Journal of the Royal Society ofMedicine Volume 71 October 1978
737
Misdiagnosis of testicular tumours' James T Hill FRCS Norfolk & Norwich Hospital, Norwich NRI 3SR
A rising incidence of testicular tumours has been noted in the Norfolk clinical area over the last decade (Figure 1). Such cases are nevertheless uncommon, accounting for only 1O% of all male cancer deaths (Fergusson 1962). A retrospective study was performed on 100 cases treated between 1966 and 1976 at the Norfolk and Norwich, Great Yarmouth and Lowestoft Hospitals. Misdiagnosed cases were carefully analysed to see if improvements could be made on current surgical management. Analysis of case material Fifty-one cases were diagnosed as teratomas, and 40 as seminomas (Table 1); 9 were miscellaneous tumours. Two patients suffered bilateral asynchronous tumours, 12 cases had suffered testicular maldescent, and in 7 cases a history of major testicular trauma was noted. All cases were initially treated by orchidectomy. Thirty-six of the teratoma cases, and all of the seminoma cases underwent postoperative radiotherapy to the para-aortic lymph nodes,
7~~~~~~~~~~~~~~~~/ C Z4
Ya o9 7P 71nt Year of Presentation
7:1
74
75
7a
Figure 1. Incidence of testicular tumours in the Norfolk clinical area (1966-1976) Paper read to Section of Urology, 23 April 1977 0 1 41-0768/78/100737-04/$O 1.00/0
4. 1978 The Royal Society of Medicine
738
Journal of the Royal Society of Medicine Volume 71 October 1978
Table 1. Histological classification of 100 cases
Type of tumour
Table 2. Three-year survival rate by stage ofdisease
No. of cases
Teratomas Seminoma Teratoma & seminoma Sertoli cell Yolk sac Adenomatoid Lymphoma Metastatic
51 40 3 2 I I 1 1
Seminoma
Teratoma
Stage
No. of cases
No. alive after 3 years
1 2 3 4 1 2 3 4
24 6 1 1 22 2 1 8
21 3 0 0 16 0 0 1
100
and to the supraclavicular nodes if they also were involved in tumour metastases. Advanced underwent chemotherapy. Sixty-five cases were followed up for 3 years. The overall 3-year survival rate was 75% for seminoma (24 out of 32 cases) and 51% for teratoma (17 out of 33 cases). The Peckham & McElwain (1974) method of staging was employed (Table 2). (Stage 1: tumour confined to the testis; Stage 2: tumour spread to the lymph nodes below the diaphragm; Stage 3: tumour spread to the lymph nodes above the diaphragm; Stage 4: tumour spread outside the lymphatic system.) Twenty-nine teratomas were reviewed in the light of the Collins & Pugh (1964) classification as shown in Table 3. The significance of histologically detectable yolk sac elements has recently been emphasized (Brown 1976, Parkinson & Beilby 1977). Evidence of such elements was found in 30 out of 42 teratomas reviewed. Eighteen such cases were followed up for 3 years during which time 10 deaths were recorded. Thirty-seven cases were initially misdiagnosed (Table 4), most commonly due to confusion with epididymo-orchitis. Such cases were initially treated with chemotherapy but failed to improve and were subsequently surgically explored after a variable delay. Cases misdiagnosed as torsion, strangulated hernia and haematocele were explored on an emergency basis, but a scrotal incision was often made. Cases misdiagnosed as hydroceles were put on the elective surgical waiting list with unavoidable delay in treatment. Table 5 shows the mean age and length of history of the general series. Seven misdiagnosed teratomas and 7 misdiagnosed seminomas were followed up for 3 years. It is apparent from Table 6 that misdiagnosed teratoma cases presented with a shorter history and a worse survival rate than those in the general series, whereas this was not true of misdiagnosed seminoma cases.
cases
Table 3. Survival ofpatients with teratomas of
different histological classification
Table 4. Testicular tumours misdiagnosed
Histology
cases
No. alive after 3 years
MTI MTA MTT TD
17 8 2 2
11 1 0 2
No. of
Diagnosis
No.
