Testicular cancer

Testicular cancer – Germ cell tumour arising in the testis

Uncommon disease Most common solid tumour among males 15-34 yrs of age in the US
 Represents 1 % of male neoplasms
5 % of urological tumours
3 to 10 cases occurring / 100 ,000 ♂/yr 
 Risk of developing testicular cancer is low
Risk of dying from it is also very low ( < 1 % of all cancer deaths in males )
 Incidence has been ↑↑ in last decades – particularly in industrialized countries
( unknown reason )
 White men have the highest incidence compared with African and Asian men
African-Americans tend to present with higher-grade disease and have much worse prognosis ( compared to whites )
 Some of the highest rates in Scandinavian countries and Germany


Risk factors- Testicular dysgenesis syndrome components as 
○ undescended testis ( cryptorchidism )
○ hypospadias
○ ↓↓ spermatogenesis ( sub or infertility )
 Family history of testicular tumours among first-grade relatives Previous h/o testicular cancer Testicular carcinoma in situ – also known as intratubular germ cell neoplasia
( TIN ) Testicular atrophy Inguinal hernia Genetic syndromes as Downs syndrome , Klinefelters Men with HIV/ AIDS White ethnicity Oestrogen exposure in utero Age- can happen at any age but most common between 15-35 yrs Very tall men ( ↑ risk ) while short stature is protective ( further information needed ) Tobacco use



Cryptorchidism is 
more common on the
 right. Repair before puberty reduces risk but if left surgically uncorrected or corrected after puberty the risk increases up 
to eightfold

Seminoma Non-seminoma

Painless
 testicular mass is the most common presentation 

Recent BJGP study found that testicular enlargement – a lump or swelling was the biggest risk factor for TC Often noticed on self examination or following trauma
 ( not the cause but triggers self examination )

Hydrocele Up to 20 % ,may present with testicle pain within mass usually due to haemorrhage or infarction of the tumour If metastatic disease – presentation 
( about 5 % ) will be based on location of the disease eg mass in left neck 
( supraclavicular L nodes ) , pulmonary metastases , back pain etc

BJGP- recent study 
( July 2018 )
 suggests that testicular 
enlargement
 caries a risk of cancer of 2.5 %.

Unlike what is traditionally taught
 painful testicular enlargement 
may signify cancer

US may be useful when a
 hydrocele diagnosis is 
uncertain

Examine both testis
Examine while standing first- start with normal side first
Assess location , shape and consistency of the mass

More than 1/2 the cases are on the rt side
Trans-illumination- can further define it
 Abdomen ( lymphadenopathy and hepatomegaly ) Supraclavicular nodes Bony tenderness Gynaecomastia ( can happen in 5 % of patients with germ cell
tumour that produce hCG )

It can be difficult if the lump is near the epididymis, concealed in the body of the testis or impossible to 
feel due to a tense hydrocele

Lumps in the epididymis are rarely cancer

Painful testicular enlargement is generally 
infectious or inflammatory

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for testicular cancer in men if they have a non-painful enlargement or change in shape or texture of the testis. Consider a direct access ultrasound scan for testicular cancer in men with unexplained or persistent testicular symptoms.

References: Further reading Testicular cancer Medscape Kush Sachdeva MD et al Updated July 2017 Guidelines on Testicular Cancer European Association of Urology 2015 Testicular cancer : symptoms for urgent referral are identified BMJ 2018 ; 362 ;k2900 Testicular Cancer : Diagnosis and Treatment Am Fam Physician. 2018 Feb 15;97 (4) : 261-268 Andrology Australia – Testicular Cancer Diagnosis and Treatment BMJ Best Practice- Testicular cancer Testicular cancer risk – Cancer Research UK Testicular Cancer : Epidemiology , Diagnosis and Management Med Clin North Am Vol 102 , Issue 2 , Pages 251-264 Epidemiology and Diagnosis of Testis Cancer Scott M.Stevenson MD et al Urol Clin N Am 42 ( 2015 ) 269-275 Lecture Notes – Urology- Amir Kaisary et al Wiley-Blackwell 2014 Selection of men for investigation of possible testicular cancer in primary care : a large case- control study using electronic patient records Br J Gen Pract 2 July 2018


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