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Testicular Seminoma

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Media Gallery

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.
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.
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 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.

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Table 1. Primary Tumor (T)

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
pT2	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

Table 2A. Regional Lymph Nodes (N): Clinical

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

pN0	No evidence of tumor in lymph nodes
pN1	Lymph node mass ≤ 2 cm in greatest dimension
pN1	≤ 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)

M0	No evidence of distant metastases
M1a	Nonregional nodal or pulmonary metastases
M2b	Nonpulmonary visceral metastases

Table 4. Serum Tumor Markers (S)

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

Table 5. Stage Grouping

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

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Author

Michael B Williams, MD, MS Assistant Professor, Department of Urology, Leroy T Canoles, Jr, Cancer Research Center, Eastern Virginia Medical School

Michael B Williams, MD, MS is a member of the following medical societies: American Association for Cancer Research, American Urological Association, Society of Urologic Oncology, Texas Medical Association, American Society of Clinical Oncology, American Association of Clinical Urologists

Disclosure: Nothing to disclose.

Coauthor(s)

Paul F Schellhammer, MD Professor of Urology, Eastern Virginia Medical School; Urologist, Urology of Virginia, PC

Paul F Schellhammer, MD is a member of the following medical societies: American Medical Association, American Urological Association, Society of Surgical Oncology, Society of Urologic Oncology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoscopic and Robotic Surgeons, Society of University Urologists

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Endourological Society Board of Directors; President Elect North Central Section of the American Urological Association<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical.

Additional Contributors

Gamal Mostafa Ghoniem, MD, FACS Professor and Vice Chair of Urology, Chief, Division of Female Urology, Pelvic Reconstructive Surgery, and Voiding Dysfunction, Department of Urology, University of California, Irvine, School of Medicine

Gamal Mostafa Ghoniem, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urogynecologic Society, American Urological Association, International Continence Society, International Urogynaecology Association, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Astellas<br/>Received research grant from: Uroplasty/Cogentix, Astellas, Allergen.

Acknowledgements

John W Davis, MD Assistant Professor, Department of Urology, University of Texas MD Anderson Cancer Center

John W Davis, MD is a member of the following medical societies: American College of Surgeons and American Urological Association

Disclosure: Nothing to disclose.

Dan Theodorescu, MD, PhD Paul A Bunn Professor of Cancer Research, Professor of Surgery and Pharmacology, Director, University of Colorado Comprehensive Cancer Center

Dan Theodorescu, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Urological Association, Medical Society of Virginia, Society for Basic Urologic Research, and Society of Urologic Oncology

Disclosure: Key Genomics Ownership interest Co-Founder-50% Stock Ownership; KromaTiD, Inc Stock Options Board membership

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