History

Fact Explanation
Testicular lump Testicular tumor is the most common form of cancer in men aged between 15 and 35 years. Majority of testicular tumors originate from germ cells – Seminomas and non-seminomatous germ cell tumors. Rare types of tumors include interstitial tumor, lymphoma etc. Seminoma characteristically presents in the fourth decade while non-seminomatous tumors present much earlier.[1] Testicular tumors usually present with a painless lump in the testis which is noticed by the patient. Trauma may bring the lump to the patients’ attention.
Dull pain or discomfort in the testis Due to the presence of a testicular mass.
Acute testicular pain and swelling Due to hemorrhage into the tumor.
Symptoms due to loco-regional spread The tumor may rarely invade the scrotum giving rise to pain, discharge and inguinal swellings.
Symptoms due to distant spread Small tumors situated within the testis may go unnoticed by the patient and may present with features of distant metastasis. Para-aortic lymph node enlargement may present with a lump the upper abdomen and back pain. Inferior vena cava obstruction may lead to lower limb swelling. Cervical lymphadenopathy may result in neck lumps. Spread to the lung may lead to development of pleural effusions and present with dyspnoea, chest pain and chronic cough. Spread to liver, brain and bone is rare.
Symptoms due to ectopic hormone production Certain testicular tumors have ectopic hormone production properties. York sac tumors secrete alpha fetoprotein(AFP) and Choriocarcinoma may secrete human chorionic gonadotrophin (HCG) and the beta subunit which can be used for disease monitoring.[2] The patient may present with features of masculinization such as deepening of voice, excess growth of external genitalia and pubic hair. This is usually associated with Leydig cell tumours. Feminization features such as Gynaecomastia and erectile dysfunction may be seen with Sertoli cell tumor.
Risk factors/ Associations The aetiology of testicular tumors is largely unknown. Both genetic and environmental factors have being implicated. History of undescended testicle, mal-development of the testis, previous history of testicular cancer and Klinefelter syndrome have shown to increase the risk of testicular tumor. Chemical exposure and infective agents have also being implicated in the pathogenesis.[3]
References
  1. BOUJELBENE N, COSINSCHI A, BOUJELBENE N, KHANFIR K, BHAGWATI S, HERRMANN E, MIRIMANOFF RO, OZSAHIN M, ZOUHAIR A. Pure seminoma: a review and update. Radiat Oncol [online] 2011 Aug 8:90 [viewed 16 August 2014] Available from: doi:10.1186/1748-717X-6-90
  2. SALLER B, CLARA R, SPöTTL G, SIDDLE K, MANN K. Testicular cancer secretes intact human choriogonadotropin (hCG) and its free beta-subunit: evidence that hCG (+hCG-beta) assays are the most reliable in diagnosis and follow-up. Clin Chem [online] 1990 Feb, 36(2):234-9 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1689221
  3. RICHIARDI L, PETTERSSON A, AKRE O. Genetic and environmental risk factors for testicular cancer. Int J Androl [online] 2007 Aug, 30(4):230-40; discussion 240-1 [viewed 16 August 2014] Available from: doi:10.1111/j.1365-2605.2007.00760.x

Examination

Fact Explanation
General examination : Cervical lymphadenopathy Due to lymphatic metastasis. Seminomas characteristically spread by the lymphatics.
General examination : Bone tenderness Due to haematogenous metastasis to bones.
General examination : Gynaecomastia Ectopic production of HCG results in feminization.[1]
Examination of the scrotum : Palpable lump in the testis Inspect the scrotal wall for features of tumor invasion and inflammation. Bimanually palpate the normal testis initially to determine its consistency and size. Move on to palpation of the affected side. The tumor if palpable will be felt as a solid, firm mass that cannot be felt separately from the testis. The testis may be atrophic. The epididymis may be difficult to feel if incorporated within the tumor. The affected testis and the tumor may be difficult to feel if a secondary hydrocele develops.
Abdominal examination : Hepatomegaly Due to vascular metastasis to the liver.
Abdominal examination : Epigastric mass Due to tumor metastasis to the para-aortic lymph nodes situated at the origin of the gonadal vessels.
References
  1. MINEUR P, DE COOMAN S, HUSTIN J, VERHOEVEN G, DE HERTOGH R. Feminizing testicular Leydig cell tumor: hormonal profile before and after unilateral orchidectomy. J Clin Endocrinol Metab [online] 1987 Apr, 64(4):686-91 [viewed 16 August 2014] Available from: doi:10.1210/jcem-64-4-686

