eMedicine Specialties > Urology > Cancer, Testicle
Testicular Seminoma: Differential Diagnoses & Workup
Updated: May 21, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Epididymitis
Hydrocele
Testicular Choriocarcinoma
Testicular Trauma
Testicular Tumors: Nonseminomatous
Other Problems to Be Considered
Testicular teratocarcinoma
Workup
Laboratory Studies
- Yolk sac elements secrete AFP; an elevated AFP level rules out pure seminoma, despite possible contrary histopathologic orchiectomy findings.
- Lactate dehydrogenase (LDH) is a less-specific marker for GCTs, but levels can correlate with overall tumor burden.
- Measure beta-human chorionic gonadotropin (bhCG).
- bHCG is a glycoprotein with the same alpha unit as thyroid-stimulating hormone, follicle-stimulating hormone, and luteinizing hormone.
- It has a 24- to 36-hour half-life and is secreted by syncytiotrophoblast cells within GCTs.
- In 5%-10% of patients with seminomas, bHCG levels are elevated. Its elevation may correlate with metastatic disease but not with overall survival.
- If bHCG levels do not normalize after orchiectomy, Richie (1998) suggests the treatment approach should be that for NSGCT, citing a study in which one third of patients who died of metastatic seminoma were found to have nonseminomatous elements at autopsy.12 With the 10% incidence of pure seminomas producing bHCG, NSGCT chemotherapy regimens may better serve these patients.
- Placentalike alkaline phosphatase levels can be elevated in patients with seminoma, especially as the tumor burden increases; it may also increase with smoking.
Imaging Studies
- Scrotal ultrasonography15
- Consider this study in any male with a suspicious or questionable testicular mass that is palpable upon physical examination (see Image 2).
Testicular seminoma. This scrotal ultrasound of a 37-year-old man with a painless mass in his right testis shows a right testis with hypoechoic solid masses compared to the homogeneous, more hyperechoic, healthy left testis. Levels of serum beta-human chorionic gonadotropin and alpha-fetoprotein were within the reference range, and the metastatic workup findings were negative. Histopathology showed a pure seminoma. Metastatic workup showed no nodal or distant spread, T1N0M0 stage I. After orchiectomy, the patient underwent adjuvant external beam radiotherapy to the para-aortic nodes. At a 3-year follow-up study, the patient is disease free and has a greater than 95% chance of remaining disease free.
- Other indications may include acute scrotal pain (especially when associated with a hydrocele), nonspecific scrotal pain, swelling, or the presence of a mass.
- If an asymptomatic hydrocele obscures physical examination of the testicle, this study may be appropriate prior to surgical intervention. It may also be appropriate for males who are at the peak age range for testicular cancer (ie, 15-35 y).
- Scrotal ultrasonography commonly shows a homogeneous hypoechoic intratesticular mass. Larger lesions may be more inhomogeneous.
- Calcifications and cystic areas are less common in seminomas than in nonseminomatous tumors.
- Consider this study in any male with a suspicious or questionable testicular mass that is palpable upon physical examination (see Image 2).
- Abdominal and pelvic CT scanning: This study, along with intravenous and oral contrast, can be used to identify metastatic disease to the retroperitoneal lymph nodes; however, CT scanning results in understaging in approximately 15%-20% of patients thought to be at stage I.16
- Chest CT scanning: This is indicated only when abnormal findings are observed on a chest radiograph.
- Fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET): This technique has been evaluated for its utility in staging and restaging of seminomatous and nonseminomatous tumors.17,18,19 In primary staging, FDG-PET has been found to have no benefit over CT scanning alone. However, in restaging assessments of residual masses, FDG-PET was noted to improve the ability to detect a fibrotic residual mass compared to that of residual teratoma postchemotherapy. Hinz et al (2008) prospectively evaluated 20 patients with a residual mass following chemotherapy for seminoma greater than stage IIa prior to surgical resection. Although all patients with viable tumor were identified, FDG-PET findings were falsely positive in 9 of the 20 patients. They concluded that FDG-PET should be as an adjunctive tool for patient counseling.20
Histologic Findings
Seminomas can have 3 histologic variants.1
The first is classic seminoma, and it has a uniform population of large cells that form sheets and nests separated by delicate connective tissue (see Images 3-4). Leukocytic infiltration (20%), multinucleated cells, syncytiotrophoblasts (7%-35%), and microcalcifications (60%) may be present. Upon gross examination, the tumor has a uniform yellow color and bulges from the cut surface. Classic seminoma is the most common histologic type.
