Most common neoplasm in men aged 2035 years.

Patient typically discovers a painless nodule.

Orchiectomy necessary for 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 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, 510% 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 he 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.

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 typical 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 510% of cases. In advanced
disease, supraclavicular adenopathy may be present, and abdominal examination may reveal a
mass. Gynecomastia is seen in 5% of germ cell tumors.

B. Laboratory Findings
Several serum markers are important in the diagnosis and monitoring of testicular
carcinoma, including human chorionic gonadotropin (hCG), alpha-fetoprotein, and lactate
dehydrogenase. Alpha-fetoprotein is never elevated with pure seminomas, and while hCG is
occasionally elevated in seminomas, levels tend to be lower than those seen with nonseminomas.
Lactate dehydrogenase may be elevated with either type of tumor. Liver function tests may be
elevated in the presence of hepatic metastases, and anemia may be present in advanced disease.

C. Imaging
Scrotal ultrasound can readily determine whether a mass is intratesticular or extratesticular. Once
the diagnosis of testicular cancer has been established by inguinal orchiectomy, clinical staging of
the disease is accomplished by chest, abdominal, and pelvic CT scanning.

Staging
Testicular cancer is staged using the TNM system created based on extent of cancer in the testis,
status of regional lymph nodes, the presence of metastases in distant lymph nodes or other
viscera, and serum levels of tumor markers. Based on these features, germ cell tumors can be
grouped to assign an overall stage: stage I lesion is confined to the testis; stage II demonstrates
regional lymph node involvement in the retroperitoneum; and stage III indicates distant metastasis.

Differential Diagnosis
An incorrect diagnosis is made at the initial examination in up to 25% of patients with testicular
tumors. Scrotal ultrasonography should be performed if any uncertainty exists with respect to the
diagnosis. Although most intratesticular masses are malignant, a benign lesionepidermoid cyst
may rarely be seen. Epidermoid cysts are usually very small benign nodules located just
underneath the tunica albuginea; occasionally, however, they can be large. Testicular lymphoma is
discussed below.

Treatment
Inguinal exploration with early vascular control of the spermatic cord structures is the initial
intervention. If cancer cannot be excluded by examination of the testis, radical orchiectomy is
warranted. Scrotal approaches and open testicular biopsies should be avoided. Further therapy
depends on the histology of the tumor as well as the clinical stage. Up to 75% of clinical stage I
nonseminomas are cured by orchiectomy alone. Selected patients who meet specific criteria may
be offered surveillance after orchiectomy. These criteria are as follows: (1) cancer is confined within
the tunica albuginea; (2) cancer does not demonstrate vascular invasion; (3) tumor markers
normalize after orchiectomy; (4) radiographic imaging of the chest and abdomen shows no
evidence of disease; and (5) the patient is reliable. Patients most likely to experience relapse on a
surveillance regimen include those with predominantly embryonal cancer and those with vascular
or lymphatic invasion identified in the orchiectomy specimen. Stage I, IIa, and IIb seminomas
(retroperitoneal disease less than 2 cm diameter in IIa and 25 cm in IIb) are treated by radical
orchiectomy and retroperitoneal irradiation. Patients with clinical stage I disease may be
candidates for surveillance or single-agent carboplatin. Seminomas of stage IIc (greater than 5 cm
diameter retroperitoneal nodes) and stage III receive primary chemotherapy (etoposide and
cisplatin or cisplatin, etoposide, and bleomycin) (Table 395). Surgical resection of one or more
residual. retroperitoneal nodes is warranted if the node is greater
than

cm

in

diameter

and

positive

on

PET

scan,

since

40%

will

harbor

residual

carcinoma.Postoperative active surveillance by the clinician and patient means patients are
followed up every 12 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 34 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 surgery.
Alternatives to surveillance for clinical stage I nonseminoma include adjuvant chemotherapy
(bleomycin, etoposide, cisplatin) (see Table 395) or retroperitoneal lymph node dissection.
Patients with bulky retroperitoneal disease (greater than 5 cm nodes) or metastatic nonseminomas
are treated with combination chemotherapy following orchiectomy (cisplatin and etoposide or
cisplatin, etoposide, and bleomycin). If tumor markers normalize and a residual mass greater than
1 cm persists on imaging studies, it is resected because 1520% will harbor residual cancer and
40% will harbor teratomas. Even if patients have a complete response to chemotherapy, some
clinicians advocate retroperitoneal lymphadenectomy since 10% of patients may harbor residual
carcinoma and 10%, retroperitoneal teratoma. If tumor markers fail to normalize following primary
chemotherapy, salvage chemotherapy is required (cisplatin, etoposide, and ifosfamide).

Prognosis
The 5-year disease-free survival rate for patients with stage A nonseminomas (includes all
treatments) ranges from 96% to 100%. For low-volume stage B disease, 90% 5-year disease-free
survival is expected. The 5-year disease- free survival rates for stage I and IIa seminomas
(retroperitoneal disease less than 2 cm in diameter) treated by radical orchiectomy and
retroperitoneal irradiation are 98% and 9294%, respectively. Ninety-five percent of patients with
stage III disease 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 5580%.

When to Refer
Refer all patients with solid masses of the testis to a urologist.