According to the AJCC, the clinical staging for testicular seminoma is:
Stage IA: T1 N0 M0 S0
Stage IB: T2/3/4 N0 M0 S0
Stage IC: any T N0 M0 S1/2/3
Stage IIA: any T N1 M0 S0/1
Stage IIB: any T N2 M0 S0/1
Stage IIC: any T N3 M0 S0/1
Stage IIIA: any T any N M1a S0/1
Stage IIIB: any T any N M0/1a S2
Stage IIIC: any T any N M1a/1b S3.
The patient in this case has IIC stage

Germ cell tumours represent 90% of primary tumours arising in the testis. They are broadly divided into seminomas and non-seminomas. Seminomas are the most common testicular germ cell tumour seen in 40% cases. The other non-seminomatous histological subtypes include embryonal (25%), teratocarcinoma (25%), teratoma (5%) and pure choriocarcinoma (1%).

Varicocele refers to dilatation and increased tortuosity of the pampiniform plexus – which is a network of veins found in spermatic cord that drain the testicle. Defective valves or extrinsic compression can result in outflow obstruction and cause dilatation near the testis. Normal diameter of the small vessels ranges from 0.5 – 1.5mm. A varicocele is a dilatation more than 2mm.

The plexus travels from the posterior aspect of testis into the inguinal canal with other structures forming the spermatic cord. They then form the testicular veins out of which the right testicular vein drains into the inferior vena cava and the left into the left renal vein.

It affects 15-20% men, and 40% of infertile males. Usually diagnosed in 15-25 years of age, they are rarely seen after 40 years of age. Because of the vertical path taken by the left testicular vein to drain into left renal vein, 98% idiopathic varicoceles occur on the left side. It is bilateral in 70% cases. Right-sided varicoceles are rare.

Symptoms include pain or heaviness in the testis, infertility, testicular atrophy, a palpable mass, which is non-tender and along the spermatic cord (resembling a ‘bag of worms’). The testis on the affected side might be smaller.

Diagnosis can be made by ultrasound. Provocative measures such as Valsalva manoeuvre or making the patient stand up to increase the dilatation by increasing the intra-abdominal venous pressure.

According to the American Joint Committee on Cancer (AJCC) 2002 guidelines, the nodal staging of testicular seminoma is the following:

N0: no regional lymph node metastases

N1: metastasis with lymph nodes 2 cm or less in their greatest dimension or multiple lymph nodes, none more than 2 cm

N2: metastasis with lymph nodes greater than 2 cm but not greater than 5 cm in their greatest dimension, or multiple lymph nodes, any one mass greater than 2 cm, but not more than 5 cm

N3: metastasis with lymph nodes greater than 5 cm in their greatest dimension.

The patient in this case has N2 testicular seminoma. This TNM staging is extremely important because treatment options are decided depending on this classification.

The AJCC uses a TNM system to stage prostatic cancer, with categories for the primary tumour, regional lymph nodes and distant metastases:

TX: cannot evaluate the primary tumour T0: no evidence of tumour

T1: tumour present, but not detectable clinically or with imaging T1a: tumour was incidentally found in less than 5% of prostate tissue resected (for other reasons)

T1b: tumour was incidentally found in more than 5% of prostate tissue resected

T1c: tumour was found in a needle biopsy performed due to an elevated serum prostate-specific antigen

T2: the tumour can be felt (palpated) on examination, but has not spread outside the prostate

T2a: the tumour is in half or less than half of one of the prostate gland’s two lobes

T2b: the tumour is in more than half of one lobe, but not both

T2c: the tumour is in both lobes

T3: the tumour has spread through the prostatic capsule (if it is only part-way through, it is still T2)

T3a: the tumour has spread through the capsule on one or both sides

T3b: the tumour has invaded one or both seminal vesicles

T4: the tumour has invaded other nearby structures.

In this case, the tumour has a T1c stage.

A teratoma is a tumour containing tissue elements that are similar to normal derivatives of more than one germ layer. They usually contain skin, hair, teeth and bone tissue and are more common in children, behaving as a benign tumour. After puberty, they are regarded as malignant and can metastasise.

The primary tumour staging for testicular seminoma is as follows, according to AJCC guidelines:

Tis: intratubular germ cell neoplasia (carcinoma in situ)

T1: tumour limited to testis/epididymis without vascular or lymphatic invasion; the tumour can invade into the tunica albuginea but not the tunica vaginalis

T2: tumour limited to testis/epididymis with vascular or lymphatic invasion or tumour extending through the tunica albuginea with involvement of the tunica vaginalis

T3: tumour invading the spermatic cord, with or without vascular/lymphatic invasion

T4: tumour invading the scrotum, with or without vascular/lymphatic invasion.

According to these guidelines, the tumour in this case has a T2 stage.

According to AJCC guidelines, the serum tumour marker staging is the following:

S0: marker studies within normal limits

S1: lactate dehydrogenase (LDH) less than 1.5 times the reference range, beta-human chorionic gonadotrophin (β-hCG) <5000 mIU/ml, and alpha-fetoprotein (AFP) <1000 ng/ml S2: LDH 1.5–10 times the reference range, β-hCG 5000–50,000 mIU/ml or AFP 1000–10,000 ng/ml S3: LDH greater than 10 times the reference range, β-hCG >50,000 mIU/ml or AFP >10,000 ng/ml.

According to this, the patient’s tumour belongs to the S1 stage.

Primary syphilis is transmitted via sexual contact. Lesions on genitalia, called a chancre occur after an asymptomatic incubation period of 10-90 days (average 21 days) after exposure. This chancre is a typically solitary (can be multiple), firm, painless, ulceration over the skin at the point of exposure to spirochete, seen on penis, vagina or rectum. It heals spontaneously after 4-6 weeks. Local lymphadenopathy can be seen.

Diagnosis is made by microscopy of fluid from lesion using dark-field illumination, taking care to not confuse with other treponemal disease. Screening tests include rapid plasma regain (RPR) and Venereal Diseases Research Laboratory (VDRL) tests. False positives are known to occur with these tests and can be seen in viral infections like hepatitis, varicella, Epstein-Barr virus, tuberculosis, lymphoma, pregnancy and IV drug use. More specific tests should therefore be carried out in case these screening tests are positive.

The Treponema pallidum hemagglutination assay (TPHA) and the fluorescent treponemal antibody absorption (FTAABS) test are based on monoclonal antibodies and immunofluorescence and are more specific. However, they can too show false positives with other treponemal diseases like yaws or pinta. Other confirmatory tests include those based on enzyme-linked immunoassays.

The AJCC uses the TNM, Gleason score and PSA levels to determine the overall stage of prostatic cancer. This staging is as follows:

Stage I: T1, N0, M0, Gleason score 6 or less, PSA less than 10; or T2a, N0, M0, Gleason score 6 or less, PSA less than 10

Stage IIa: T1, N0, M0, Gleason score of 7, PSA less than 20; or T1, N0, M0, Gleason score of 6 or less, PSA at least 10 but less than 20; or T2a or T2b, N0, M0, Gleason score of 7 or less, PSA less than 20

Stage IIb: T2c, N0, M0, any Gleason score, any PSA; or T1 or T2, N0, M0, any Gleason score PSA of 20 or more; or T1 or T2, N0, M0, Gleason score of 8 or higher, any PSA

Stage III: T3, N0, M0, any Gleason score, any PSA Stage IV: T4, N0, M0,any Gleason score, any PSA; or any T, N1, M0,any Gleason score, any PSA; or Any T, any N, M1, any Gleason score, any PSA.

The patient in this case has a T2 N0 M0 G2 tumour, meaning it belongs in stage II