Differential Diagnoses

Fact Explanation
Hydrocele Hydrocele is defined as an abnormal collection of serous fluid within the two layers of the tunica vaginalis. Excess accumulation of fluid may be due to increased production as in secondary hydrocele or due to impaired absorption of fluid. The aetilogy is idiopathic in a majority while testicular disease- malignancy, infection may predispose to secondary hydrocele. Primary hydrocele is commonly seen among the middle age or elderly patients. Acute onset hydrocele in a young patient carries a possibility of underlying malignancy. The patient presents with a painless testicular lump which may have progressively enlarged in size. On examination the swelling is limited to the scrotum and appears to surround the testis. The hydrocele is fluctuant and a majority are translucent. The diagnosis is clinical. The treatment of choice is surgical evacuation – Lord’s operation or Jaboulay’s procedure.[1] Simple aspiration fails to provide a permanent cure.
Varicocele Varicocele is the abnormal dilatation of the veins of the pampiniform plexus. This is commonly seen among adolescents and young adults. The aetiology is unknown in a majority of patients while renal cell carcinoma and nephrectomy have known associations due to obstruction of testicular venous drainage.[2] Symptoms are minimum and the patient may present with a dragging sensation of the testis. On examination the enlarged veins are visible as a bag of worms. The affected testis lies at a lower level compared to the normal side. In the supine position the veins are emptied by gravity and the varicocele may disappear. Diagnosis is by clinical examination.
Epididymo-orchitis Inflammation of the epididymis and the testis is usually due to infection. The pathogenic organism reaches the epididymis via the vas deferens. Sexually transmitted infections, urethral instrumentation and bladder outlet obstruction predispose to retrograde spread of organisms into the epididymis. Haematogenous spread to the epididymis is rare. Testicular pain and swelling is usually heralded by the symptoms urethritis. The testis is swollen, erythematous and warm. Abscess formation may occur rarely with discharge of pus via the scrotal skin. Elevation of the testis characteristically reduces the pain. Urine samples and swabs from the urethra are required to identify the aetiological agent. Antibiotics should be started promptly. Resolution is slow and make take 5-8 weeks.
Testicular torsion Torsion of the testis is a surgical emergency which requires prompt intervention to preserve the testis. Torsion of the testis is most common among the age group 10 to 25 years. The normal testis is well anchored and rarely undergoes torsion. For torsion to occur anatomical abnormalities such as inversion of the testis, bell-clapper abnormality or separation of the testis from the epididymis must be present. The patient develops acute onset severe pain in the groin which may also involve the lower abdomen. The patient may be febrile and feel nauseated. The affected testis is tense, swollen and extremely tender. The affected hemi-scrotum may be reddened and elevated. Investigations are avoided to minimize the delay. Prompt exploration the scrotum is carried out in suspected patients. The torted testis is untwisted, viability assessed and fixed. Non-viable testicles may need to be removed.[3]
References
  1. TARIEL E, MONGIAT-ARTUS P. [Treatment of adult hydrocele]. Ann Urol (Paris) [online] 2004 Aug, 38(4):180-5 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15485157
  2. ESPINOSA BRAVO R, LEMOURT OLIVA M, PéREZ MONZóN AF, PUENTE GUILLEN M, NAVARRO CUTIñO M, SANDOVAL LóPEZ O, DE LA C FUENTES MILERA A. [Renal cell carcinoma and simultaneous left varicocele]. Arch Esp Urol [online] 2003 Jun, 56(5):533-5 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12918314
  3. PENTYALA S, LEE J, YALAMANCHILI P, VITKUN S, KHAN SA. Testicular torsion: a review. J Low Genit Tract Dis [online] 2001 Jan, 5(1):38-47 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17043561