Epididymo-orchitis Torsion Hydrocele Strangulated hernia Haematocele
23 6 5 2 1 37
MTI: malignant teratoma intermediate MTA: malignant teratoma anaplastic MTT: malignant teratoma trophoblastic TD: teratoma differentiated
Journal of the Royal Society of Medicine Volume 71 October 1978
739
Table 5. Mean age and length of history
Seminoma
Teratoma
Mean age: overall of 3-year survivors of deaths within 3 years
42.8 years 41.6 years 53.4 years
35.5 years 35.5 years 35.5 years
Mean length of history: overall of 3-year survivors of deaths within 3 years
10.4 months 13.0 months 2.1 months
7.7 months 4.7 months 9.8 months
Table 6. Length of history and survival rate in cases misdiagnosed as epididymo-orchitis Type of tumour
Mean length of history
No. surviving 3 years
Seminoma Teratoma
10.4 months 3.0 months
6 out of 7 cases 1 out of 7 cases
This histological classification of misdiagnosed teratomas (Table 7) shows a high incidence of poor cellular differentiation and of yolk sac elements when compared with the general series (Table 3). All cases presenting with any degree of testicular pain were reviewed. Seventeen cases were seminomas, 13 of which survived 3 years, and 20 cases were teratomas, 9 of which survived 3 years, suggesting that pain per se was not an indication of a poor prognosis. No correlation was found between the incidence of tumour formation and occupation or environment. Table 7. Histology of testicular teratomas misdiagnosed as epididymo-orchitis Histology
No.
Yolk sac elements Chorion carcinoma elements MTI MTA MTT TD
13 out of 14 5 out of 14 7 out of 14 7 out of 14 0 0
Discussion The misdiagnosis of testicular tumours is commonly due to confusion with epididymo-orchitis. During examination of such cases it should be noted that in testicular tumours sensation is often impaired, the testis is heavy and hangs lower but the cord often feels normal, whereas in epididymo-orchitis the testis is tender, is often drawn up to the groin and the cord feels thickened and tender (Stephen 1958). Doubtful cases should be given an adequate course of standard chemotherapy; failure to resolve after one month warrants surgical exploration. The high incidence of yolk sac elements, poor cellular differentiation, short history and poor survival rate in teratoma cases misdiagnosed as epididymo-orchitis suggest that they are a unique group of rapidly growing, highly invasive tumours. Other authors have noted a worse prognosis associated with the presence of yolk sac elements (Pierce et al 1970, Parkinson & Beilby 1977).
740
Journal of the Royal Society ofMedicine Volume 71 October 1978
The aspiration of hydroceles might result in the mistaken perforation of a tumour with subsequent local invasion (Stephen 1962). However, misdiagnosing a tumour as a simple hydrocele has a much greater risk if the testis is not correctly palpated after aspiration of the hydrocele in all cases. Testicular trauma often draws attention to an underlying tumour either because testicular sensation is impaired or the haematocele fails to resolve. Such cases always warrant surgical exploration by a groin incision. During such a procedure (Chevassu 1906), it is suggested that the spermatic cord is lightly clamped at the level of the superficial inguinal ring, where there is a free anastomosis between the pampiniform plexus and the cremasteric circulation which would not be controlled by a clamp at the level of the deep inguinal ring. The testis can then be manipulated and, if orchidectomy is decided upon, the cord is ligated further at the deep inguinal ring. Summary One hundred cases of testicular tumour have been reviewed: 37%O of cases were initially misdiagnosed mainly because of confusion between testicular tumour and epididymo-orchitis. A more aggressive surgical approach to doubtful testicular swellings is suggested.
