Testicular Tumors

Testicular Tumors - Nuts & Bolts

• Most common solid malignancy in men: 15-35 yrs.
• Incidence: 1-2% of male cancers.
• Risk Factors:
  • Cryptorchidism (most significant, ↑4-10x risk)
  • Family history
  • Previous testicular Ca
  • Klinefelter syndrome
  • DES exposure
• Types:
  • Germ Cell Tumors (GCTs): >95% (seminoma & non-seminoma)
  • Non-Germ Cell Tumors (NGCTs): <5% (e.g., Leydig, Sertoli, Lymphoma)
• Presentation: Painless testicular mass.

⭐ Cryptorchidism is the single most important risk factor, increasing the likelihood of developing testicular cancer by 4 to 10 times.

Tumor Types - The Rogue's Gallery

• Germ Cell Tumors (GCTs): ~95% of testicular tumors.
  • Seminoma (50% of GCTs):
    • Most common type. Peak: 30-40 yrs.
    • Markers: PLAP (+), hCG (±, if syncytiotrophoblasts), LDH (±). AFP always negative.
    • Classic, Anaplastic, Spermatocytic variants.
  • Non-Seminomatous GCTs (NSGCTs):
    • Embryonal Carcinoma (20%):
      • Aggressive. Peak: 20-30 yrs.
      • Markers: AFP (±), hCG (±), CD30 (+).
    • Yolk Sac Tumor (Endodermal Sinus Tumor):
      • Most common in infants/children (<3 yrs).
      • Markers: AFP (+++). Schiller-Duval bodies (pathognomonic).
    • Choriocarcinoma (<1%):
      • Highly malignant, early hematogenous spread.
      • Markers: hCG (+++).
    • Teratoma (5%):
      • Mature, Immature, with somatic-type malignancy.
      • Markers: AFP (±), hCG (±). Often chemoresistant.
• Non-Germ Cell Tumors (Sex Cord-Stromal Tumors): ~5%
  • Leydig Cell Tumors: Androgen/estrogen secretion. Reinke crystals.
  • Sertoli Cell Tumors: Usually benign.
  • Gonadoblastoma: Associated with dysgenetic gonads.

⭐ > Yolk Sac Tumor is the most common testicular tumor in pre-pubertal children, typically presenting before 3 years of age and strongly associated with ↑AFP.

Signs & Sleuthing - The Detective Work

• Presentation:
  • Painless testicular mass (commonest).
  • Dull ache, scrotal heaviness.
  • Acute pain (~10%; hemorrhage/infarction).
  • Metastatic: cough, back pain, neck mass.
  • Gynecomastia (hCG-producing tumors).
• Examination:
  • Firm, non-tender mass in testis.
  • Check contralateral testis, abdomen, supraclavicular nodes.
• Investigations:
  • Scrotal USG: Initial imaging.
    • Seminoma: hypoechoic, homogeneous.
    • NSGCT: heterogeneous, cystic, calcified.
  • Tumor Markers: AFP, β-hCG, LDH.

    ⭐ AFP is NEVER elevated in pure Seminoma. (Key for Yolk Sac, Embryonal Ca).

    • β-hCG: ↑ Choriocarcinoma, Embryonal Ca, ~15-20% Seminomas.
    • LDH: Indicates tumor burden.
  • Staging: CT (Chest, Abdomen, Pelvis).
  • Diagnosis/Treatment: Radical inguinal orchiectomy.
    • ⚠️ Avoid trans-scrotal biopsy (risk of tumor spillage).

Staging & Strategy - The Game Plan

Staging uses AJCC TNM system & serum markers (S) post-orchiectomy.

• T (Tumor): pTis, pT1 (testis), pT2 (tunica vaginalis/LVI), pT3 (spermatic cord), pT4 (scrotum).
• N (Nodes): N0 (none), N1 (≤2cm), N2 (>2-5cm), N3 (>5cm).
• M (Metastasis): M0 (none), M1a (non-regional nodes/lung), M1b (other visceral).
• S (Markers): Post-orchiectomy. S0 (normal). S1, S2, S3 by highest marker value:
  • LDH (xULN): S1 (>1.5-10), S2 (>10)
  • hCG (mIU/mL): S1 (5-<5k), S2 (5k-50k), S3 (>50k)
  • AFP (ng/mL): S1 (1k-<10k), S2 (≥10k)

IGCCCG classifies metastatic GCTs: Good, Intermediate, Poor prognosis.

⭐ For clinical Stage I Seminoma, adjuvant single-dose Carboplatin (Area Under Curve 7) is a key option reducing relapse vs surveillance, an alternative to radiotherapy.

High‑Yield Points - ⚡ Biggest Takeaways

• Testicular tumors: Peak incidence 15-35 years; often painless scrotal mass.
• Seminoma: Most common GCT, radiosensitive, can have ↑ β-hCG.
• Non-seminomas (NSGCTs): Include yolk sac (↑ AFP), choriocarcinoma (↑ β-hCG), teratoma.
• Tumor Markers: AFP (never in pure seminoma), β-hCG, LDH (tumor burden).
• Management: Radical inguinal orchiectomy is initial step for diagnosis & treatment.
• Risk Factor: Cryptorchidism is the most significant predisposing factor.