A 55-year-old male presented to surgery OPD with complaints of scrotal swelling. Patient also gives a history of anorexia and weight loss. On examination the swelling was hard. All of the following investigations are advised except:
Ans. A. Incisional biopsyExplanationBecause of the characteristic and well-described lymph drainage of the testicle, there is no role for trans-scrotal biopsy or orchiectomy.If the intrascrotal tissue planes are violated during orchiectomy, the lymphatic drainage can be altered, affecting future treatment.Testicular cancerMost cases of primary testicular cancer are germ cell origin (95%); the remainder are predominantly stromal (Leydig cell) or sex cord (Sertoli cell) tumors.The most common presenting complaint in men with testicular cancer is a painless testicular mass.Specific tumor markers: a-fetoprotein, (3-human chorionic gonadotropin, and lactate dehydrogenase staging.Primary Tumor (T)pTX Primary tumor cannot be assessedpT0 No evidence of primary tumorpTis Intratubular germ cell neoplasiapT1 Tumor limited to the testis and epididymis without lymphovascular invasion, may invade tunica albuginea but not tunica vaginalispT2 Tumor limited to the testis and epididymis with lymphovascular invasion or tumor involving the tunica vaginalispT3 Tumor invades the spermatic cord with or without lymphovascular invasionpT4 Tumor invades the scrotum with or without lymphovascular invasionRegional Lymph Nodes (Clinical) (N)NX Regional lymph nodes cannot be assessedNO-No regional lymph node metastasisN1-Metastasis within one or more lymph nodes less than 2 cm in sizeN2-Metastasis within one or more lymph nodes greater than.2.cm but less the 5 cm in sizeN3-Metastasis within one or more lymph nodes greater than.5.cm in sizeRegional Lymph Nodes (Pathologic) (N)NX Regional lymph nodes cannot be assessedNO No regional lymph node metastasisN1 Metastasis within 1-5 lymph nodes; all node masses less than 2 cm in sizeN2 Metastasis within a lymph node greater than 2 cm but not greater than 5 cm in size, or more than 5 lymph nodes involved, none greater than 5 cm and none demonstrating extranodal extension of tumorN3 Metastasis within one or more lymph nodes greater than 5 cm in size Distant Metastasis (M)MX Distant metastasis cannot be assessedMO No distant metastasisMl Distant metastasisM1a Nonregional nodal or pulmonary metastasisM1b Distant metastasis at site other than nonregional lymph nodes or lung Serum Tumor Markers (S)SX Tumor markers not available or performedSO Tumor markers within normal limitsSI LDH <1.5x normal, hCG <5000 IU/L, alpha-fetoprotein (AFP) <1000 ng/mLS2 LDH 1.5-10x normal, hCG 5000-50,000 IU/L, alpha-fetoprotein (AFP) 1000-10,000 ng/mLS3 LDH >10x normal, hCG >50,000 IU/L, AFP >10,000 ng/mLInitial treatment of suspected testicular tumor is radical inguinal orchiectomy, which involves removal of the testicle and spermatic cord at the level of the inguinal ring.Second-line treatment is directed by tumor histology and lymph node stagingFor seminoma stage IA and IB disease, treatment options include surveillance, radiotherapy to the regional lymph nodes (20 Gy), and one or two cycles of carboplatin-based chemotherapy.For seminoma stage IIA and IIB, radiotherapy of the retroperitoneal lymph nodes is standard therapy; for stage IIC or III, platinum-based chemotherapy is standard therapy.For non-seminomatous germ cell tumors (NSGCT) stage I disease, the options include surveillance, retroperitoneal lumph node dissection (RPLND), and cisplatin-based chemotherapy.For NSGCT stage IIA, either primary RPLND (in patients with normal levels of tumor markers) or three or four cycles of cisplatin-based chemotherapy is standard;For NSGCT stage IIB, three or four cycles of cisplatin-based chemotherapy is standard, followed by RPLND or surveillance.
Incisional biopsy
High frequency ultrasonography of scrotum
Serum human chorionic gonadotropin (hCG) levels
Serum lactate dehydrogenase (LDH) levels
Testis & Scrotum