Updated: 12/6/2017

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
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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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.ON.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? Review Topic

QID: 103016
1

Needle biopsy

13%

(2/15)

2

Testicular ultrasound

67%

(10/15)

3

MRI abdomen and pelvis

7%

(1/15)

4

CT abdomen and pelvis

7%

(1/15)

5

Send labs

0%

(0/15)

M2

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