Testicular Cancer

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

• 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)

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

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

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

Demographics

• 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 non-germ cell neoplasms (Leydig cell, Sertoli cell, gonadoblastoma)

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

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: occasionally elevated in seminomas, levels tend to be lower than those seen with nonseminomas

• α-Fetoprotein: never elevated with pure seminomas

• Lactate dehydrogenase: may be elevated with either type of tumor and is a marker for disease burden

• Liver biochemical tests: may be elevated in the presence of hepatic metastases

• Anemia: may be present in advanced disease

Imaging

• Scrotal ultrasound

• CT scan of chest, abdomen, and pelvis for clinical staging:

  • Stage I: lesion confined to testis

  • Stage 2: demonstrates regional lymph node involvement

  • Stage 3: distant metastasis

Treatment

Surgery

• Inguinal exploration with early vascular control of the spermatic cord structures

• Radical orchiectomy is warranted if cancer cannot be excluded

• 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 or primary systemic chemotherapy (etoposide and cisplatin, or ...