Testicular Cancer

TESTICULAR CANCER

Testicular cancer typically presents with a firm, painless testicular mass; nonsemi-nomatous tumors may present with widespread metastasis. Caucasians have a higher incidence than African Americans.

Risk factors include:

•         Cryptorchidism (3–5 times increased risk)

•         Testicular dysgenesis (testicular feminization and Klinefelter syndrome)

•         Positive family history

Clinically, U/S typically shows a hypoechoic intratesticular mass. Serum tumor marker studies can be helpful in confirming the diagnosis. Treatment is radical orchiectomy and possible chemotherapy/radiotherapy. Staging includes examination of the surgically resected specimen, including a lymph node dissection, along with imaging studies and lab tests.

Serum markers are used to monitor disease.

•         AFP is produced by yolk sac tumors.

•         β-hCG is produced by choriocarcinoma and any tumor with syncytiotropho-blastic giant cells.

•         LDH is used to measure tumor burden.

Germ Cell Tumors

Germ cell tumors are usually hyperdiploid.

Seminoma is the most common germ cell tumor in adults, with mean age 40. It is characteristically sensitive to both chemotherapy and radiation, and has an excel-lent prognosis (early stage seminoma has 95% cure rate).

A variant is spermatocytic seminoma, a disease of older men, also with an excellent prognosis.On gross examination the tumor has a pale tan, bulging cut surface. Microscopic exam shows sheets of monotonous cells (with clear cytoplasm and round nuclei) separated by fibrous septae. Lymphocytes, granulomas, and giant cells may be seen

Choriocarcinoma is a highly malignant tumor that often has widespread metastasis at the time of diagnosis; hematogenous spread to lungs and liver is particularly com-mon. The often small tumor has extensive hemorrhage and necrosis. Microscopi-cally, syncytiotrophoblasts and cytotrophoblasts are seen.

Yolk sac tumor (endodermal sinus tumor) is the most common germ cell tumor in children; in pediatric cases, the prognosis is good. In adults, the prognosis may depend on the other histologic types that are admixed. Microscopically, yolk sac tumors show numerous patterns. Schiller-Duval bodies are glomeruloid structures.

Teratoma often causes cystic masses which may contain cartilage and bone. Micro-scopically, mature teratoma usually contains ectodermal, endodermal, and meso-dermal tissue in a haphazard arrangement. Immature elements contain embryonic tissue. Prepubertal cases are benign regardless of immature elements; teratomas in adults have malignant potential.

Mixed germ cell tumors. As many as 60% of germ cell tumors contain >1 component. When both teratoma and embryonal carcinoma are present, the name teratocarci-noma is used.

Sex Cord–Stromal Tumors

Sex cord–stromal tumors include Leydig cell and Sertoli cell tumors.

Leydig cell tumors cause painless testicular masses, and have a bimodal distri-bution (prepubertal and age >50). They may produce androgens and estrogens.

•         In adults, the hormonal secretion can produce gynecomastia; in chil-dren, it can produce precocious puberty.

•         Benign tumors (90%) have an excellent prognosis; malignant tumors (10%) can be refractory to chemotherapy and radiation therapy.

•         Tumor cells have abundant pink cytoplasm.

Sertoli cell tumors are rare and usually benign. Microscopically, they show tubule formation.

Other Tumors

•         Testicular lymphoma is the most common testicular tumor in men >age 60. It is most commonly non-Hodgkin lymphoma, diffuse large cell type.

•         Scrotal squamous cell carcinoma is associated with exposure to soot (chimney sweeps).