Clinical manifestations, diagnosis, and staging of testicular germ cell tumors
- Graeme S Steele, MBBCh, FCS
Graeme S Steele, MBBCh, FCS
- Assistant Professor of Surgery
- Harvard Medical School
- Jerome P Richie, MD, FACS
Jerome P Richie, MD, FACS
- Section Editor — Cancer of the Urethra, Penis, and Ureter; Urologic Surgery; Prostate Cancer
- Elliott Carr Cutler Professor of Surgery
- Harvard Medical School
- William K Oh, MD
William K Oh, MD
- Section Editor — Testicular Cancer
- Professor of Medicine
- Mount Sinai School of Medicine
- Chief, Division of Hematology Oncology
- Tisch Cancer Institute
- M Dror Michaelson, MD, PhD
M Dror Michaelson, MD, PhD
- Associate Professor in Medicine
- Harvard Medical School
Testicular cancer is the most common solid malignancy affecting males between the ages of 15 and 35, although it accounts for only 1 percent of all cancers in men . Germ cell tumors (GCTs) account for 95 percent of testicular cancers (table 1). They may consist of one predominant histologic pattern or represent a mix of multiple histologic types. For treatment purposes, two broad categories of testis tumors are recognized: pure seminoma (no nonseminomatous elements present) and all others, which together are termed nonseminomatous germ cell tumors (NSGCTs). In most series, the ratio of seminoma to NSGCT is approximately one.
Testicular cancer has become one of the most curable of solid neoplasms because of remarkable treatment advances beginning in the late 1970s. Prior to that time, testicular cancer accounted for 11 percent of all cancer deaths in men between the ages of 25 and 34, and the five-year survival rate was 64 percent . In 2017, approximately 400 deaths from testicular cancer are expected in the United States, with a five-year survival rate of over 95 percent .
The clinical manifestations, diagnosis, and staging of testicular cancer will be presented here. Optimal therapy, which varies with the stage of disease, is discussed separately. (See "Overview of the treatment of testicular germ cell tumors".)
Testicular tumors usually present as a nodule or painless swelling of one testicle, which may be noted incidentally by the patient or by his sexual partner . Occasionally, a man with a previously small atrophic testis will note enlargement. Approximately 30 to 40 percent of patients complain of a dull ache or heavy sensation in the lower abdomen, perianal area, or scrotum, while acute pain is the presenting symptom in 10 percent.
The presenting manifestations of testicular cancer are attributable to metastatic disease in approximately 10 percent of patients. Symptoms vary with the site of metastasis:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA Cancer J Clin 2017; 67:7.
- Einhorn LH. Treatment of testicular cancer: a new and improved model. J Clin Oncol 1990; 8:1777.
- Bosl GJ, Motzer RJ. Testicular germ-cell cancer. N Engl J Med 1997; 337:242.
- Tseng A Jr, Horning SJ, Freiha FS, et al. Gynecomastia in testicular cancer patients. Prognostic and therapeutic implications. Cancer 1985; 56:2534.
- Gabrilove JL, Nicolis GL, Mitty HA, Sohval AR. Feminizing interstitial cell tumor of the testis: personal observations and a review of the literature. Cancer 1975; 35:1184.
- Oosting SF, de Haas EC, Links TP, et al. Prevalence of paraneoplastic hyperthyroidism in patients with metastatic non-seminomatous germ-cell tumors. Ann Oncol 2010; 21:104.
- Voltz R, Gultekin SH, Rosenfeld MR, et al. A serologic marker of paraneoplastic limbic and brain-stem encephalitis in patients with testicular cancer. N Engl J Med 1999; 340:1788.
- Benson CB. The role of ultrasound in diagnosis and staging of testicular cancer. Semin Urol 1988; 6:189.
- Marth D, Scheidegger J, Studer UE. Ultrasonography of testicular tumors. Urol Int 1990; 45:237.
- Schultz-Lampel D, Bogaert G, Thüroff JW, et al. MRI for evaluation of scrotal pathology. Urol Res 1991; 19:289.