Acknowledgments: I am grateful to Mr N A Green, Mr M H Ashken and Mr C G C Gaches for their advice and permission to study their patients; and to Dr H Baker and Dr P F Roberts for reviewing the histological preparations. References Brown N J (1976) Journal of Clinical Pathology 29, 1021-1025 Chevassu M (1906) Tumeurs du testicule, These de Paris. No. 193, G Steinheil, Paris Collins D H & Pugh R C B (1964) British Journal of Urology 36, Suppl 1 & 2 Fergusson J D (1962) British Journal of Urology 34, 407-421 Parkinson C & Beilby J 0 W (1977) Journal of Clinical Pathology 30, 113-119 Peckham M J & McElwain T J (1974) Proceedings of the Royal Society of Medicine 67, 300-303 Pierce G B, Bullock W K & Huntington R W (1970) Cancer 25, 644-658 Stephen R A (1958) Annals of the Royal College of Surgeons of England 23, 71-88 Stephen R A (1962) British Journal of Urology 34, 448-450
737
Misdiagnosis of testicular tumours' James T Hill FRCS Norfolk & Norwich Hospital, Norwich NRI 3SR
A rising incidence of testicular tumours has been noted in the Norfolk clinical area over the last decade (Figure 1). Such cases are nevertheless uncommon, accounting for only 1O% of all male cancer deaths (Fergusson 1962). A retrospective study was performed on 100 cases treated between 1966 and 1976 at the Norfolk and Norwich, Great Yarmouth and Lowestoft Hospitals. Misdiagnosed cases were carefully analysed to see if improvements could be made on current surgical management. Analysis of case material Fifty-one cases were diagnosed as teratomas, and 40 as seminomas (Table 1); 9 were miscellaneous tumours. Two patients suffered bilateral asynchronous tumours, 12 cases had suffered testicular maldescent, and in 7 cases a history of major testicular trauma was noted. All cases were initially treated by orchidectomy. Thirty-six of the teratoma cases, and all of the seminoma cases underwent postoperative radiotherapy to the para-aortic lymph nodes,
7~~~~~~~~~~~~~~~~/ C Z4
Ya o9 7P 71nt Year of Presentation
7:1
74
75
7a
Figure 1. Incidence of testicular tumours in the Norfolk clinical area (1966-1976) Paper read to Section of Urology, 23 April 1977 0 1 41-0768/78/100737-04/$O 1.00/0
4. 1978 The Royal Society of Medicine
738
Journal of the Royal Society of Medicine Volume 71 October 1978
Table 1. Histological classification of 100 cases
Type of tumour
Table 2. Three-year survival rate by stage ofdisease
No. of cases
Teratomas Seminoma Teratoma & seminoma Sertoli cell Yolk sac Adenomatoid Lymphoma Metastatic
51 40 3 2 I I 1 1
Seminoma
Teratoma
Stage
No. of cases
No. alive after 3 years
1 2 3 4 1 2 3 4
24 6 1 1 22 2 1 8
21 3 0 0 16 0 0 1
100
and to the supraclavicular nodes if they also were involved in tumour metastases. Advanced underwent chemotherapy. Sixty-five cases were followed up for 3 years. The overall 3-year survival rate was 75% for seminoma (24 out of 32 cases) and 51% for teratoma (17 out of 33 cases). The Peckham & McElwain (1974) method of staging was employed (Table 2). (Stage 1: tumour confined to the testis; Stage 2: tumour spread to the lymph nodes below the diaphragm; Stage 3: tumour spread to the lymph nodes above the diaphragm; Stage 4: tumour spread outside the lymphatic system.) Twenty-nine teratomas were reviewed in the light of the Collins & Pugh (1964) classification as shown in Table 3. The significance of histologically detectable yolk sac elements has recently been emphasized (Brown 1976, Parkinson & Beilby 1977). Evidence of such elements was found in 30 out of 42 teratomas reviewed. Eighteen such cases were followed up for 3 years during which time 10 deaths were recorded. Thirty-seven cases were initially misdiagnosed (Table 4), most commonly due to confusion with epididymo-orchitis. Such cases were initially treated with chemotherapy but failed to improve and were subsequently surgically explored after a variable delay. Cases misdiagnosed as torsion, strangulated hernia and haematocele were explored on an emergency basis, but a scrotal incision was often made. Cases misdiagnosed as hydroceles were put on the elective surgical waiting list with unavoidable delay in treatment. Table 5 shows the mean age and length of history of the general series. Seven misdiagnosed teratomas and 7 misdiagnosed seminomas were followed up for 3 years. It is apparent from Table 6 that misdiagnosed teratoma cases presented with a shorter history and a worse survival rate than those in the general series, whereas this was not true of misdiagnosed seminoma cases.
cases
Table 3. Survival ofpatients with teratomas of
different histological classification
Table 4. Testicular tumours misdiagnosed
Histology
cases
No. alive after 3 years
MTI MTA MTT TD
17 8 2 2
11 1 0 2
No. of
Diagnosis
No.
