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.
Tables
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 |
|||||
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 |
| 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 |