- Toren PJ, Roberts M, Lecker I, et al. Small incidentally discovered testicular masses in infertile men--is active surveillance the new standard of care? J Urol 2010; 183:1373.
- Eifler JB Jr, King P, Schlegel PN. Incidental testicular lesions found during infertility evaluation are usually benign and may be managed conservatively. J Urol 2008; 180:261.
- Powell TM, Tarter TH. Management of nonpalpable incidental testicular masses. J Urol 2006; 176:96.
- Rolle L, Tamagnone A, Destefanis P, et al. Microsurgical "testis-sparing" surgery for nonpalpable hypoechoic testicular lesions. Urology 2006; 68:381.
- Costabile RA. How worrisome is testicular microlithiasis? Curr Opin Urol 2007; 17:419.
- Richie JP, Garnick MB, Finberg H. Computerized tomography: how accurate for abdominal staging of testis tumors? J Urol 1982; 127:715.
- Read G, Stenning SP, Cullen MH, et al. Medical Research Council prospective study of surveillance for stage I testicular teratoma. Medical Research Council Testicular Tumors Working Party. J Clin Oncol 1992; 10:1762.
- Gels ME, Hoekstra HJ, Sleijfer DT, et al. Detection of recurrence in patients with clinical stage I nonseminomatous testicular germ cell tumors and consequences for further follow-up: a single-center 10-year experience. J Clin Oncol 1995; 13:1188.
- Nicolai N, Pizzocaro G. A surveillance study of clinical stage I nonseminomatous germ cell tumors of the testis: 10-year followup. J Urol 1995; 154:1045.
- Socinski MA, Stomper PC. Radiologic evaluation of nonseminomatous germ cell tumor of the testis. Semin Urol 1988; 6:203.
- Howard SA, Gray KP, O'Donnell EK, et al. Craniocaudal retroperitoneal node length as a risk factor for relapse from clinical stage I testicular germ cell tumor. AJR Am J Roentgenol 2014; 203:W415.
- de Wit M, Hartmann M, Kotzerke J, et al. [18F]-FDG-PET in clinical stageI and II non-seminomatous germ cell tumors: first results of the german multicenter trial (abstract). J Clin Oncol 2005; 23:379s.
- Huddart RA, O'Doherty MJ, Padhani A, et al. 18fluorodeoxyglucose positron emission tomography in the prediction of relapse in patients with high-risk, clinical stage I nonseminomatous germ cell tumors: preliminary report of MRC Trial TE22--the NCRI Testis Tumour Clinical Study Group. J Clin Oncol 2007; 25:3090.
- Bower M, Rustin GJ. Serum tumor markers and their role in monitoring germ cell cancers of the testis. In: Textbook of Genitourinary Oncology, 2nd, Vogelzang NJ, Scardino PT, Shipley,WU, Coffey, DS (Eds), Lippincott, Williams and Wilkins, Philadelphia 2000. p.931.
- Moch, H., Humphrey, et al. WHO Classification of Tumours of the Urinary System and Male Genital Organs, 4.
- Grigor KM, Rørth M. Should the contralateral testis be biopsied? Round table discussion. Eur Urol 1993; 23:129.
- Fosså SD, Chen J, Schonfeld SJ, et al. Risk of contralateral testicular cancer: a population-based study of 29,515 U.S. men. J Natl Cancer Inst 2005; 97:1056.
- Sharma P, Dhillon J, Sexton WJ. Intratubular Germ Cell Neoplasia of the Testis, Bilateral Testicular Cancer, and Aberrant Histologies. Urol Clin North Am 2015; 42:277.
- Albers P, Albrecht W, Algaba F, et al. Guidelines on Testicular Cancer: 2015 Update. Eur Urol 2015; 68:1054.
- Brimo F, Srigley JR, Ryan CJ, et al. Testis. In: AJCC Cancer Staging Manual, 8th, Amin MB (Ed), Springer, New York 2017. p.727.
- Birch R, Williams S, Cone A, et al. Prognostic factors for favorable outcome in disseminated germ cell tumors. J Clin Oncol 1986; 4:400.