Investigations - for Diagnosis

Fact Explanation
Ultrasound scan USS is the first line diagnostic investigation. Information regarding the characteristics of the tumor and regarding involvement of the contra-lateral testis can be gathered. Seminomas usually appear as a hypoechoic mass with well defined margins. Nonseminomatous tumors are usually hyperechoic and may have cysts and calcifications within the tumor. Use of color Doppler US scans for evaluation of testicular cancers have limited use.[1]
Biopsy Biopsy is avoided due to the risk of tumor seeding along the needle tract. Histological studies are carried out after complete orchidectomy.
Tumor markers : AFP, hCG, and LDH levels These alone have a low specificity and sensitivity for diagnosis of cancer. But it may provide information regarding the tumor variety and prognosis.[2]
References
  1. HORSTMAN WG, MELSON GL, MIDDLETON WD, ANDRIOLE GL. Testicular tumors: findings with color Doppler US. Radiology [online] 1992 Dec, 185(3):733-7 [viewed 16 August 2014] Available from: doi:10.1148/radiology.185.3.1438754
  2. MANN K. [Tumor markers in testicular cancer]. Urologe A [online] 1990 Mar, 29(2):77-86 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2158684

Investigations - Fitness for Management

Fact Explanation
Full blood count To assess the hemoglobin level prior to surgery.
Renal function tests In preparation for surgery.
References

Investigations - Followup

Fact Explanation
Serum tumor marker levels AFP and HCG are commonly secreted by non-seminomatous germ cell tumors. Seminomas may also secrete HCG. Tumor marker levels are measured prior to orchidectomy and can be used to monitor disease activity.[1]
CT-chest and abdomen To monitor response to therapy.
References
  1. KLEIN EA. Tumor markers in testis cancer. Urol Clin North Am [online] 1993 Feb, 20(1):67-73 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/7679533

Investigations - Screening/Staging

Fact Explanation
Staging of testicular tumors Testicular tumors are staged into 4 groups. Stage 1 : Tumor limited to the testis, Stage 2 : Positive lymph node involvement which is limited to nodes below the diaphragm, Stage 3 : nodal disease present above the diaphragm, Stage 4 : Non-lymphatic metastatic disease particularly to the lungs.
CT- Abdomen and pelvis To investigate for abdominal lymph node enlargement and liver metastasis.[1]
Chest X-ray To exclude lung metastases. Lung deposits characteristically appear as cannon ball secondaries. CT chest is recommended if the X-ray is inconclusive and there is a strong suspicion of metastatic disease.
CT-chest CT is increasingly being used for detection of tumor metastases due to its higher sensitivity. Mediastenal and thoracic lymph node involvement can be assessed. CT chest can exclude lung secondaries.
References
  1. DALAL PU, SOHAIB SA, HUDDART R. Imaging of testicular germ cell tumours Cancer Imaging [online] , 6(1):124-134 [viewed 16 August 2014] Available from: doi:10.1102/1470-7330.2006.0020

Management - General Measures

Fact Explanation
Patient counseling The diagnosis of testicular carcinoma should be informed to the patient sensitively. Counsel the patient regarding the stage of the malignancy and prognosis. Provide adequate psychological support to the patient and family.
Patient education Provide information regarding the natural course, complications, investigations required and the treatment options available.
Optimization of patient prior to surgery Prior to radical surgery any concomitant medical conditions should be optimized. Correct anemia if present. Achieve optimum control of blood pressure and blood glucose level.
References

