Purpose: This study aimed to determine survival rate and clinical characteristics of testicular tumor patients with a history of scrotal violation. Materials and Methods: This study was a retrospective cohort; we reviewed medical records from 2017 to 2021 with testicular tumors who had a history of scrotal violation. We evaluate clinical characteristics and survival up to 5 years. We used the KaplanMeier survival analysis and log-rank test. Results: There are 27 patients with testicular tumor who had a history of scrotal violation. Based on histopathological findings, the most common type was seminoma testis. While based on TNMS staging of the testicular tumor, the most common presentation is T2; Nx; Mx; and S3. Furthermore, based on the prognostic group for testicular tumor we found 5 patients with stage IB, 15 patients with stage IS, 2 patients with stage II, and 5 patients with stage III. Clinical manifestations of scrotal violation were residual tumor found in scrotal region in 2 patients, inguinal and abdominal region in 3 patients. Using the Kaplan-Meier survival curve, the 5-year survival rate was 44% from Statistical test in log-rank test, a significant result is obtained. Conclusion: Survival rate of testicular tumors who had a history of scrotal violation were lower and influenced by ECOG Performance Status Scale. Prognosis of a scrotal breach in the late stage may have a higher mortality rate. In contrast, there was a significant difference in outcome if the scrotal violation had been known at the early stages.
Keywords: Scrotal violation, survival, testicular tumor
|How to cite this URL:|
Pramod SV, Yuananda A, Safriadi F, Hernowo BS. Testicular tumor patients presented with scrotal violation-nonstandard surgical approach and its survival rate. Urol Sci [Epub ahead of print] [cited 2023 Jun 1]. Available from: https://www.e-urol-sci.com/preprintarticle.asp?id=377645
| Introduction|| |
This study describes scrotal violation as part of an unusual surgical approach for suspected cases of testicular cancer or unexplained testicular abnormality. Testicular cancer accounts for 1% of newly diagnosed cancers in men worldwide., In Southeast Asia, South-Central Asia, and Africa, the incidence-to-mortality ratio is 2:1. These significantly improved outcomes are the result of sophisticated surgical techniques, tumor markers to guide treatment options, and platinum-based chemotherapy., For suspected testicular cancer, a radical inguinal orchiectomy is advised. To prevent disease spread, inguinal approach is preferred over scrotal manipulations. Inguinal orchiectomy allows for early ligation of the vessels and prevents tumor spillage. Scrotal violation can occur as a result of an intentional trans-scrotal orchiectomy, a testicular mass biopsy, or scrotal exploration that results in an incidental diagnosis [Figure 1]., The average survival increase every 5 years was 0.5% for 1-year survival and 1% for 5-year survival. The purpose of this study was to determine the survival rate and clinical characteristics of patients with testicular cancer who had a history of scrotal violation.
|Figure 1: Trans-scrotal orchiectomy. Scrotal violation is defined as any trans-scrotal intervention that may impact the spread of disease in testicular cancer, including trans-scrotal orchiectomy|
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| Materials and Methods|| |
This was a retrospective cohort study of 27 patients with testicular tumors who had scrotal violation. Trans-scrotal orchiectomy, testicular biopsy, and epididymectomy were performed at another hospital by a nonurologist. The secondary medical record was used to collect the data. Further, clinical manifestations of scrotal violation in the study included a residual tumor, metastases, treatment, and survival rate [Figure 2].
Kaplan–Meier and the log-rank test were used in this study. The Kaplan-Meier survival curve described the patient's characteristics of survival probability, followed by a log-rank test to see if there were differences between curves. Based on the results of the log-rank test, the analysis and discussion revealed that testicular tumor patients with scrotal violation differed significantly.
