Testicular Cancer

Imaging and Diagnosis

4/28/2011

Patient Presentation
HPI
30 year old Caucasian male presented to the Urology clinic with
hard, painful right testicle.
R testicle painful to touch and the pain sometimes radiates to his
groin and stomach, no pain at rest.
Pain aggravated by intercourse, has affected ability to have
erections.
Symptoms began 18 months ago and is progressively getting
worse.
Reports mild dysuria, frequency, but does not have hematuria.
Denies history of trauma or previous vasectomies.
Past Medical/Surgical History
Prematurity and successful surgery for closure of patent ductus
arteriosis
Seizure disorder (Grand mal type) - controlled with Carbamazepine
Appendectomy in 8/2005

Patient Presentation
Social/Family History
No family history of GU or any other cancers
Works at a meat packing company, is married with one child.
Does not smoke, occasionally drinks alcohol, no illicit drugs, and
is only sexually active with his wife.
ROS
Otherwise , negative
Physical Exam Findings
Unremarkable HEENT, Respiratory, CV, Abdomen,
Musculoskeletal, Neuro, and Lymph node exam
Genital exam: Normal circumcised penis, no varicocele present
and no hernia detected. The left testicle is normal with no
palpable masses, the right testicle is hard and painful to
touch, no overlying discoloration, the superior portion of
the testicle is firmer and forms a ridge.

Scrotal Ultrasound (With

Spectral and Color Doppler) Basics

The transducer emits sound waves at a specific

frequency and receives reflected sound waves to

produce the image.

Homogeneous substances appear homogeneous

because they transmit sound waves uniformly. (e.g.
normal liver, thyroid, testis, cysts)

The use of high frequency transducers can detect

intrascrotal mass with nearly 100 percent accuracy.

Transverse and Longitudinal views

Conditions like inflammation of the scrotum,

testicular and spermatic cord torsion, undescended
testis, and abnormal blood vessels can be
accurately demonstrated.

Scrotal Ultrasound (With

Spectral and Color Doppler) Basics

Ultrasound

especially useful for its ability to demonstrate

extratesticular from intratesticular masses, and inhomogeneity
within the testis.

Inhomogeneous/heterogeneous findings are considered abnormal.

Generally a mass found within the scrotum but outside the testicle
will be non-cancerous or benign, whereas those inside the testicles
are, with few exceptions cancerous.

The normal testis appears homogenous on ultrasound with an echo

texture similar to the thyroid gland. The normal testis appears
encapsulated due to the hypoechoic ring, the tunica vaginalis.

Doppler waveform imaging can help determine hyperemic

conditions that occur with inflammatory changes.

Color Doppler (CD) is an imaging technique that can demonstrate

blood flow images in color placed over real time B-mode images.

Red indicates flow towards the transducer and blue indicates blood
flow away from the transducer

Scrotal Ultrasound (With Spectral and

Color Doppler) - Findings
Clinical Indications on requisition: Right testicular pain,
evaluate for right testicular mass
Findings:
There is a large heterogeneous, hypoechoic lesion
within the right testicle measuring 3.1 x 2.4 x 3.7 cm
with internal vascularity. There are 2 smaller adjacent
hypoechoic foci in the right testicle measuring 4.2 x 4.5
x 5.4 mm and 2.7 x 3.5 x 4.4 mm. There are no focal
lesions in the left testicle or either epididymis. The right and
left testes measure 4.5 x 2.9 x 3.6 cm and 4.1 x 2.4 x 2.8 cm,
respectively. Color Doppler shows normal flow to the testes and
epididymides.
Impression:
Heterogeneous right testicular mass is consistent with
primary neoplasm. Smaller adjacent foci may represent
satellite lesions.

Plan/Course
Despite the patients atypical presentation (painful

lesion), PE findings of the right testicle was thought to

be concerning for cancer.
UA and micro with trace blood - otherwise negative,
testicular tumor markers were drawn (HCG <2 wnl,
Alpha-fetoprotein 1.9 wnl, and Lactic acid
dehydrogenase hemolyzed), and scrotal Ultrasound
was obtained.
Chest X-ray was obtained to evaluate for metastasis
normal. The high concern for testicular cancer was
explained and radical orchiectomy was recommended.
He wanted to proceed with the right inguinal radical
orchiectomy, scheduled for 4/28 afternoon.

