All palpable masses within the testicles must be considered to be testicular cancer until proven otherwise.
The sensitivity of an ultrasonographic examination is almost 100%, and should be carried out if a solid tumour is suspected or the clinical assessment of a scrotal mass remains uncertain.
Obtaining a tissue sample through the scrotum is contraindicated if cancer is suspected.
The prognosis of testicular cancer is good.
Self examination of the testicles is important especially in those belonging to the risk group. Patients in the risk group are those whose father or brother has been diagnosed with testicular cancer and those who have been treated for undescended testes.
Epidemiology
Testicular cancer is relatively rare (1-1.5 % of all cancers in men), but it is the most common cancer in young men aged 15-35 years. Globally, over 74 000 new cases were detected in 2020 http://gco.iarc.fr/today/online-analysis-table?v=2020&mode=cancer. The incidence is highest at the age of 30-34 years: about 19/100 000 men annually.
Undescended testes (cryptorchidism) and hereditary factors are risk factors for testicular cancer. The contribution of environmental factors is also evident.
Over 90% of testicular cancers originate from the germ cells. Germ cell tumours are further divided into two main histological categories: seminomas and other germ cell tumours, known as non-seminomas.
Signs and symptoms
The most common presenting symptom is an enlargement of one testicle.
Testicular pain is the presenting symptom in one out of five cases, and in about 10% symptoms are due to metastatic disease. These symptoms include back and abdominal pain, dyspnoea and haemoptysis. Gynaecomastia occurs in about 5% of patients.
The tumour is typically felt as a solid or rubbery mass inside the testicle.
Ultrasonography of the scrotum is the first-line imaging study. According to current understanding, testicular microlithiasis does not increase the risk of testicular cancer. Shining a torch through the scrotum will help differentiate a cancerous tumour, which does not allow the light to pass through, from a hydrocele or spermatocele.
The sensitivity of computed tomography (CT) scanning in the detection of metastases is good, and it is indicated for disease staging in all patients.
Serum tumour markers for testicular cancer exist (alpha-fetoprotein, human chorionic gonadotropin and lactate dehydrogenase) and are of benefit both in diagnosis and surveillance. However, normal levels of tumour markers do not exclude the possibility of testicular cancer, which is why the use of these tests in primary health care is often unnecessary.
Treatment
The first treatment option for testicular cancer is the surgical removal of the affected testicle and spermatic cord through an incision in the inguinal region. The removed testicle can be replaced by a prosthetic testicle.
Depending on the stage of the disease the surgery may be followed by adjuvant radiotherapy and chemotherapy, retroperitoneal lymph node dissection or their combination.
Additional treatments are avoided if the cancer is localised in the testicle. Should the disease recur, the treatment results with oncological therapy are equally good as those achieved with immediate adjuvant therapy.
Surveillance
Over 95% of the patients are alive five years after the diagnosis. Even if the disease recurs, the prognosis is usually good.
Surveillance is based on a physical examination, which includes the palpation of lymph nodes and abdomen, as well as the determination of the tumour markers. The most important imaging study is CT scan, which is why surveillance is mostly carried out in hospitals.
The surveillance schedule depends on the type of tumour, tumour marker levels and adjuvant therapy administered.
References
Pierorazio PM, Albers P, Black PC ym. Non-risk-adapted Surveillance for Stage I Testicular Cancer: Critical Review and Summary. Eur Urol 2018;73(6):899-907. [PubMed]