History
The classic presentation of a testicular tumor is a painless testicular mass in an otherwise healthy man in the third or fourth decade of life. The presentation can vary depending on the amount of disease, clinical stage, and the presence of metastases at the time of referral. Roughly one-third of patients diagnosed with a nonseminomatous germ cell tumor (NSGCT) will present with metastatic disease.
In all patients in whom testicular tumors are suspected, obtain a complete history and perform a complete physical examination. More specifically, questions about how and when the mass was noted and by whom are useful. The history should also include specific questions regarding possible risk factors for testicular cancer, including a history of cryptorchidism and in such cases, the timing of orchidopexy. Similarly, questions regarding prior urologic history should be asked to idenitify additional risk factors or prior procedures that may alter the typical presentation or natural history of the disease. A full family history should be obtained as well, as there is increased risk in those who have a first-degree relative with testicular cancer.
Physical Examination
Both testicles should be carefully examined. The testicles should be readily palpable in the scrotum. The contour of each testicle should be smooth and the consistency uniform. Any size discrepancy between the two testicles should be assessed and noted. Any palpable firmness within the testicular parenchyma should raise suspiscion for malignany and prompt further workup.
Differentiation of the scrotal contents should be found with careful palpation. The epididymis, attached to the posterolateral aspect of the testicle, is frequently the site of induration or cysts. These conditions should be identifiable during the physical examination. Additionally, testis tumors can cause hydrocele, limiting the ability to perform complete exam. If inability to perform an adequate evaluation is a concern, scrotal ultrasonography must be performed to aid in the diagnosis.
During the general physical examination, special attention should be given to the presence of gynecomastia, which is a finding in 5% of testicular cancer cases. Supraclavicular adenopathy may be a finding in advanced disease. Lung examination in patients with widespread lung metastases may reveal areas of decreased breath sounds, or these patients may present with hemoptysis, dyspnea, or cough. Abdominal examination should be performed to assess for visceral or bulky lymphatic involvement. In patients with risk factors for altered lymphatic drainage (see Relevant Anatomy, above) careful examination of the inguinal lymph nodes should be performed.
Finally, a neurologic examination should be conducted. This is important to evaluate for possible brain metastasis.
Complications
Complications of radical orchiectomy, as with any surgical procedure, include risks of bleeding and infection. Additionally, injury to the ilioinguinal nerve may occur, which can cause hypoesthesia of the ipsilateral groin and lateral aspect of the ipsilateral hemiscrotum.
For patients with more advanced disease that requires retroperitoneal lymph node dissection, complications of that procedure can include the following:
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Bleeding, which may result in retroperitoneal hematoma
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Wound infection
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Anejaculation from damage to nearby sympathetic nerves
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Chylous leak secondary to lymphatic system injury
Finally, patients requiring chemotherapy may be susceptible to both the acute and delayed toxicity associated with the chemotherapeutic agents; those effects depend on the agents used. Acute complications seen with cisplatin-based therapy include but are not limited to myelosuppression, fatigue, peripheral neuropathy, diminished renal function, and—in a small percentage—death. Later sequelae can include the following [7] :
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Hearing loss
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Peripheral neuropathy
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Cardiovascular disease
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Hypogonadism
Tables
Stage |
LDH |
hCG (mIU/mL) |
AFP (ng/mL) |
S0 |
Normal or below normal |
Normal or below normal |
Normal or below normal |
S1 |
< 1.5 times the reference range |
< 5,000 |
< 1,000 |
S2 |
1.5-10 times the reference range |
5,000-50,000 |
1,000-10,000 |
S3 |
>10 times the reference range |
>50,000 |
>10,000 |
