Updated: 12/1/2020

Testicular Cancer

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Snapshot
  • A 33-year-old man presents to his physician's office after noticing a mass on his left testicle while showering. He reports this has never happened before and denies any pain or discomfort. On physical examination, there is a firm and fixed mass on the left testicle. Bilateral scrotal ultrasound is performed and significant findings are shown.
Introduction
  • Clinical definition
    • testicular malignancy that can be divided into
      • germ cell tumors (~95% of cases and more commonly malignant) which can further divided into
        • seminomas
          • cells can resemble primordial germ cells and early gonocytes
        • nonseminomas
          • cells can be undifferentiated and appear as
            • embryonic stem cells (in embryonal carcinoma)
          • cells can differentiate into
            • yolk sac tumors
            • choriocarcinomas
            • teratomas
      • sex cord-stromal tumors (usually benign)
  • Epidemiology
    • germ cell tumors
      • incidence
        • 6 per 100,000
      • demographics
        • most common tumor in men 15-34 years of age
      • risk factors
        • cryptorchidism
        • family history
        • infertility
  • Pathogenesis
    • germ cell tumors
      • most originate from intratubular germ cell neoplasia and may progress to a seminoma or nonseminomatous tumor
  • Prognosis
    • ~95% cure is expected with treatment
Testicular Tumors
Germ Cell Tumor Type Comments
Seminoma                         
  • Most common type of germ cell tumor
  • Peak incidence is in the third decade of life
  • Morphology
    • cells have a
      • large central nucleus with prominent nucleoli
      • clear and watery-appearing cytoplasm ("fried-egg")
    • ↑ placental alkaline phosphatase (PLAP)
  • Similar to dysgerminoma in females
Yolk sac tumor
  • Also known as endodermal sinus tumor
  • Most common testicular tumor in infants and children (<3 years of age)
  • Morphology
    • Yellow-white mucinous appearance
    • Schiller-Duval bodies in ~50% of cases
    • α-fetoprotein (AFP) and α1-antitrypsin can be seen on immunocytochemical staining
Choriocarcinoma
  • Highly malignant and can metastasize to the
    • lung
    • brain
  • Morphology
    • contains syncytiotrophoblasts (contains hCG) and cytotrophoblasts
  • Laboratory findings
    • ↑ hCG that can result in
      • gynecomastia
      • hyperthyroidism 
      • recall that hCG is structurally similar to luteinizing hormone (LH), follicle-stimulating horomone (FSH), and thyroid-stimulating hormone (TSH)
Teratoma
  • A testicular tumor with cells that are reminiscent of
    • more than one germ layer
  • Can occur at any age
  • Morphology
    • cells or organoid structures may include
      • neural tissue
      • muscle
      • thyroid-like tissue
      • tissue from the intestinal wall
Embryonal carcinoma
  • Mostly affects men at 20-30 years of age
  • Painful
  • More aggressive than seminomas
  • Morphology
    • cells may show
      • glandular patterns
      • papillary convolutions
  • In pure embryonal carcinoma there can be
    • ↑ hCG and normal AFP
      • AFP can be elevated when there is mixed embryonal carcinoma
Sex Cord-Stromal Tumors Comments
Leydig cell tumor
  • Most cases occur at 20-60 years of age
  • Most commonly presents with
    • testicular swelling 
      • gynecomastia may be the first presenting symptom
  • Can produce androgens and estrogens 
    • can result in ↓ LH
  • Morphology
    • golden brown and homogenous cut surface
    • cells contain
      • crystalloids of Reinke in their cytoplasm
Sertoli cell tumor
  • Most cases are benign
  • These tumors are hormonally silent
Non-Hodgkin Lymphomas Comments
Testicular lymphoma             
  • Most common testicular neoplasm in men > 60 years of age
  • Most common testicular lymphoma is
    • diffuse large B-cell lymphoma
  • These tumors have a higher propensity to involve the central nervous system
 
Presentation
  • Symptoms
    • painless nodule or swelling in one testicle (usually)
    • please refer to above chart for specific clinical presentations
  • Physical exam
    • firm, hard, or fixed mass should raise suspicion
      • it is considered testicular cancer until proven otherwise
Imaging
  • Ultrasound  
    • indication
      • initial test for the evaluation of a testicular mass
    • modality
      • bilateral scrotum
    • findings
      • seminomas can show
        • hypoechoic lesions without cystic findings
      • nonseminomatous germ cell tumors can show
        • inhomogenous lesions
        • calcifications
        • cystic areas
        • indistinct margins
  • Radiography
    • indication
      • to assess for suspected mediastinal, hilar, or lung metastasis
    • modality
      • chest
  • Computerized tomography (CT) scan 
    • indications
      • to detect for metastasis to the retroperitoneal lymph nodes in patients diagnosed with testicular cancer
      • to detect for metastasis to the thorax when the chest radiograph is abnormal or when metastatic disease is highly suspected
Studies
  • Labs 
    • serum tumor marks
      • AFP
      • hCG
      • lactate dehydrogenase (LDH)
  • Histology
    • refer to chart
Differential
  • Orchitis
  • Epididymitis
  • Varicoceles
  • Hydroceles
  • Indirect inguinal hernias
Treatment
  • Surgical
    • radical inguinal orchiectomy 
      • indication
        • primary treatment for testicular tumors and further treatment is determined by microscopic findings and staging
Complications
  • Infertility
  • Metastasis
  • Endocrine abnormalities
 

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(M2.ON.14.75) A 30-year-old male presents with a testicular mass of unknown duration. The patient states he first noticed something unusual with his right testicle two weeks ago, but states he did not think it was urgent because it was not painful and believed it would resolve on its own. It has not changed since he first noticed the mass, and the patient still denies pain. On exam, the patient’s right testicle is non-tender, and a firm mass is felt. There is a negative transillumination test, and the mass is non-reducible. Which of the following is the best next step in management?

QID: 103016
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Needle biopsy

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Testicular ultrasound

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MRI abdomen and pelvis

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CT abdomen and pelvis

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Send labs

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