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Updated: Dec 1 2020

Testicular Cancer

  • 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.
  • 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
  • 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
  • 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)
  • 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
  • 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
  • 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
  • Labs 
    • serum tumor marks
      • AFP
      • hCG
      • lactate dehydrogenase (LDH)
  • Histology
    • refer to chart
  • Orchitis
  • Epididymitis
  • Varicoceles
  • Hydroceles
  • Indirect inguinal hernias
  • Surgical
    • radical inguinal orchiectomy 
      • indication
        • primary treatment for testicular tumors and further treatment is determined by microscopic findings and staging
  • Infertility
  • Metastasis
  • Endocrine abnormalities
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