Testicular seminoma. This is a classic seminoma at low power. Uniform tumor cells are observed with mild inflammatory response (lymphocytes). Other seminoma findings not seen could include a fibrovascular stroma, syncytiotrophoblastic cells, and multinucleated histiocytes.
This is a classic testicular seminoma, high-power view, from a 37-year-old man with a painless mass in his right testis. Levels of serum beta-human chorionic gonadotropin and alpha-fetoprotein were within the reference range, and the metastatic workup findings were negative. Histopathology showed a pure seminoma. Metastatic workup showed no nodal or distant spread, T1N0M0 stage I. After orchiectomy, the patient underwent adjuvant external beam radiotherapy to the para-aortic nodes. At a 3-year follow-up study, the patient is disease free and has a greater than 95% chance of remaining disease free. See Image 2 for a scrotal sonogram of this patient. Note here that tumor cells are uniform, have abundant clear cytoplasm, a large centrally located nucleus, and a variable mitotic pattern.
The second is anaplastic seminoma, and it is observed in 5%-15% of patients with seminomas. Histopathology is as described for classic seminoma but with increased mitotic figures. Patients tend to present at more advanced stages than those with classic seminoma, but stage prognosis is similar.
The third is spermatocytic seminoma, and it is a rare variant that occurs in older adults. Histopathology shows tumor cells arranged in solid sheets, containing poorly developed inconspicuous septae without leukocytic infiltrate. No glycogen is present. Small, medium, and large cell types are observed. Orchiectomy alone is sufficient treatment; metastases are rare.
Staging
American Joint Committee on Cancer and the International Union Against Cancer: Testicular Cancer Staging System21
Table 1. Primary Tumor (T)
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Table
| pTx | Primary tumor cannot be assessed |
| p0 | No evidence of primary tumor |
| pTis | Intratubular germ cell neoplasia |
| pT1 | Tumor limited to the testis and epididymis |
| No vascular/lymphatic invasion | |
| May invade the tunica albuginea | |
| No invasion of the tunica vaginalis | |
| pT2 | Tumor limited to the testis and epididymis |
| Vascular/lymphatic invasion or tumor extending through the tunica albuginea with involvement of the tunica vaginalis | |
| Invades beyond the tunica albuginea or into the epididymis | |
| pT3 | Tumor invades the spermatic cord with or without vascular/lymphatic invasion |
| pT4 | Tumor invades the scrotum with or without vascular/lymphatic invasion |
| pTx | Primary tumor cannot be assessed |
| p0 | No evidence of primary tumor |
| pTis | Intratubular germ cell neoplasia |
| pT1 | Tumor limited to the testis and epididymis |
| No vascular/lymphatic invasion | |
| May invade the tunica albuginea | |
| No invasion of the tunica vaginalis | |
| pT2 | Tumor limited to the testis and epididymis |
| Vascular/lymphatic invasion or tumor extending through the tunica albuginea with involvement of the tunica vaginalis | |
| Invades beyond the tunica albuginea or into the epididymis | |
| pT3 | Tumor invades the spermatic cord with or without vascular/lymphatic invasion |
| pT4 | Tumor invades the scrotum with or without vascular/lymphatic invasion |
Table 2A. Regional Lymph Nodes (N): Clinical
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Table
| Nx | Nodes not assessed |
| N0 | No regional lymph node metastasis |
| N1 | Lymph node mass or multiple lymph node masses £ 2 cm in greatest dimension |
| N2 | Lymph node mass or multiple lymph node masses >2 cm but £ 5 cm in greatest dimension |
| N3 | Lymph node mass >5 cm in greatest dimension |
| Nx | Nodes not assessed |
| N0 | No regional lymph node metastasis |
| N1 | Lymph node mass or multiple lymph node masses £ 2 cm in greatest dimension |
| N2 | Lymph node mass or multiple lymph node masses >2 cm but £ 5 cm in greatest dimension |
