Testicular Cancer

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 side 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

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

Laboratory Tests

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

• Liver biochemical tests

Imaging Studies

• Scrotal ultrasound

• CT scan of chest, abdomen, and pelvis

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 seminomas (retroperitoneal disease < 2 cm diameter in IIa and 2–5 cm in IIb) are treated by

  • Radical orchiectomy plus retroperitoneal irradiation or

  • Primary systemic chemotherapy (etoposide and cisplatin or cisplatin, etoposide, and bleomycin)

• 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 systemic chemotherapy

• 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 imaging (chest radiograph and CT scan) shows no evidence of disease

• Patients with bulky retroperitoneal disease (> 5 cm nodes) or metastases are treated with combination chemotherapy following orchiectomy (cisplatin and etoposide or cisplatin, etoposide, and bleomycin)

• If tumor markers normalize and a residual mass > 1 cm persists, the mass is resected

• Retroperitoneal lymphadenectomy may be considered even if patients have a complete response to chemotherapy, since 10% of patients may have residual cancer and 10% may have teratomas

• If tumor markers fail to normalize following primary chemotherapy, salvage chemotherapy is required (cisplatin, etoposide, bleomycin, and ifosfamide)

Follow-Up

• Postoperative active surveillance for patients who undergo resection

  • Every 1–2 months for the first 2 years and quarterly in the third year

  • Tumor markers are obtained at each visit, and chest radiographs and CT scans are obtained every 3–4 months

  • Follow-up continues beyond the initial 3 years; however, 80% of relapses will occur within the first 2 years

  • With rare exceptions, patients who relapse can be cured by chemotherapy or additional surgery

• Alternatives to surveillance for clinical stage I nonseminoma include

  • Adjuvant chemotherapy (bleomycin, etoposide, cisplatin)

  • Retroperitoneal lymph node dissection

Prognosis

• The 5-year disease-free survival rates for stage I and IIa seminomas (retroperitoneal disease < 10 cm in diameter) treated by radical orchiectomy and retroperitoneal irradiation are 98% and 92–94%, respectively

• Among patients with stage III disease, 95% attain a complete response following orchiectomy and chemotherapy

• Patients with bulky retroperitoneal or disseminated disease treated with primary chemotherapy followed by surgery have a 5-year disease-free survival rate of 55–80%

• For patients with stage I nonseminomas (includes all treatments, orchiectomy and subsequently), the 5-year disease-free survival rate ranges from 96% to 100%

• For low-volume stage II disease, a 5-year disease-free survival rate of 90% can be expected

When to Refer

• Refer all patients with solid masses of the testis to a urologist or medical oncologist if metastatic disease is suspected