This research had received ethics committee permission and ethical practices from the Ethics Committee of Dr. Hasan Sadikin General Hospital Bandung (No.: LB.02.01/X.6.5/317/2022). Because of the nature of this study, the requirement for informed consent was waived.
| Results|| |
Between 2017 and 2021, we obtained 27 patients diagnosed with testicular tumors who had a history of scrotal violation by a nonurologist at another hospital. The subjects' age was ranged from 1 to 55 years, with a mean age of 31–45 years in nine patients (33.3%). Eastern cooperative oncology group (ECOG) performance status was found >2 in 15 patients (55.6%) and <2 in 12 patients (44.4%). Of the 27 patients, 21 (77.7%) had trans-scrotal orchiectomy [Figure 1], 5 (18.5%) had testicular biopsy, and 1 (3.7%) had epididymectomy. The right testicular was the site of the majority of the scrotal violations, which occurred in 14 patients (51.8%). Based on pathology anatomy, the most common testicular tumor was seminoma testis (15 patients or 55.6%), whereas based on the stage of the testicular tumor (TNMS), the most common are T2 (37.0%), Nx (62.9%), Mx (62.9%), and S3 (55.6%). Meanwhile, based on the clinical stage (CS) (prognostic groups), 15 patients (55.5%) were classified as stage 1S, followed by stage 1B in 5 patients (18.5%) and stage 3 in 5 patients (18.5%), and the rarest was stage 2 in 2 patients (7.4%) [Table 1].
A serum tumor marker was used for disease staging, risk stratification, and prognosis. The tumor markers assessed were lactate dehydrogenase, human chorionic gonadotropin (hCG), and alpha fetoprotein (AFP). The S3 category had the highest level of serum marker in these studies on scrotal violation (15 patients or 55.6%). Clinical manifestations of scrotal violation included residual tumors in the scrotum, inguinal, and abdomen regions in approximately 8 patients (29.6%) and no residual tumors 19 patients (70.4%). Chemotherapy and/or residual tumor resection (RTR) were the most commonly used treatments in about 16 patients (51.85%) [Figure 3].
|Figure 3: Residual tumor of scrotal violation. (a) Residual tumor at abdomen region, computed tomography scan of the abdomen with lobulated inhomogeneous hypodense lesion in right lower abdomen pressing on intestine and right common iliac artery, (b) Residual tumor at inguinal region, computed tomography scan of the abdomen with inhomogeneous hypodense lesion in the right parailiac, (c) Residual tumor at scrotum region, on physical examination there was a lump in the right scrotum, fixed, hard, slough, and pus|
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Tumor stages were classified as 1B, 1S, 2, and 3. The ECOG score was divided into two categories: 0–1 and >2. [Table 2] shows the stage, type of tumor, ECOG score, chemotherapy, and 5-year survival.
|Table 2: Eastern Cooperative Oncology Group Performance Status Scale of testicular tumor patients presented with scrotal violation|
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In this study, the survival rate in this study was 48.15% and the mortality rate was 51.85%. For the scrotal violation group, Kaplan–Meier survival curves were used; it was found that the higher the clinical staging, the lower the survival rate [Figure 4]. The median survival at stage 1b was 100% after 5 years, stage 1s was 40% after 5 years, stage 2 was 0% after 4 years, and stage 3 was 20% after 4 years. Furthermore, the median overall survival rate of the group was 44.4%. The results of the log-rank test revealed that testicular tumor patients presented with scrotal violation differed significantly.
|Figure 4: KaplanMeier curve of scrotal violation. Time to testicular tumor patient who suffered from a scrotal violation at tertiary hospital who were followed based on testicular tumor stage|
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| Discussion|| |
A scrotal violation is defined as any trans-scrotal action that can affect tumor germination. A systematic review by Patel et al. revealed that scrotal violation occurred in patients with a mean age ranging from 25 to 40 years, with the majority of scrotal violations occurring on the right side (54.9%)., In this study, the mean age ranged from 31 to 45 years, and majority of scrotal violations occurred in the right testicular (14 patients or 51.8%).,
Scrotal contamination can occur as a result of scrotal violation, resulting in tumor spillage and possibly higher rates of local recurrence.,, Based on the risk of local recurrence, patients with scrotal violations can be classified into two groups. Patients in the first group have scrotal violation with tumor contamination. Adjuvant therapies are appropriate in this group. Patients in the second group have scrotal violation but no tumor spillage, contamination, or positive surgical margins.