| N3 | Lymph node mass >5 cm in greatest dimension |
Table 2B. Regional Lymph Nodes (N): Pathologic
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Table
| pN0 | No evidence of tumor in lymph nodes |
| pN1 | Lymph node mass £ 2 cm in greatest dimension |
| £ 5 nodes positive | |
| pN2 | Lymph node mass >2 cm but <5 cm in greatest dimension |
| >5 nodes positive | |
| Evidence of extranodal extension of tumor | |
| pN3 | Lymph node mass >5 cm in greatest dimension |
| pN0 | No evidence of tumor in lymph nodes |
| pN1 | Lymph node mass £ 2 cm in greatest dimension |
| £ 5 nodes positive | |
| pN2 | Lymph node mass >2 cm but <5 cm in greatest dimension |
| >5 nodes positive | |
| Evidence of extranodal extension of tumor | |
| pN3 | Lymph node mass >5 cm in greatest dimension |
Table 3. Distant Metastases (M)
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Table
| M0 | No evidence of distant metastases |
| M1a | Nonregional nodal or pulmonary metastases |
| M2b | Nonpulmonary visceral metastases |
| M0 | No evidence of distant metastases |
| M1a | Nonregional nodal or pulmonary metastases |
| M2b | Nonpulmonary visceral metastases |
Table 4. Serum Tumor Markers (S)
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Table
| S | LDH | hCG† (mIU/mL) | AFP (ng/mL) | ||
| Sx | Not assessed | Not assessed | Not assessed | ||
| S0 | £ N | and | Normal | and | Normal |
| S1 | <1.5 x N | and | <5,000 | and | <1,000 |
| S2 | 1.5-10 x N | or | 5,000-50,000 | or | 1,000-10,000 |
| S3 | >10 x N | or | >50,000 | or | >10,000 |
| S | LDH | hCG† (mIU/mL) | AFP (ng/mL) | ||
| Sx | Not assessed | Not assessed | Not assessed | ||
| S0 | £ N | and | Normal | and | Normal |
| S1 | <1.5 x N | and | <5,000 | and | <1,000 |
| S2 | 1.5-10 x N | or | 5,000-50,000 | or | 1,000-10,000 |
| S3 | >10 x N | or | >50,000 | or | >10,000 |
N = upper limit of normal for the LDH assay
†HCG = human chorionic gonadotropin
Table 5. Stage Grouping
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Table
| Stage grouping | T | N | M | S |
|---|---|---|---|---|
| Stage 0 | pTis | N0 | M0 | S0 |
| Stage I | T1-T4 | N0 | M0 | Sx |
| Stage IA | T1 | N0 | M0 | S0 |
| Stage IB | T2-4 | N0 | M0 | S0 |
| Stage IS | Any T | N0 | M0 | S1-S3 |
| Stage II | Any T | Any N | M0 | Sx |
| Stage IIA | Any T | N1 | M0 | S0-S1 |
| Stage IIB | Any T | N2 | M0 | S0-S1 |
| Stage IIC | Any T | N3 | M0 | S0-S1 |
| Stage III | Any T | Any N | M1 | Sx |
| Stage IIIA | Any T | Any N | M1a | S0-S1 |
| Stage IIIB | Any T | Any N | M0-M1a | S2 |
| Stage IIIC | Any T | Any N | M0-M1a | S3 |
| … | Any T | Any N | M1b | Any S |
| Stage grouping | T | N | M | S |
|---|---|---|---|---|
| Stage 0 | pTis | N0 | M0 | S0 |
| Stage I | T1-T4 | N0 | M0 | Sx |
| Stage IA | T1 | N0 | M0 | S0 |
| Stage IB | T2-4 | N0 | M0 | S0 |
| Stage IS | Any T | N0 | M0 | S1-S3 |
| Stage II | Any T | Any N | M0 | Sx |
| Stage IIA | Any T | N1 | M0 | S0-S1 |
| Stage IIB | Any T | N2 | M0 | S0-S1 |
| Stage IIC | Any T | N3 | M0 | S0-S1 |
| Stage III | Any T | Any N | M1 | Sx |
| Stage IIIA | Any T | Any N | M1a | S0-S1 |
| Stage IIIB | Any T | Any N | M0-M1a | S2 |
| Stage IIIC | Any T | Any N | M0-M1a | S3 |
| … | Any T | Any N | M1b | Any S |
Additional staging systems are well discussed by Prow (1998).22
More on Testicular Seminoma |
| Overview: Testicular Seminoma |
 Differential Diagnoses & Workup: Testicular Seminoma |
| Treatment & Medication: Testicular Seminoma |
| Follow-up: Testicular Seminoma |
| Multimedia: Testicular Seminoma |
| References |
| Further Reading |
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References
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Keywords
testicular seminoma, testis cancer, cancer of the testes, testis germ cell carcinoma, testicular cancer, seminoma, germ cell tumor, GCT, radical orchiectomy, germ cell carcinoma in situ, germ cell CIS, classic seminoma, anaplastic seminoma, spermatocytic seminoma
