History
Testicular seminoma is most often diagnosed when a male aged 15-35 years presents with a painless testicular lump that has been noticeable for several days to months. Delay in diagnosis is common because of patients' failure to perform self-examinations or to seek medical attention after noticing a testicular mass, or a physician's delay while treating the patient for presumed epididymo-orchitis or testicular trauma.
Patients commonly have abnormal findings on semen analysis at presentation, and they may be subfertile. [3]
Overall, in approximately 75% of patients, the seminomas are localized (stage I) at diagnosis. However, 15% have metastatic disease to the regional lymph nodes, and 5-10% have involvement of juxtaregional nodes or visceral metastases.
Uncommon presentations include the following:
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Testicular pain, possibly with an acute onset, especially when an associated hydrocele prevents adequate physical examination.
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A testis tumor may become metastatic and may manifest as large retroperitoneal and/or chest lesions, while the primary tumor is nonpalpable. Scrotal ultrasonography may locate the primary tumor. Histopathology of the primary testis often shows a focus of tumor surrounded by fibrous scar, termed burned-out testis cancer.
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In 1996, Miller and associates reported on a series of patients with previously nonpalpable testes that were explored and incorrectly diagnosed as vanished testes. A subsequent seminoma was diagnosed intra-abdominally. [2]
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Testicular seminoma. A 57-year-old man presents with abdominal pain of slow onset. CT scanning shows a large 25-cm retroperitoneal lesion encompassing the aorta and renal vasculature and displacing the right kidney laterally. The patient had a history of cryptorchidism repaired at age 8 years. Testes were normal and descended; however, ultrasonography showed a small 5-mm lesion on the right testis, which proved to be pure seminoma at orchiectomy. The beta-human chorionic gonadotropin level was 70 mIU/mL (reference range, < 5 mIU/mL), and the alpha-fetoprotein level was within the reference range; no metastatic lesions were observed above the diaphragm, indicating stage IIb (bulky), T1N3M0. The patient was referred for 4 cycles of cisplatin-based chemotherapy.
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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.
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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.
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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 related image 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.
Tables
pTx |
Primary tumor cannot be assessed |
p0 |
No evidence of primary tumor |
pTis |
Germ cell neoplasia in situ |
pT1 |
Tumor limited to the testis without lymphovascular invasion |
| pT1a | Tumor smaller than 3 cm |
| pT1b | Tumor 3 cm or larger |
pT2 |
Tumor limited to the testis and epididymis with lymphovascular invasion OR |
Tumor invading hilar soft tissue or epididymis or penetrating viceral mesothelial layer covering the external surface of tunica albuginea with or without lymphovascular invasion |
|
pT3 |
Tumor invades the spermatic cord with or without lymphovascular invasion |
pT4 |
Tumor invades the scrotum with or without lymphovascular invasion |
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 |
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 |
M0 |
No evidence of distant metastases |
M1a |
Nonregional nodal or pulmonary metastases |
M2b |
Nonpulmonary visceral metastases |
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 |
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 |
N1-3 |
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 |