Management - Specific Treatments

Fact Explanation
Scrotal exploration and orchidectomy The first step in the management process is exploration of the scrotum via an inguinal approach. A soft clamp is applied to the spermatic cord to prevent embolization of tumor cells while handling the tumor. Inspect the testis for the presence of a tumor. The testis may need to be opened to visualize small tumors within the testis. If a tumor is detected orchidectomy is performed and sent for histological assessment. The spermatic cord is excised and the inguinal incision is closed.[1]
Management of stage 1 tumors : Seminoma Radical orchidectomy alone may be adequate for low grade malignancy. Adjuvant radiotherapy or chemotherapy may be considered for higher grade seminomas. Seminomas are extremely radiosensitive and hence is considered the mainstay of treatment. Adjuvant radiotherapy 20-30 Gy is administered to the infradiaphragmatic area, including the para-aortic lymph nodes.[2] Alternatively adjuvant platinum-based chemotherapy may administered (single dose of carboplatin).
Management of stage 1 tumors : Non-seminomatous germ cell tumors Non-seminomatous germ cell tumors show a good response to chemotherapy while being relatively insensitive to radiotherapy. Following radical inguinal orchidectomy the patient may be managed with active surveillance or chemotherapy. Retroperitoneal lymph node dissection can be used as a guide to deciding on the chemotherapeutic regime. Two commonly used regimes are etoposide & cisplatin (EP) and bleomycin, etoposide and cis-platinum (BEP chemotherapy).[3]
Retroperitoneal lymph node dissection (RPLND) This procedure aims at removing retroperitoneal abdominal lymph nodes which are the primary site of testicular cancer metastasis. Positive metastases in these lymph nodes suggest malignancy that has spread beyond the testis. Staging of the tumor helps in planning the future management. Both open surgery and laparoscopy can be used for this procedure. The main risk is damage or severing of the autonomic nerves running parallel to the spinal cord. Common complications include impotence, retrograde ejaculation and infertility. Nerve-sparing technique may avoid these complications. According to available evidence open nerve-sparing RPLND is preferred over laparoscopic RPLND. Laparoscopic RPLND is less cost effective, requires specific facilities & expertise and increases hospital stay.[4]
Management of stage 2-4 tumors Combination chemotherapy with the BEP regime is the first line treatment option. The dosage and number of chemotherapy cycles required is determined by retroperitoneal lymph node dissection.
Management of widely disseminated incurable disease These patients are offered palliative radiotherapy or chemotherapy.
Recurrent disease Patients in whom primary treatment fails to clear the tumor or who develop recurrences should be categorized according to disease severity. In low degree recurrence can be managed with chemotherapy- VeIP or TIP regimes. For solitary metastatic lesions salvage surgery may be attempted. Patients with high degree recurrences are usually treated with increasingly potent chemotherapeutic regimes. These patients require stem cell rescue to avoid the risks of bone marrow toxicity. Late recurrences are known to occur with testicular cancer and patients should be adequately informed about the symptoms and signs of recurrences. Advise the patients to seek immediate medical care in such situations.[5]
References
  1. DEARNALEY D.. Regular review: Managing testicular cancer. [online] 2001 June, 322(7302):1583-1588 [viewed 16 August 2014] Available from: doi:10.1136/bmj.322.7302.1583
  2. CLASSEN J, SCHMIDBERGER H, MEISNER C, WINKLER C, DUNST J, SOUCHON R, WEISSBACH L, BUDACH V, ALBERTI W, BAMBERG M, GERMAN TESTICULAR CANCER STUDY GROUP (GTCSG. Para-aortic irradiation for stage I testicular seminoma: results of a prospective study in 675 patients. A trial of the German testicular cancer study group (GTCSG). Br J Cancer [online] 2004 Jun 14, 90(12):2305-11 [viewed 16 August 2014] Available from: doi:10.1038/sj.bjc.6601867
  3. STEPHENSON AJ, APRIKIAN AG, GILLIGAN TD, OLDENBURG J, POWLES T, TONER GC, WATERS WB. Management of low-stage nonseminomatous germ cell tumors of testis: SIU/ICUD Consensus Meeting on Germ Cell Tumors (GCT), Shanghai 2009. Urology [online] 2011 Oct, 78(4 Suppl):S444-55 [viewed 16 August 2014] Available from: doi:10.1016/j.urology.2011.02.030
  4. OGAN K, LOTAN Y, KOENEMAN K, PEARLE MS, CADEDDU JA, RASSWEILER J. Laparoscopic versus open retroperitoneal lymph node dissection: a cost analysis. J Urol [online] 2002 Nov, 168(5):1945-9; discussion 1949 [viewed 16 August 2014] Available from: doi:10.1097/01.ju.0000028608.89099.28
  5. BORGE N, FOSSå SD, OUS S, STENWIG AE, LIEN HH. Late recurrence of testicular cancer. J Clin Oncol [online] 1988 Aug, 6(8):1248-53 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2842463