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Key Features

Essentials of Diagnosis

  • Most common neoplasm in men aged 20–35

  • Patient typically discovers a painless nodule

  • Orchiectomy necessary for diagnosis

General Considerations

  • Rare, 5–6 new cases per 100,000 males in the United States each year

  • 90–95% of all primary testicular cancers are germ cell tumors (seminoma and nonseminoma); 5–10% are nongerminal neoplasms (Leydig cell, Sertoli cell, gonadoblastoma)

  • Lifetime probability of developing testicular cancer is 0.3% for an American male

  • Slightly more common on the right than on the left, bilateral in 1–2%

  • Cause unknown, but there may be a history of cryptorchism

    • Risk of development of malignancy is highest for an intra-abdominal cryptorchid testis (1:20) and lower for an inguinal cryptorchid testis (1:80)

    • Orchiopexy does not alter the malignant potential of the cryptorchid testis; it does facilitate examination and cancer detection

    • 5–10% of testicular cancers occur in the contralateral, normally descended testis

Clinical Findings

Symptoms and Signs

  • Most common symptom: painless enlargement of the testis

  • Sensation of heaviness

  • Acute testicular pain from intratesticular hemorrhage in ~10%

  • Symptoms relating to metastatic disease in 10%, such as back pain (retroperitoneal metastases), cough (pulmonary metastases), or lower extremity edema (vena cava obstruction)

  • Asymptomatic at presentation in 10%

  • Physical examination: testicular mass or diffuse enlargement of the testis in most cases

  • Secondary hydroceles in 5–10%

  • Supraclavicular adenopathy

  • Retroperitoneal mass

  • Gynecomastia in 5% of germ cell tumors

Differential Diagnosis

  • Epidermoid cyst

Diagnosis

Laboratory Tests

  • Serum human chorionic gonadotropin, α-fetoprotein, and lactate dehydrogenase

  • Liver biochemical tests

Imaging Studies

  • Scrotal ultrasound

  • CT scan of chest, abdomen, and pelvis

Treatment

Surgery

  • Radical orchiectomy by inguinal exploration with early vascular control of the spermatic cord structures

  • Scrotal approaches and open testicular biopsies should be avoided

Seminomas

  • Stage IIa and IIb (retroperitoneal disease < 2 cm diameter in IIa and 2–5 cm in diameter in IIb) seminomas are treated by radical orchiectomy and retroperitoneal irradiation

  • Patients with clinical stage I disease are candidates for surveillance (watchful waiting), single-agent carboplatin, or adjuvant radiotherapy

  • Stage IIc (> 5 cm diameter retroperitoneal nodes) and stage III seminomas are treated with primary chemotherapy (etoposide and cisplatin or cisplatin, etoposide, and bleomycin)

  • Surgical resection of one or more residual retroperitoneal nodes is warranted if the node is > 3 cm in diameter and positive on positron emission tomography, since 40% will harbor residual carcinoma

Nonseminomas

  • Up to 75% of stage I nonseminomas are cured by orchiectomy alone

  • Selected patients who are reliable may be offered surveillance if

    • Tumor is confined within the tunica albuginea

    • Tumor does not demonstrate vascular invasion

    • Tumor markers normalize after orchiectomy

    • Radiographic ...

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