More than 95% of testicular cancers are curable., Disease recurrence is classified into two types: local and distant., The scrotal and inguinal regions, including superficial inguinal lymph nodes, are involved in local recurrence., Patel et al. discovered that after 3–5 years, the rate of local recurrence with scrotal violation was low but significantly higher than with high inguinal orchiectomy (2.5% vs. 0.0%, P < 0.001).
According to Capelouto et al., residual tumors for testicular cancer were significantly different between patients who had inguinal orchiectomies (0.4%) and those who had scrotal violations (2.9%). In this study, 27 patients underwent scrotal violation. We found scrotal violation residual tumors in the scrotum (7%), inguinal (11%), and abdomen (11%).
Serum AFP and beta hCG are the most sensitive and specific markers for initial diagnosis, staging, predicting recurrence, and prognosis of testicular cancer, in addition to guiding treatment strategies. Correct patient classification based on TNM and Union for International Cancer Control staging is enabled by correct interpretation of tumor markers before and after orchiectomy in conjunction with computed tomography findings. To tailor further treatment, patients with metastatic disease should be classified according to the International Germ Cell Cancer Collaborative Group.
The majority of scrotal violation patients received adjuvant therapy to prevent further recurrence., According to Gorin et al., trans-scrotal surgery was associated with a significantly increased risk of subsequent distant metastasis. However, other researchers did not find scrotal violation to be a poor prognostic indicator., In these group studies, the survival rate was 48.15% and the mortality rate was 51.85%.,
The treatment of testicular tumors with scrotal was mostly chemotherapy and RTR in this study.,, Different local treatment options for scrotal violation, such as inguinal node dissection, pelvic lymphadenectomy, scrotal irradiation, and hemiscrotectomy, have been proposed by Khetpal et al.
A single cycle of bleomycin, etoposide and cisplatin prevents more than 90% of nonseminoma stage 1 relapses. In seminoma stage 1, studies using one cycle of carboplatin reported a lower 5-year relapse rate of 3%–4% compared to 14%–16% with active surveillance.,, Patients in stage 2 receive chemotherapy as well as RTR. Adjuvant chemotherapy reduces the risk of relapse, and primary retroperitoneal lymph node dissection for CS II seminoma has also been reported. Patients with an ECOG score of 0–1 who received chemotherapy in stage 3 had a higher survival rate than patients with an ECOG score of >2 who underwent RTR but did not receive therapy for all types of testicular tumors.,, It performed RTR on stage 3 nonseminoma and seminoma tumors with a history of testicular biopsy.,
In this cohort, the overall 5-year survival rate for all testicular cancers was 83.9%. nonseminomatous germ cell tumor had a higher 5-year survival rate of 90.5% compared to seminomas, which had a 5-year survival rate of 83.3%. The seminoma type good prognosis group has a 5-year survival rate of 86%, while the nonseminoma type has 92%. The 5-year survival rate for nonseminoma type poor prognosis patients is 48%. Patients with an ECOG score >2 had a lower survival rate for all types of testicular tumors in this study., The 5-year survival rate for seminoma and nonseminoma types with ECOG scores >2 is 0%. According to Capelouto et al., scrotal violation does not result in a significantly worse overall prognosis., These findings also suggest that patients with stage I disease and a scrotal violation should not be excluded from surveillance protocols or subjected to adjuvant local therapy.,,
| Conclusion|| |
This study concluded that the ECOG Performance Status Scale influenced the survival of testicular tumors with a history of scrotal violation. A scrotal breach in its late stages may have a higher mortality rate. In contrast, there was a significant difference in outcome if the scrotal violation was discovered early on. Chemotherapy has a high cure rate in testicular tumors.
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Conflicts of interest
There are no conflicts of interest.
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Sawkar Vijay Pramod,
Dr. Hasan Sadikin General Hospital, Bandung, West Java
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]