M/C solid malignancy of young men (but only accounts for about 1% of all cancers in men)
Peak incidence: 15-35 years
Classification
2016 WHO classification:
In the 2016 edition of the World Health Organization classification, germ cell tumour classification is restructured into tumours derived from germ cell neoplasia in situ (GCNIS) and those not derived from GCNIS. NOS, not otherwise specified; YST, yolk sac tumour | Williamson, S.R., Delahunt, B., Magi-Galluzzi, C., Algaba, F., Egevad, L., Ulbright, T.M., Tickoo, S.K., Srigley, J.R., Epstein, J.I., & Berney, D.M. (2016). The World Health Organization 2016 classification of testicular germ cell tumours: a review and update from the International Society of Urological Pathology Testis Consultation Panel. Histopathology, 70 3, 335-346 .
Testicular germ cell tumour (TGCT) classification (based on origin):
Type I (pediatric)
Embryonic stem cells or totipotent primordial germ cells
Type II (adolescents & young adults) (M/C)
Totipotent primordial germ cells
Always malignant
Type III (elderly)
Committed germ cells
Indolent tumours
Schematic representation of the types of testicular germ cell tumours. | Cheng, L., Albers, P., Berney, D. M., Feldman, D. R., Daugaard, G., Gilligan, T., & Looijenga, L. H. J. (2018). Testicular cancer. Nature Reviews Disease Primers, 4(1), 29. https://doi.org/10.1038/s41572-018-0029-0
Etiology
Risk factors:
Cryptorchidism (testicular maldescent)—2–4 fold increase in risk
Carcinoma in situ (intratubular germ cell neoplasia)
Prior history of testis cancer or extragonadal germ cell tumour
Family history— relative risk increased 6–10 fold in brothers or sons of affected man.
HIV infection— slightly increased risk of seminoma
Down syndrome
Testicular trauma
Schematic illustration of aetiology and pathogenesis of disorders grouped within Testicular Dysgenesis Syndrome (TDS): The TDS concept implicates disturbed function of testicular somatic cells (Leydig- and Sertoli cells) caused by inherited genetic mutations /polymorphisms in combination with environmental /lifestyle factors acting during early development. Dysfunction of the somatic cells results in disturbed hormonal homeostasis and causes impaired germ cell differentiation. Depending on the severity of the impairment, multiple outcomes or phenotypes may occur, ranging from reduced anogenital distance (AGD), genital malformations to testicular cancer. Note that the most severe forms of TDS (disorders of sex development with gonadoblastoma (GDB) or GCNIS are the least frequently seen, whereas the mildest forms, such as impaired spermatogenesis are quite common. | Modified from Skakkebæk et al., Hum Reprod 2001 and Physiol Rev 2016
Presentation
Variable presentation.
Scrotal:
Acute pain in the testis or scrotum
Dull ache in the scrotum or abdomen
Firmness of the testis
Painless, solid testicular mass
Scrotal heaviness
Scrotal swelling
Metastasis:
Systemic symptoms: anorexia, malaise, weight loss
Body aches
Gynecomastia
Headaches
Retroduodenal metastases: GI symptoms (nausea, vomiting or GI haemorrhage)
Cerebral, spinal cord or peripheral nerve root involvement: CNS/PNS symptoms
Testicular carcinoma. Ultrasound demonstrating heterogeneous echotexture throughout the testicle. | Dalal, P. U., Sohaib, S. A., & Huddart, R. (2006). Imaging of testicular germ cell tumours. Cancer Imaging : The Official Publication of the International Cancer Imaging Society, 6(1), 124–134. https://doi.org/10.1102/1470-7330.2006.0020
Chest radiograhy:
Chest radiographs taken 4 days apart of a 32‐year‐old man with poor prognosis metastatic germ cell cancer indicating rapid progression of disease. | Baird, D. C., Meyers, G. J., & Hu, J. S. (2018). Testicular Cancer: Diagnosis and Treatment. American Family Physician, 97(4), 261–268.
CT scan (chest/abdomen):
Nuclear imaging:
Non-seminomatous germ cell tumour. (a) Coronal and (b) axial images on 18-FDG enhanced PETCT and (c) iodinated contrast enhanced CT showing a large metabolically active retroperitoneal mass (arrows). | Dalal, P. U., Sohaib, S. A., & Huddart, R. (2006). Imaging of testicular germ cell tumours. Cancer Imaging : The Official Publication of the International Cancer Imaging Society, 6(1), 124–134. https://doi.org/10.1102/1470-7330.2006.0020
Tumor markers:
Beta-hCG
Choriocarcinoma
AFP (Alpha fetal proteins)
Yolk sac tumour
LDH
Non-selective
TNM Staging:
TNMS System for Staging of Testicular Cancer | Baird, D. C., Meyers, G. J., & Hu, J. S. (2018). Testicular Cancer: Diagnosis and Treatment. American Family Physician, 97(4), 261–268.
Histopathology:
Differential diagnosis:
Testicular torsion (acute, severe pain)
Epididymitis/epididymo‐orchitis (associated with fever, pain not as acute)
Hydrocoele
Varicocoele
Hernia
Haematoma
Spermatocele
Management
Screening & prevention:
Self-examination
Early detection
Surgical management
Radical Inguinal Orchiectomy
Adjuvant chemotherapy: BEP (Bleomycin, etoposide, cisplatin)
Biology, epidemiology, diagnosis and management of testicular germ cell tumours (GCTs), which are the most common type of testicular cancer. | Cheng, L., Albers, P., Berney, D. M., Feldman, D. R., Daugaard, G., Gilligan, T., & Looijenga, L. H. J. (2018). Testicular cancer. Nature Reviews Disease Primers, 4(1), 29. https://doi.org/10.1038/s41572-018-0029-0