- Samuels ML, Johnson DE, Holoye PY. Continuous intravenous bleomycin (NSC-125066) therapy with vinblastine (NSC-49842) in stage III testicular neoplasia. Cancer Chemother Rep 1975; 59:563.
- Bosl GJ, Geller NL, Cirrincione C, et al. Multivariate analysis of prognostic variables in patients with metastatic testicular cancer. Cancer Res 1983; 43:3403.
- Warde P, Gospodarowicz MK, Panzarella T, et al. Stage I testicular seminoma: results of adjuvant irradiation and surveillance. J Clin Oncol 1995; 13:2255.
- Hoskin P, Dilly S, Easton D, et al. Prognostic factors in stage I non-seminomatous germ-cell testicular tumors managed by orchiectomy and surveillance: implications for adjuvant chemotherapy. J Clin Oncol 1986; 4:1031.
- International Germ Cell Consensus Classification: a prognostic factor-based staging system for metastatic germ cell cancers. International Germ Cell Cancer Collaborative Group. J Clin Oncol 1997; 15:594.
- Karpathakis A, Jamal-Hanjani M, Kwan A, et al. Testicular germ cell tumors with bony metastases: Diagnosis, management, and outcomes (a case series). J Clin Oncol 30, 2012 (suppl 5; abstr 343).
- Fosså SD, Kravdal O. Fertility in Norwegian testicular cancer patients. Br J Cancer 2000; 82:737.
- Gordon W Jr, Siegmund K, Stanisic TH, et al. A study of reproductive function in patients with seminoma treated with radiotherapy and orchidectomy: (SWOG-8711). Southwest Oncology Group. Int J Radiat Oncol Biol Phys 1997; 38:83.
- Ohl DA, Sonksen J. What are the chances of infertility and should sperm be banked? Semin Urol Oncol 1996; 14:36.
- Panidis D, Rousso D, Stergiopoulos K, et al. The effect of testicular seminoma in semen quality. Eur J Obstet Gynecol Reprod Biol 1999; 83:219.
- Hallak J, Kolettis PN, Sekhon VS, et al. Sperm cryopreservation in patients with testicular cancer. Urology 1999; 54:894.
- Carroll PR, Whitmore WF Jr, Herr HW, et al. Endocrine and exocrine profiles of men with testicular tumors before orchiectomy. J Urol 1987; 137:420.
- Petersen PM, Skakkebaek NE, Rørth M, Giwercman A. Semen quality and reproductive hormones before and after orchiectomy in men with testicular cancer. J Urol 1999; 161:822.
- Sibert L, Rives N, Rey D, et al. Semen cryopreservation after orchidectomy in men with testicular cancer. BJU Int 1999; 84:1038.
- Jacobsen R, Bostofte E, Engholm G, et al. Risk of testicular cancer in men with abnormal semen characteristics: cohort study. BMJ 2000; 321:789.
- Agarwal A, Tolentino MV Jr, Sidhu RS, et al. Effect of cryopreservation on semen quality in patients with testicular cancer. Urology 1995; 46:382.
- Hartmann JT, Albrecht C, Schmoll HJ, et al. Long-term effects on sexual function and fertility after treatment of testicular cancer. Br J Cancer 1999; 80:801.
- Turek PJ, Lowther DN, Carroll PR. Fertility issues and their management in men with testis cancer. Urol Clin North Am 1998; 25:517.
- Nalesnik JG, Sabanegh ES Jr, Eng TY, Buchholz TA. Fertility in men after treatment for stage 1 and 2A seminoma. Am J Clin Oncol 2004; 27:584.
- CLINICAL MANIFESTATIONS
- Testicular examination
- - Cryptorchidism
- DIAGNOSTIC EVALUATION
- Scrotal ultrasound
- - Microlithiasis
- CT scan
- PET scan
- Serum tumor markers
- Radical inguinal orchiectomy
- Contralateral testicular biopsy
- Retroperitoneal lymph node dissection
- CRYOPRESERVATION OF SPERM
- INFORMATION FOR PATIENTS