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Background

Testicular malignancy can be divided into germ cell tumors (seminoma and nonseminoma) that are usually malignant and sex cord-stromal tumors that are usually benign
Testicular cancer is usually more common in men 15 - 35 years of age
Risk factors include: cryptorchidism, family history and infertility
Germ cell tumors account for 95% of all testicular cancers (arise from germ cells that produce sperms)
Testicular cancers do not transilluminate
Testicular cancers are usually not biopsies (risk of seeding scrotum)

Testicular Tumors
Germ cell tumors
Seminoma	Most common type of germ cell tumor Peak incidence is in the third decade of life Morphology: cells have a large central nuclei with prominent nucleoli and clear and watery-appearing cytoplasm ("fried-egg") ↑ placental alkaline phosphatase (PLAP) Similar to dysgerminoma in females
Embryonal	Mostly affects men at 20-30 years of age Painful More aggressive than seminomas Morphology: cells may show glandular patterns and papillary convolutions In pure embryonal carcinoma there can be ↑ hCG and normal AFP AFP can be elevated when there is mixed embryonal carcinoma
Choriocarcinoma	Highly malignant and can metastasize to the lung or brain Morphology: contains syncytiotrophoblasts (contains hCG) and cytotrophoblasts Laboratory findings: ↑ hCG that can result in gynecomastia or hyperthyroidism Recall that hCG is structurally similar to luteinizing hormone (LH), follicle-stimulating horomone (FSH), and thyroid-stimulating hormone (TSH)
Yolk sac tumor	Also known as endodermal sinus tumor Most common testicular tumor in infants and children (<3 years of age) Morphology: Yellow-white mucinous appearance and Schiller-Duval bodies in ~50% of cases α-fetoprotein (AFP) and α1-antitrypsin can be seen on immunocytochemical staining
Teratoma	A testicular tumor with cells that are reminiscent of more than one germ layer Can occur at any age Morphology: cells or organoid structures may include neural tissue, muscle, thyroid-like tissue, tissue from the intestinal wall
Sex cord-stromal tumors
Leydig cell tumor	Most cases occur at 20-60 years of age Most commonly presents with testicular swelling (gynecomastia may be the first presenting symptom) Can produce androgens and estrogens (can result in ↓ LH) Morphology: golden brown and homogenous cut surface cells contain crystalloids of Reinke in their cytoplasm
Sertoli cell tumor	Most cases are benign These tumors are hormonally silent
Non-Hodgkin Lymphomas
Testicular lymphoma	Most common testicular neoplasm in men > 60 years of age Most common testicular lymphoma is diffuse large B-cell lymphoma These tumors have a higher propensity to involve the central nervous system

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Clinical features

Symptoms
- Painless nodule or swelling in one testicle (usually)
Physical exam
- Firm, hard, or fixed mass (must be considered testicular cancer until proven otherwise)

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Diagnosis

Imaging

Ultrasonography (bilaterally)

Ultrasound findings in Seminomas and Nonseminomatous germ cell tumors
Seminoma	Seminomas show hypoechoic lesions WITHOUT cystic findings
Nonseminomatous germ cell tumors	Nonseminomatous germ cell tumors can show (inhomogeneous lesions, calcifications, cystic areas and indistinct margins)

Radiography (to assess for mediastinal, hilar or lung metastasis)
CT scan (to detect retroperitoneal lymph nodes metastasis in patients diagnosed with testicular cancer)

Serum labs

Serum markers including; AFP, hCG, lactate dehydrogenase (LDH)

Seminoma Yolk sac Choriocarcinoma Teratoma Embryonal

PLAP ↑ — — — —

AFP — ↑↑ — —/↑ —/↑ (when mixed)

B-hCG —/↑ —/↑ ↑↑ — ↑

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Differential diagnosis

Orchitis
Epididymitis
Varicoceles
Hydroceles
Indirect inguinal hernias

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Treatment

Radical inguinal orchiectomy

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Complications

Infertility
Metastasis
Endocrine abnormalities

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Supplementary tables

Table 1: epidemiology, manifestations, diagnosis and treatment of testicular cancer

Testicular cancer
Epidemiology	Age 15 - 35 years Risk factors: family history, cryptorchidism
Manifestations	Unilateral, painless testicular nodule or swelling Dull lower abdominal ache Metastatic symptoms (eg, dyspnea, neck mass, low back pain)
Diagnosis	Examination: firm, ovoid mass or unilateral swelling Scrotal ultrasound Tumor markers (alpha fetoprotein, beta-HCG)
Treatment	Radical orchiectomy Chemotherapy Cure rate (95%)

Table 2: malignant testicular neoplasms types and main details

Malignant testicular neoplasms
Germ cell (95 %)	Seminoma	Retain features of spermatogenesis beta-HCG, AFP usually negative
Germ cell (95 %)	Nonseminoma	>1 partially differentiated cells: yolk sac, embryonal carcinoma, teratoma, and/or choriocarcinoma beta-HCG, AFP usually positive
Stromal (5%)	Leydig	Often produces excessive estrogen (gynecomastia) or testosterone (acne) Can cause precocious puberty
Stromal (5%)	Sertoli	Rare Occasionally associated with excessive estrogen secretions (gynecomastia)

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اشترك الآن

الدرس التالي Testicular torsion

الدرس السابق Varicocele

Testicular cancer

Background

Clinical features

Diagnosis

Imaging

Serum labs

Differential diagnosis

Treatment

Complications

Supplementary tables

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المساعد الطبي الذكي

ادرس في أي مكان

	Seminoma	Yolk sac	Choriocarcinoma	Teratoma	Embryonal
PLAP	↑	—	—	—	—
AFP	—	↑↑	—	—/↑	—/↑ (when mixed)
B-hCG	—/↑	—/↑	↑↑	—	↑