Introduction
Testicular cancer generally affects young men between puberty and age 35 years. Successful treatment incorporates a number of modalities, including radical orchiectomy, retroperitoneal lymph node dissection, chemotherapy, and radiation.
Frequency
In the United States, 3.7 new cases of testicular cancer per 100,000 population occur each year. International rates vary but are highest in Scandinavia (9 per 100,000 population) and lowest in Africa (1 per 100,000 population).
For the last 30 years, the incidence of testicular cancer has been rising steadily at a rate of 2% per year in Western countries. The reasons for this are unclear. However, it may be due to improved detection.
Etiology
Cryptorchidism is associated with a relative risk of testicular cancer at a rate of 3-14 times the baseline risk. Approximately 9% of patients with testicular cancer have a history of cryptorchidism.
Exogenous hormones (eg, diethylstilbestrol) and genetic predisposition may play a role.
Other risk factors include intratubular germ cell neoplasia, a history of contralateral testis cancer, and race.
Presentation
Testicular cancer occurs in males from 3 peak age groups—boys aged 0-10 years, men aged 20-40 years, and men older than 60 years (seminoma).
Of all primary testicular malignancies, 90% are of the germ cell type. The distribution of subtypes is as follows:
- Seminoma (40%)
- Nonseminomatous germ cell tumors
- Embryonal carcinoma (20-25%)
- Teratocarcinoma (25-30%)
- Teratoma (5-10%)
- Pure choriocarcinoma (1%)
The differential diagnoses of a mass in the body of the testis includes germ cell tumor, epidermoid cyst, adenomatoid tumor, carcinoid, Leydig cell tumor, Sertoli cell tumor, gonadoblastoma, and tuberculosis (rarely).
Testicular tumors can cause both local and distant signs and symptoms. Local symptoms include scrotal swelling, acute pain, and scrotal heaviness. Distant signs and symptoms result from metastases.
The clinical presentations with the corresponding metastatic locations are as follows:
- Neck mass - Supraclavicular node
- Respiratory symptoms - Pulmonary metastases
- Nausea and vomiting - Retroduodenal metastases
- Lumbar back pain - Psoas or nerve roots (retroperitoneal disease)
- Bone pain - Skeletal metastases
- CNS and/or PNS involvement - Spinal cord and/or root involvement
- Unilateral and/or bilateral leg swelling - Iliac and/or inferior vena cava (IVC) obstruction
- Gynecomastia - Systemic endocrine manifestation
In patients who present with a testicular mass, the physical examination involves inspecting the body of the testicle and epididymis and then assessing for the presence of a mass arising from the body of the testicle. Upon palpation, testicular tumors tend to be painless, firm, and irregular masses. They do not themselves transilluminate, but they can be associated with a hydrocele that does.
Perform an abdominal examination to rule out nodal disease or visceral involvement. Check for supraclavicular lymph nodes and examine the chest to rule out gynecomastia.
Indications
A radical orchiectomy is indicated in the management of a suspected testicular tumor. Suspect a testicular tumor in any patient with the physical findings of a painless, firm, and irregular mass arising from the testicle. Confirm this with Doppler ultrasonography of the scrotum. Most cases of testicular tumors demonstrate hypoechoic hypervascular intratesticular lesions. Elevated levels of alpha-fetoprotein (AFP) and/or human chorionic gonadotropin (hCG) should also suggest a testicular tumor (germ cell type).
Relevant Anatomy
Spermatic cord
The spermatic cord suspends the testis in the scrotum and contains the following:
- Vas deferens
- Testicular artery, artery of vas deferens, and cremasteric artery
- Pampiniform plexus (as many as 12 veins that come from the testes and coalesce into the single testicular vein)
- Genitofemoral nerve (supplies the cremasteric muscle), sympathetic fibers of the arteries, and sympathetic and parasympathetic fibers of the vas deferens
- Lymph vessels
Testis
The main functions or the testicles are to produce sperm and androgenic steroid hormones, particularly testosterone. Sperm form in convoluted seminiferous tubules that empty in 20-30 tubuli rectae. These join to form the rete testis. The efferent ductules then join the head of the epididymis and, eventually, form an epididymal duct, which continues to the body and tail of the epididymis and, ultimately, forms the vas deferens. The testicle is covered by a tunica albuginea and the visceral layer of the tunica vaginalis. The visceral layer does not cover the posterolateral layer of the testicle.
The arterial supply to the testicle is from the testicular artery, which arises from the anterolateral surface of the aorta and is contributed to by the vasal and cremasteric arteries. The venous system draining the testicle is composed of both deep and superficial components. The deep component consists of the pampiniform plexus, testicular vein, deferential vein, and cremasteric veins. The superficial component consists of the scrotal veins. The testicular lymphatics from the right testicle drain to the nodes of the interaortocaval zone, the right paracaval, and right common iliac. The testicular lymphatics from the left testicle drain to the nodes of the left paraaortic and infrarenal hilar zones, the right paracaval, and the right iliac.
Contraindications
In some patients with a testicular mass, causes other than a testicular tumor need to be excluded before radical orchiectomy is performed. For example, if a patient presents with testicular enlargement but a history consistent with an orchitis, then, obviously, antibiotic therapy would be indicated prior to surgery. Similarly, if a patient with a history of congenital adrenal hyperplasia presents with bilateral multifocal testicular masses, a frozen section biopsy would be indicated at the time of the operation to confirm that the lesions are hyperplastic nodules of adrenal rests rather than multiple germ cell tumors.
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References
Dean AL Jr. The treatment of teratoid tumors of the testes with radium and the x-ray. J Urol. 1925;13:149-75.
Capelouto CC, Clark PE, Ransil BJ, Loughlin KR. A review of scrotal violation in testicular cancer: is adjuvant local therapy necessary?. J Urol. Mar 1995;153(3 Pt 2):981-5. [Medline].
Leibovitch I, Baniel J, Foster RS, Donohue JP. The clinical implications of procedural deviations during orchiectomy for nonseminomatous testis cancer. J Urol. Sep 1995;154(3):935-9. [Medline].
Hinman F. Radical Orchiectomy. In: Atlas of Urologic Surgery. 2nd ed. 1998:380-84.
Hinman F. Urosurgical Anatomy. Philadelphia, Pa: WB Saunders Company; 1993.
Lane JE, Gamblin TC, Solis M, Barron T. Laparoscopic orchiectomy for unilateral intra-abdominal testis. Curr Surg. May-Jun 2002;59(3):333-5. [Medline].
Marshall FF. Urologic Complications. In: Medical and Surgical, Adult and Pediatric. 2nd ed. St Louis, Mo: Mosby-Year Book; 1990.
Richie JP. Neoplasms of the Testis. In: Campbell's Urology. 7th ed. 1998:2411-52.
Wingo PA, Tong T, Bolden S. Cancer statistics, 1995. CA Cancer J Clin. Jan-Feb 1995;45(1):8-30. [Medline].
Further Reading
Keywords
radical orchidectomy, orchiectomy, orchidectomy, testicular cancer, cryptorchidism, intratubular germ cell neoplasia, contralateral testis cancer, testicular malignancy, diethylstilbestrol, testicular seminoma, testicular nonseminomatous germ cell tumors, testicular embryonal carcinoma, testicular teratocarcinoma, testicular teratoma, testicular pure choriocarcinoma, testicular choriocarcinoma, testicular carcinoma
