History
In patients with localized disease, painless swelling or a nodule in one testicle is the most common presenting sign. On physical examination, this mass/nodule cannot be separated from the testis. Patients with atrophic testes will feel enlargement. A dull ache or heavy sensation in the lower abdomen could be the presenting symptom. Patients who experience a hematoma with trauma should undergo evaluation to rule out testicular cancer.
Patients with disseminated disease can present with manifestations of lymphatic or hematogenous spread. With supraclavicular lymph node metastasis, the presenting sign can be a neck mass. Metastatic disease may also result in anorexia, nausea, and other gastrointestinal symptoms. Bulky retroperitoneal disease can present as back pain. Cough, chest pain, hemoptysis, and shortness of breath can be presenting symptoms of mediastinal adenopathy or lung metastasis. Central nervous system disease could rarely present as neurological symptoms. Bone pain is rare.
Gynecomastia may occur in about 5% of patients with testicular germ cell tumors that produce human chorionic gonadotropin (hCG), such as choriocarcinoma. Marked overproduction of hCG can result in hyperthyroidism, since hCG and thyroid-stimulating hormone have a common alpha-subunit and a beta-subunit with considerable homology.
Physical
Any solid, firm mass within the testis should be considered testicular cancer until proven otherwise. Prompt diagnosis and early treatment are required for cure.
Testicular cancer may be painless, in which case the patient may be unaware of its presence. In patients with scrotal pain, testicular cancer must be differentiated from epididymitis. The clinician should consider the full differential diagnosis of a testicular mass, which includes not only epididymitis but the following:
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Epididymo-orchitis
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Testicular torsion
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Hydrocele
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Hernia
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Hematoma
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Spermatocele
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Varicocele
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Syphilitic gumma
Unilateral or bilateral lower extremity swelling may be present in patients with iliac or caval venous obstruction or thrombosis.
Physical examination of the testicles is performed by fully palpating all areas of the testicle between thumb and fingers. Examination should begin with bimanual examination of the scrotal contents, starting with the normal testis. This permits the examiner to evaluate the relative size, contour, and consistency of the normal testis. Other areas of emphasis include examination of the abdomen for lymphadenopathy and hepatomegaly. The examination should also include evaluation for supraclavicular nodes, bone tenderness, and gynecomastia.
Causes
Various risk factors have been associated with testicular tumors, but the specific etiology is not known.
Cryptorchidism
In patients with cryptorchidism, the risk of developing germ cell tumor is increased fourfold to eightfold. The risk of developing germ cell tumor when a cryptorchid testis is intra-abdominal is about 5%. The risk is 1% if the testis is retained in the inguinal canal. Surgical placement of the undescended testis in the scrotum—orchiopexy—when the patient is younger than 6 years lowers the risk further. About 5%-20% of patients with a history of cryptorchid testis develop tumors in the normally descended testis.
In Sweden from 1965 to 2000, a total of 16,983 males underwent orchiopexy and 56 cases of testicular cancer were reported. The relative risk of testicular cancer among those who underwent orchiopexy before reaching 13 years of age was 2.23, compared with that of the Swedish general population. For those treated at 13 years of age or older, the relative risk was 5.4. [10]
Prior Testicular Cancer
A previous history of testicular cancer is the strongest risk factor for germ cell tumor. Approximately 1-2% of testicular cancer patients will develop a second primary testicular cancer contralaterally—a 500-fold higher rate than in the general population. [11, 12]
Genetics
Patients with Klinefelter syndrome (47XXY) have higher incidence of germ cell tumor, particularly primary mediastinal germ cell tumor. Family members of Klinefelter syndrome patients has a sixfold to 10-fold increased risk of germ cell tumor. Patients with Down syndrome also are at increased risk for germ cell tumors. Increased risk has also been reported in patients with any of the following:
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Cutaneous ichthyosis
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Mullerian syndrome
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Androgen insensitivity syndrome (testicular feminization)
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Mixed gonadal dysgenesis
Family history
First-degree relatives have a higher risk of developing testicular cancer than the general population, although the incidence is low. About 2% of testicular cancer patients report having an affected relative. Brothers are at particularly high risk, with a relative risk of 8–10. Among sons of affected men, twofold to sixfold increases in testicular cancer have been reported.
Infertility
Walsh et al have reported that men with male factor infertility are nearly 3 times more likely to develop subsequent testicular cancer. [13] Intratubular germ cell neoplasia (testicular carcinoma in situ) has been found in 0.4%–1.1% of men undergoing testicular biopsy because of infertility.
Environmental exposure
Exposure to diethylstilbestrol (DES) in utero is associated with cryptorchidism. Increased risk has been suggested with Agent Orange exposure and numerous industrial occupations.
Recurrent activity such as horseback or motorcycle riding, local trauma, and increased scrotal temperature have not been associated with increased risk.
Tables
Incidence of Testicular Cancer by Race |
|
Race/Ethnicity |
Annual rate per 100,000 men |
All Races |
5.7 |
White |
6.7 |
Black |
1.5 |
Asian/Pacific Islander |
2.1 |
American Indian/Alaska Native |
4.9 |
Hispanic |
5.0 |
|
|
|
|
Stage |
LDH |
HCG (mIU/mL) |
AFP (ng/mL) |
|
|
|
|
S1 |
< 1.5 times normal |
< 5,000 |
< 1,000 |
S2 |
1.5-10 times normal |
5,000-50,000 |
1,000-10,000 |
S3 |
>10 times normal |
>50,000 |
>10,000 |
LDH=lactate dehydrogenase; HCG=beta human chorionic gonadotropin; AFP=alpha fetoprotein. |
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- Overview
- Presentation
- DDx
- Workup
- Treatment
- Medication
- Medication Summary
- Antineoplastic Agent, Topoisomerase II Inhibitors
- Antineoplastic Agent, Antibiotics
- Antineoplastic Agent, Alkylating Agents
- Antineoplastic Agents, Antimicrotubular
- Antineoplastic Agent, Vinca Alkaloids
- Antineoplastic Agent, Antimetabolites
- Antidote, Cyclosphosphamide-induced Hemorrhagic Cystitis
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- Follow-up
- Tables
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