargement. After this, however, he noticed that the right side of the scrotum was slightly enlarged, but stated that the size had not increased since his attention was first called to it. There was no venereal or tuberculous history. He had always been in the best of health. His appetite was good, and there was no loss of weight. Examination of the right scrotal contents was painful, and revealed a moderate enlargement of the epididymis on this side, which was rather smooth, with no nodules present. The testis and cord were normal, as were the seminal vesicles and prostate. No infection of the urinary tract could be demonstrated. There was no adenopathy present. The general physical examination showed nothing of interest. After a period of six weeks' observation there was no change in his original condition except some decrease in pain. A tentative diagnosis of tuberculous epididymitis was made. Epididymectomy was advised and accepted. The epididymis together with the vas was removed to the external ring. There was a smooth tumor mass about 2 cm. in diameter involving the body of the epididymis. The testicle and vas appeared normal. The pathological examination of the tumor revealed a typical embryonal carcinoma with lymphoid stroma (Ewing and Monger). After receiving the pathological report, it was thought advisable to remove the testicle which was done five days later. The testicle was not involved. 388
PRIMARY CARCINOMA OF EPIDIDYMIS
389
A course of deep x-ray therapy was given immediately upon his discharge from the hospital. A recent examination of the urine showed an absence of prolan A (Fergueson). The patient has gained 15 pounds in weight, shows no evidence of metastasis, and is apparently in good health two years after the operation.
Discussion. The rarity of carcinoma of the epididymis together with the fact that it presents no characteristic diagnostic feature, makes the preoperative diagnosis extremely difficult. Chronic specific epididymitis, tuberculous epididymitis, teratoma testis, syphilis, hydrocele, spermatocele, and hematocele are the usual diagnoses. Unfortunately in many of these cases hydrocele may be a complicating feature obscuring the malignant tumor. The absence of involvement of the vas should help to eliminate tuberculous epididymitis. In the seminoma type of carcinoma, prolan A estimation of the urine may be of some value, but in other types of carcinoma the estimation of prolan A is valueless, unless the condition is advanced and the testicle involved. Pain is the most common chief complaint, and is usually the thing which causes the patient to seek medical aid. Thompson states that about 60 per cent of all tumors of the epididymis are malignant and 40 per cent are benign. Of the malignant ones, about two-thirds are of epithelial origin and one-third are sarcomatous in type. Embryonal carcinoma of the epididymis is very malignant. The tumor usually grows rapidly and tends to metastasize early. Metastases take the same course as do those of malignant neoplasms of the testis, namely along the spermatic lymphatics to the retroperitoneal lymph nodes of the lumbar region. The chain of retroperitoneal, mediastinal, and supraclavicular glands may later be involved. Metastasis by way of the blood stream into the lungs, liver, and other organs is also frequent. The prognosis is somewhat more favorable in tumors of the epididymis than those originating in the testis, of the former group about 30 per cent succumb within the first year. Where the diagnosis can be made prior to operation the ideal treatment is preoperative irradiation followed by castration of the involved side. When a solid tumor of the epididymis is unsuspectedly encoun~ tered at operation, it should be subjected to an immediate biopsy. If it proves benign, removal of the tumor is all that is necessary. If malignant, castration followed by postoperative irradiation is the proTH:EJ ,JOURNAL OF UROLOGY, VOL.
36,
NO.
4
390
G. A. WILLIAMSON, JR. AND TOM R. BARRY
cedure of choice. The radical removal of the retroperitoneal lymph glands is not indicated.
307 Medical Building, Knoxville, Tenn. REFERENCES COLEMAN, C. A., MACKIE, J. A., AND SIMPSON, W. M.: Primary malignant neoplasms of the epididymis. Surg., Gynec. and Obstet., 55: 111, 1932. FERRIER, PAUL A., AND FooRD, ALVIN C.: Primary carcinoma of the epididymis. Urol. and Cutan. Rev., 38: 646, 1934. HINMAN, FRANK: Principles and Practice of Urology. W. B. Saunders Company, 1935, p. 793. JAISOHN, PmLLIP, AND JORDAN, E. V.: Carcinoma of the epididymis. Jour. Amer. Med. Assoc., 100: 1021, 1933. MACKENZIE, DAVID M., AND RATNER, MAX: Tumors of the testis. Surg., Gynec. and Obstet., 52: 336, 1931. THOMPSON, G. J.: Tumors of the spermatic cord, epididymis and testicular tunics. Surg., Gynec. and Obstet., 62: 712, 1936. YOUNG, HUGH H.: Practice of Urology. W. B. Saunders Company, 1926, 1: 686.