Testicular Cancer: Epidemiology

Most common solid tumor of men aged 20-34

years
2-3 new cases per 100,000 males annually in
the U.S.
90-95% of testis cancers are germ cell tumors
(seminoma and nonseminoma)
Remainder nongerminal cell tumors (leydig cell,
sertoli cell, gonadoblastoma)
In the US, incidence in blacks 1/4 th that of white
1-2% are bilateral

Testicular Cancer: Risk Factors

Cause unknown
Strong association with cryptorchid testis: 7-10% of tumors

develop in patients with history of cryptorchidism

Patients with cryptorchidism have 3-14 times the incidence
of testis cancer compared to patients with normally
descended testis
5-10% of tumors occur in the contralateral descended
testis
Relative risk of malignancy highest for intra-abdominal
testis (1 in 20), and lower for inguinal testis (1 in 80)
Recent data shows that pre-pubertal orchidopexy may
decrease the risk of testis cancer
Exogenous estrogen administration to the mother has been
associated with increased relative risk (2.8-5.3) of testis
cancer in the fetus

Testicular Cancer: Histologic

Classification of Germ Cell
Tumors
Seminoma (35%)
Classic (85%)
Anaplastic (5-10%)
Spermatocytic (5-10%)
Nonseminoma (25%)
Embryonal
Yolk sac
Choriocarcinoma
Teratoma
Mixed (40%)

Testicular Cancer: Patterns of

Metastasis
Choriocarcinoma: hematogenous, thus can have

early metastases especially to the lung

Rest of germ cell tumors: lymphatic, stepwise
Right testis: landing zone is interaortocaval area at
the level of the right renal hilum
Left testis: landing zone is para-aortic area at level
of left renal hilum
Right to left cross-over metastases are common, but
left to right are not
Scrotal violation may result in inguinal metastases
Advanced disease: can have visceral metastases to
lung, liver, brain, among other organs

Testicular Cancer: Signs and

Symptoms
Most common symtom is painless enlargement of the testis
Typical delay in presentation is 3 to 6 months
Acute pain seen in 10% only (due to intratesticular

hemorrhage)
Metastatic symptoms in 10% (back pain, cough, dyspnea, bone
pain, LE edema)
10% are asymptomatic and tumor detected on routine physical
exam or after traumaTesticular mass: firm and nontender
Hydrocele may be present and make diagnosis more difficult
(importance of scrotal ultrasound in this situation)
Adenopathy: supraclavicular, axillary, inguinal
Gynecomastia: present in 5% (hCG)
Hemoptysis: advanced pulmonary disease

Testicular Cancer: Differential

Diagnosis
Epididymitis/epididymorchitis
Hydrocele (transilluminates)
Spermatocele
Hematocele (related to trauma)
Varicocele
Epidermoid cyst

Testicular Cancer: Diagnostic

Studies
Tumor Markers
Alpha-fetoprotein (AFP): produced by yolk sac tumors and
embryonal cancers. Never elevated in seminoma. If elevated in
seminoma, treat as nonseminoma.
Human chorionic gonadotropin (hCG): produced by
choriocarcinoma and 15% of seminoma.
Lactic acid dehaydrogenase (LDH): reflects tumor burden
Liver function tests may be elevated in the presence of hepatic
metastases, and anemia may be present in advanced disease.
Imaging
Scrotal ultrasound: confirm that the mass is testicular and solid,
especially useful in the presence of hydrocele
Chest X-ray: rule out pulmonary metastases
CT of abdomen and pelvis: rule out retroperitoneal
lymphadenopathy/distant metastases

Testicular Cancer: Simplified

Staging
Stage I: testis
Stage II: nodes
IIa: nodes <2cm
IIb: 2-5 cm
IIc: >5 cm

Stage III: mets/visceral disease

Testicular Cancer: Treatment/Prognosis

Radical orchiectomy by inguinal exploration with early vascular

control of the spermatic cord structures initial intervention.

Scrotal approaches and open testicular biopsies should be avoided.
Treatment depends on the histology of the tumor as well as the
clinical stage.
Seminomas stage I and IIa treated by radical orchiectemy and

retroperitoneal irradiation
Seminomas stage II b and beyond treated with primary chemotherapy
Nonseminomas up to 75% of stage I are cured by orchiectemy alone
Nonseminomas With bulky retroperitoneal diseae or mets treated with
chemotherapy
The 5-year disease-free survival rates for stage I and IIa seminomas

(retroperitoneal disease < 10 cm in diameter) treated by radical

orchiectomy and retroperitoneal irradiation are 98% and 9294%,
respectively.
Patients with bulky retroperitoneal or disseminated disease treated
with primary chemotherapy followed by surgery have a 5-year
disease-free survival rate of 5580%.

Take Home Points

Not all patients with testicular cancer present with the

classic symptom of painless enlargement.

Malignant disease can sometimes originate in the
testes, and the prognosis is poor unless it is discovered
and treated while in the testes only.
Ultrasound is a primary diagnostic tool for evaluating
the testes and discovering pathology.
Scrotal ultrasound can readily determine whether a
mass is intratesticular or extratesticular.
Once the diagnosis of testicular cancer has been
established by inguinal orchiectemy, clinical staging of
the disease is accomplished by chest, abdominal, and
pelvic CT scanning.