Testicular cancer: Clinical sciences

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Introduction0:00–0:30

Testicular cancer is the most common solid tumor in young biological males aged 15 to 34. Since there are no standard recommendations to screen for this form of cancer, it is important to assess all testicular masses with a scrotal ultrasound.
Testicular tumors can be categorized into germ cell tumors which include seminoma, non-seminoma, and mixed germ cell tumors; and sex cord, or stromal tumors.
If your patient presents with a chief concern suggesting testicular cancer, first perform a focused history and physical examination, and obtain a scrotal ultrasound.

Stable Patient0:30–2:16

These patients will report a scrotal lump, often associated with scrotal pain, and they may even have a history of cryptorchidism, infertility, or a positive family history of testicular cancer.
The exam will reveal a palpable scrotal mass, and there might be scrotal tenderness and lymphadenopathy. Finally, scrotal ultrasound will show solid intratesticular mass.
With these findings suspect testicular malignancy. Here’s a clinical pearl to keep in mind!
Aside from testicular malignancies, scrotal masses and pain can have a wide differential diagnosis ranging from benign conditions to surgical emergencies.
For example, hydroceles and varicoceles are benign conditions typically found incidentally by the patient or physician. A hydrocele is a buildup of fluid in the scrotum, whereas a varicocele refers to enlarged scrotal veins classically described as a "bag of worms."
Both can likely be managed conservatively. On the other hand, infectious causes of scrotal masses and pain include epididymitis and orchitis, with patients describing sudden pain at the epididymis, extending to the testicle.
Most cases are caused by Chlamydia trachomatis and Neisseria gonorrhoeae and need immediate empiric antibiotic coverage.
Finally, look out for sudden scrotal swelling caused by testicular torsion. In this case, the spermatic cord becomes twisted and strangulated, cutting off blood supply to the testes.
Emergency surgery is the only treatment. Alright if you suspect testicular malignancy, order labs, meaning tumor markers like human chorionic gonadotropin, or hCG, lactate dehydrogenase, or LDH, and alpha-fetoprotein, or AFP, to help confirm the diagnosis.

Suspect Testicular Malignancy2:16–3:49

Additionally, order an abdominal-pelvic CT scan and a chest x-ray to assess for metastasis. Now, because a solid testicular mass is typically cancer until proven otherwise, you should consult urology to perform an orchiectomy and send a tissue sample for pathology.
Orchiectomy is done, not only to confirm the diagnosis but provide treatment as well. Testicular-sparing surgery is possible but rarely performed due to a high risk of recurrence.
Before undergoing an orchiectomy, counsel your patient on the risks of infertility, hypogonadism, and the possibility of recurrence, as well as sperm banking for future family planning.
Post-orchiectomy, your patient might opt for a testicular prosthetic. Here’s a clinical pearl!
Tumor markers obtained prior to surgical or medical treatment of testicular cancer serve not only to help diagnose the type of tumor present but also as a baseline against which future levels are compared.
After treatment, levels typically decline and remain stable as long as the cancer is in remission. On the other hand, increasing levels post-treatment may indicate tumor recurrence and need prompt re-evaluation.
Okay, your final diagnosis depends on labs, imaging, and pathology findings. Let’s start with seminoma germ cell tumors.

Seminoma Germ Cell Tumor3:49–4:22

Lab results may show elevated or normal hCG and LDH, but normal AFP. Imaging studies may show suspicious pelvic, abdominal, or chest lesions suggesting metastasis, and the pathology results will show a well-circumscribed solid tumor that might be grey in color with a nodular appearance.
If this is the case, diagnose a seminoma germ cell tumor. Next up are non-seminoma germ cell tumors.

Non-seminoma Germ Cell Tumor4:22–4:50

These patients might have either elevated or normal hCG and LDH with elevated AFP. Imaging may reveal lesions suspicious for metastasis, and pathology results from the orchiectomy will show an embryonal carcinoma, yolk sac tumor, choriocarcinoma, or teratoma.
If this is the case, diagnose a non-seminoma germ cell tumor. Now let’s talk about mixed germ cell tumors.

Mixed Germ Cell Tumor4:50–5:41

Patients with these tumors may have either elevated or normal hCG, LDH, or AFP results. Their imaging studies may show lesions that suggest metastasis, and the pathology results will show any combination of seminoma and non-seminoma tumor features.
With these findings, diagnose a mixed germ cell tumor. Here’s a clinical pearl!
In some cases, history will give clues about germ cell tumors. If your patient has a history of androgen sensitivity syndrome, HIV, or Down Syndrome, suspect a germ cell tumor.
The same goes for sex cord or stromal tumors. History might reveal certain genetic disorders that increase the risk of these tumors, like Peutz-Jeghers Syndrome, Carney Complex, or Klinefelter Syndrome.
Speaking of which, patients with a sex cord or stromal tumor will have normal levels of hCG, LDH, and AFP. The imaging might show lesions that suggest metastasis, and the pathology results will show a sex cord or stromal tumor.

Sex Cord or Stromal Tumor5:41–6:16

For example, Leydig tumors tend to be well-circumscribed, brown or green in color, and may have calcifications. On the other hand, Sertoli tumors are typically white or yellow in appearance and may have a cystic component.
With these findings, diagnose a sex cord or stromal tumor. When it comes to treatment, it is the same for all testicular cancers.

Treatment6:16–7:14

So, consult urology and oncology for additional treatment options that your patient may need after orchiectomy. All patients should receive counseling regarding their diagnosis and treatment options, which might include surveillance, retroperitoneal lymph node dissection, chemotherapy, or radiation therapy.
Here’s one last clinical pearl! Survival rates of patients with testicular cancer depend on the risk classification and staging of the specific type of tumor.
In general, patients with seminoma or non-seminoma germ cell tumors tend to have the highest survival rates if they don’t relapse for 2 years after being diagnosed.
On the other hand, patients with sex cord or stromal tumors have the best survival rates when the disease is localized, however prognosis is extremely poor if metastases are present.

Review7:14–7:59

Alright, as a quick recap… Testicular cancer is the most common solid tumor in biological males aged 15 to 34. A testicular mass is considered cancer unless proven otherwise, so always order a scrotal ultrasound to investigate.
If you suspect testicular malignancy, consult urology for orchiectomy. Next, differentiate between germ cell and sex cord or stromal tumors by ordering tumor markers, imaging, and pathology of the mass.
Post orchiectomy, treatment for all testicular tumors involves a referral to urology and oncology for further management, which may include surveillance, retroperitoneal lymph node dissection, chemotherapy, or radiation.
Testicular cancer: Clinical Sciences: Video | Osmosis