AND
TOM R. BARRY
Primary carcinoma of the epididymis occurs so rarely that its existence is more of academic than clinical interest. Ferrier and Foord, in 1934, reviewed the literature and summarized 14 previously reported cases. To these they added one of their own. Thompson has recently reported 7 cases seen at the Mayo Clinic, and also one reported by DeVincentis. To this number we wish to add an additional case, bringing the total to 24 authentic cases thus far published. Case report. H. T. M., a white male, grocery store clerk, aged 26 years, was first seen June, 1934. His chief and only complaint was a severe pain in the right lower quadrant and right testicle of two weeks' duration. This was first noticed after lifting a heavy crate. Prior to this he was not conscious of any discomfort or scrotal enlargement. After this, however, he noticed that the right side of the scrotum was slightly enlarged, but stated that the size had not increased since his attention was first called to it. There was no venereal or tuberculous history. He had always been in the best of health. His appetite was good, and there was no loss of weight. Examination of the right scrotal contents was painful, and revealed a moderate enlargement of the epididymis on this side, which was rather smooth, with no nodules present. The testis and cord were normal, as were the seminal vesicles and prostate. No infection of the urinary tract could be demonstrated. There was no adenopathy present. The general physical examination showed nothing of interest. After a period of six weeks' observation there was no change in his original condition except some decrease in pain. A tentative diagnosis of tuberculous epididymitis was made. Epididymectomy was advised and accepted. The epididymis together with the vas was removed to the external ring. There was a smooth tumor mass about 2 cm. in diameter involving the body of the epididymis. The testicle and vas appeared normal. The pathological examination of the tumor revealed a typical embryonal carcinoma with lymphoid stroma (Ewing and Monger). After receiving the pathological report, it was thought advisable to remove the testicle which was done five days later. The testicle was not involved. 388
PRIMARY CARCINOMA OF EPIDIDYMIS
389
A course of deep x-ray therapy was given immediately upon his discharge from the hospital. A recent examination of the urine showed an absence of prolan A (Fergueson). The patient has gained 15 pounds in weight, shows no evidence of metastasis, and is apparently in good health two years after the operation.
Discussion. The rarity of carcinoma of the epididymis together with the fact that it presents no characteristic diagnostic feature, makes the preoperative diagnosis extremely difficult. Chronic specific epididymitis, tuberculous epididymitis, teratoma testis, syphilis, hydrocele, spermatocele, and hematocele are the usual diagnoses. Unfortunately in many of these cases hydrocele may be a complicating feature obscuring the malignant tumor. The absence of involvement of the vas should help to eliminate tuberculous epididymitis. In the seminoma type of carcinoma, prolan A estimation of the urine may be of some value, but in other types of carcinoma the estimation of prolan A is valueless, unless the condition is advanced and the testicle involved. Pain is the most common chief complaint, and is usually the thing which causes the patient to seek medical aid. Thompson states that about 60 per cent of all tumors of the epididymis are malignant and 40 per cent are benign. Of the malignant ones, about two-thirds are of epithelial origin and one-third are sarcomatous in type. Embryonal carcinoma of the epididymis is very malignant. The tumor usually grows rapidly and tends to metastasize early. Metastases take the same course as do those of malignant neoplasms of the testis, namely along the spermatic lymphatics to the retroperitoneal lymph nodes of the lumbar region. The chain of retroperitoneal, mediastinal, and supraclavicular glands may later be involved. Metastasis by way of the blood stream into the lungs, liver, and other organs is also frequent. The prognosis is somewhat more favorable in tumors of the epididymis than those originating in the testis, of the former group about 30 per cent succumb within the first year. Where the diagnosis can be made prior to operation the ideal treatment is preoperative irradiation followed by castration of the involved side. When a solid tumor of the epididymis is unsuspectedly encoun~ tered at operation, it should be subjected to an immediate biopsy. If it proves benign, removal of the tumor is all that is necessary. If malignant, castration followed by postoperative irradiation is the proTH:EJ ,JOURNAL OF UROLOGY, VOL.
36,
NO.
4
390
G. A. WILLIAMSON, JR. AND TOM R. BARRY
cedure of choice. The radical removal of the retroperitoneal lymph glands is not indicated.
307 Medical Building, Knoxville, Tenn. REFERENCES COLEMAN, C. A., MACKIE, J. A., AND SIMPSON, W. M.: Primary malignant neoplasms of the epididymis. Surg., Gynec. and Obstet., 55: 111, 1932. FERRIER, PAUL A., AND FooRD, ALVIN C.: Primary carcinoma of the epididymis. Urol. and Cutan. Rev., 38: 646, 1934. HINMAN, FRANK: Principles and Practice of Urology. W. B. Saunders Company, 1935, p. 793. JAISOHN, PmLLIP, AND JORDAN, E. V.: Carcinoma of the epididymis. Jour. Amer. Med. Assoc., 100: 1021, 1933. MACKENZIE, DAVID M., AND RATNER, MAX: Tumors of the testis. Surg., Gynec. and Obstet., 52: 336, 1931. THOMPSON, G. J.: Tumors of the spermatic cord, epididymis and testicular tunics. Surg., Gynec. and Obstet., 62: 712, 1936. YOUNG, HUGH H.: Practice of Urology. W. B. Saunders Company, 1926, 1: 686.