39-23: Testicular Cancers (Germ Cell Tumors)

ESSENTIALS OF DIAGNOSIS

GENERAL CONSIDERATIONS

Malignant tumors of the testis are rare, with approximately five to six cases per 100,000 males reported in the United States each year. Ninety to 95 percent of all primary testicular tumors are germ cell tumors and can be divided into two major categories: nonseminomas, including embryonal cell carcinoma (20%), teratoma (5%), choriocarcinoma (less than 1%), and mixed cell types (40%); and seminomas (35%). The remainder of primary testicular tumors are non-germ cell neoplasms (Leydig cell, Sertoli cell, gonadoblastoma). The lifetime probability of developing testicular cancer is 0.3% for an American male.

Approximately 5% of testicular cancers develop in a patient with a history of cryptorchism, with seminoma being the most common. However, 5–10% of these tumors occur in the contralateral, normally descended testis. The relative risk of development of malignancy is higher for the intra-abdominal testis (1:20) and lower for the inguinal testis (1:80). Placement of the cryptorchid testis into the scrotum (orchidopexy) does not alter its malignant potential but does facilitate routine examination and cancer detection.

Testicular cancer is slightly more common on the right than the left, paralleling the increased incidence of cryptorchidism on the right side. One to 2 percent of primary testicular cancers are bilateral and up to 50% of these men have a history of unilateral or bilateral cryptorchidism. Primary bilateral testicular cancers may occur synchronously or asynchronously but tend to be of the same histology. Seminoma is the most common histologic finding in bilateral primary testicular cancers, while malignant lymphoma is the most common bilateral testicular tumor overall.

In animal models, exogenous estrogen administration during pregnancy has been associated with an increased development of testicular tumors with relative risk ranging from 2.8 to 5.3. Other acquired factors such as trauma and infection-related testicular atrophy have been associated with testicular tumors; however, a causal relationship has not been established.

CLINICAL FINDINGS

A. Symptoms and Signs

The most common symptom of testicular cancer is painless enlargement of the testis. Sensations of heaviness are not unusual. Patients are usually the first to recognize an abnormality, yet often delay in seeking medical attention ranges from 3 to 6 months. Acute testicular pain resulting from intratesticular hemorrhage occurs in approximately 10% of cases. Ten percent of patients are asymptomatic at presentation, and 10% manifest symptoms relating to metastatic disease such as back pain (retroperitoneal metastases), cough (pulmonary metastases), or lower extremity edema (vena cava obstruction).

A discrete mass or diffuse testicular enlargement is noted in most cases. Secondary hydroceles may be present in 5–10% of cases. In advanced disease, supraclavicular adenopathy may be present, and abdominal examination may reveal a ...