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.

Some patients present with a swollen painful mass in the scrotum that may be misdiagnosed as infectious or inflammatory in nature, potentially resulting in a detrimental delay in starting treatment for NSGCT. In all patients in whom testicular tumors are suspected, obtain a complete history and perform a complete physical examination. 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. Questions about trauma and mumps orchitis are useful. Likewise, the patient's occupational, chemical exposure, and smoking history should be obtained. 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

In the physical exam, both testicles should be carefully evaluated. 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 malignancy 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.

Whenever the physical examination reveals any deviation from a palpably normal testicle, scrotal ultrasonography should be performed. Scrotal ultrasonography is also necessary if inability to perform an adequate evaluation is a concern.

In 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), 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.

Differential Diagnoses

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Table 1. Serum Tumor Markers (S)

S	LDH		HCG (mIU/mL)		AFP (ng/mL)
Sx	Not assessed		Not assessed		Not assessed
S0	Normal	and	Normal	and	Normal
S1	< 1.5 x N	and	< 5000	and	< 1000
S2	1.5-10 x N	or	5000-50,000	or	1000-10,000
S3	> 10 x N	or	> 50,000	or	> 10,000
*N=upper limit of reference range for the LDH assay

Table 2. Stage Grouping

Stage grouping	T	N	M	S
Stage 0	pTis	N0	M0	S0
Stage I	pT1-T4	N0	M0	Sx
Stage IA	pT1	N0	M0	S0
Stage IB	pT2-4	N0	M0	S0
Stage IS	Any pT/TX	N0	M0	S1-S3
Stage II	Any pT/TX	N1-3	M0	Sx
Stage IIA	Any pT/TX	N1	M0	S0-S1
Stage IIB	Any pT/TX	N2	M0	S0-S1
Stage IIC	Any pT/TX	N3	M0	S0-S1
Stage III	Any pT/TX	Any N	M1	Sx
Stage IIIA	Any pT/TX	Any N	M1a	S0-S1
Stage IIIB	Any PT/TX	N1-3	M0	S2
Stage IIIB	Any pT/TX	Any N	M1a	S2
Stage IIIC	Any PT/TX	N1-3	M0	S3
	Any pT/TX	Any N	M1a	S3
	Any pT/TX	Any N	M1b	Any S

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Author

Alexander D Tapper, MD Resident Physician, Department of Urology, William Beaumont Hospital

Alexander D Tapper, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Urological Association, Michigan State Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Syed Mohammad Akbar Jafri, MD Assistant Professor, Department of Urology, Oakland University William Beaumont School of Medicine

Syed Mohammad Akbar Jafri, MD is a member of the following medical societies: American Urological Association, Michigan Association of Physicians of Indian Heritage, Michigan Urological Society

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

David M Hoenig, MD Chief of Urology, North Shore University Hospital Northwell Health

David M Hoenig, MD is a member of the following medical societies: American Urological Association, Endourological Society

Disclosure: Received income in an amount equal to or greater than $250 from: various law firms- legal consultation<br/>Received honoraria from Best Doctors Inc for consulting.

Thomas H Rechtschaffen, MD Consulting Staff, Department of Urology, A Family Urology Practice, PC

Disclosure: Nothing to disclose.

Janice Angela Santos-Cortes, MD Assistant Professor of Urology at Columbia University, Division of Urology at Mount Sinai Medical Center (Miami Beach)

Janice Angela Santos-Cortes, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Urological Association, Society of Urologic Oncology, Society of Women in Urology, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction

Disclosure: Nothing to disclose.