Epididymo-orchitis Torsion Hydrocele Strangulated hernia Haematocele
23 6 5 2 1 37
MTI: malignant teratoma intermediate MTA: malignant teratoma anaplastic MTT: malignant teratoma trophoblastic TD: teratoma differentiated
Journal of the Royal Society of Medicine Volume 71 October 1978
739
Table 5. Mean age and length of history
Seminoma
Teratoma
Mean age: overall of 3-year survivors of deaths within 3 years
42.8 years 41.6 years 53.4 years
35.5 years 35.5 years 35.5 years
Mean length of history: overall of 3-year survivors of deaths within 3 years
10.4 months 13.0 months 2.1 months
7.7 months 4.7 months 9.8 months
Table 6. Length of history and survival rate in cases misdiagnosed as epididymo-orchitis Type of tumour
Mean length of history
No. surviving 3 years
Seminoma Teratoma
10.4 months 3.0 months
6 out of 7 cases 1 out of 7 cases
This histological classification of misdiagnosed teratomas (Table 7) shows a high incidence of poor cellular differentiation and of yolk sac elements when compared with the general series (Table 3). All cases presenting with any degree of testicular pain were reviewed. Seventeen cases were seminomas, 13 of which survived 3 years, and 20 cases were teratomas, 9 of which survived 3 years, suggesting that pain per se was not an indication of a poor prognosis. No correlation was found between the incidence of tumour formation and occupation or environment. Table 7. Histology of testicular teratomas misdiagnosed as epididymo-orchitis Histology
No.
Yolk sac elements Chorion carcinoma elements MTI MTA MTT TD
13 out of 14 5 out of 14 7 out of 14 7 out of 14 0 0
Discussion The misdiagnosis of testicular tumours is commonly due to confusion with epididymo-orchitis. During examination of such cases it should be noted that in testicular tumours sensation is often impaired, the testis is heavy and hangs lower but the cord often feels normal, whereas in epididymo-orchitis the testis is tender, is often drawn up to the groin and the cord feels thickened and tender (Stephen 1958). Doubtful cases should be given an adequate course of standard chemotherapy; failure to resolve after one month warrants surgical exploration. The high incidence of yolk sac elements, poor cellular differentiation, short history and poor survival rate in teratoma cases misdiagnosed as epididymo-orchitis suggest that they are a unique group of rapidly growing, highly invasive tumours. Other authors have noted a worse prognosis associated with the presence of yolk sac elements (Pierce et al 1970, Parkinson & Beilby 1977).
740
Journal of the Royal Society ofMedicine Volume 71 October 1978
The aspiration of hydroceles might result in the mistaken perforation of a tumour with subsequent local invasion (Stephen 1962). However, misdiagnosing a tumour as a simple hydrocele has a much greater risk if the testis is not correctly palpated after aspiration of the hydrocele in all cases. Testicular trauma often draws attention to an underlying tumour either because testicular sensation is impaired or the haematocele fails to resolve. Such cases always warrant surgical exploration by a groin incision. During such a procedure (Chevassu 1906), it is suggested that the spermatic cord is lightly clamped at the level of the superficial inguinal ring, where there is a free anastomosis between the pampiniform plexus and the cremasteric circulation which would not be controlled by a clamp at the level of the deep inguinal ring. The testis can then be manipulated and, if orchidectomy is decided upon, the cord is ligated further at the deep inguinal ring. Summary One hundred cases of testicular tumour have been reviewed: 37%O of cases were initially misdiagnosed mainly because of confusion between testicular tumour and epididymo-orchitis. A more aggressive surgical approach to doubtful testicular swellings is suggested.
Acknowledgments: I am grateful to Mr N A Green, Mr M H Ashken and Mr C G C Gaches for their advice and permission to study their patients; and to Dr H Baker and Dr P F Roberts for reviewing the histological preparations. References Brown N J (1976) Journal of Clinical Pathology 29, 1021-1025 Chevassu M (1906) Tumeurs du testicule, These de Paris. No. 193, G Steinheil, Paris Collins D H & Pugh R C B (1964) British Journal of Urology 36, Suppl 1 & 2 Fergusson J D (1962) British Journal of Urology 34, 407-421 Parkinson C & Beilby J 0 W (1977) Journal of Clinical Pathology 30, 113-119 Peckham M J & McElwain T J (1974) Proceedings of the Royal Society of Medicine 67, 300-303 Pierce G B, Bullock W K & Huntington R W (1970) Cancer 25, 644-658 Stephen R A (1958) Annals of the Royal College of Surgeons of England 23, 71-88 Stephen R A (1962) British Journal of Urology 34, 448-450
