Testicular cancer: Clinical sciences

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. 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. 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.