Click here to Enlarge
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
- Testicular cancer Medscape Kush Sachdeva MD et al updated July 2017 https://emedicine.medscape.com/article/279007-overview
- Guidelines on Testicular Cancer European Association of Urology 2016 P. Albers (Chair), W. Albrecht, F. Algaba, C. Bokemeyer, G. Cohn-Cedermark, K. Fizazi, A. Horwich, M.P. Laguna, N. Nicolai, J. Oldenburg https://uroweb.org/guideline/testicular-cancer/
- 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 https://bestpractice.bmj.com/topics/en-gb/255
- Testicular cancer risk -Cancer Research UK https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/testicular-cancer
- 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