The hallmark of testicular neoplasia is the appearance of a painless mass in the testicle that can be palpated during a physical examination, but patients often notice themselves and recognize the presence of a mass. In rare cases, pain and tenderness may be observed. Constitutional and other symptoms are very rare, as very few patients reach advanced metastatic disease.

• Malaise

  […] swelling in a testicle pain in a testicle or scrotum discomfort in a testicle or scrotum a sensation of heaviness in the scrotum a dull ache in the lower back, groin, or abdomen a sudden accumulation of fluid in the scrotum unexplained tiredness or malaise [medicalnewstoday.com]

• Cough

  Shortness of breath, chest pain, or a cough (even coughing up blood) may develop from cancer spread in the lungs. Belly pain, either from enlarged lymph nodes or because the cancer has spread to the liver. [cancer.org]

  In metastatic disease Cough, shortness of breath, chest pain Lower back or bone pain Gynecomastia Paraneoplastic hyperthyroidism Until proven otherwise, a firm nodule on the testis should be considered cancer! [amboss.com]

  Shortly after his second cycle, he presented with a dry cough, coryzal symptoms, headache, tachycardia and pyrexia of 39.1oc. He was successfully treated with Tazocin and GCSF (granulocyte colony stimulating factor) for neutropenic sepsis. [ijcasereportsandimages.com]

  Common side effects may include nausea, hair loss, fatigue, diarrhea, vomiting, fever, chills, coughing/shortness of breath, mouth sores or skin rash. Other side effects are dizziness, numbness, loss of reflexes or difficulty hearing. [medstargeorgetown.org]

  Patients with symptoms of metastatic disease (about 5 percent of patients with testicular cancer) may present with a neck mass, abdominal mass, lumbar back pain, cough, hemoptysis, dyspnea, or gastrointestinal symptoms. [aafp.org]

• Hemoptysis

  […] metabolic rate of the neoplasm outgrowing its blood supply have been implicated in the pathogenesis, but the exact mechanism remains a medical curiosity. 5 Case Report A 36-year-old male presented with swelling on neck, shortness of breath, dysphagia, hemoptysis [ispub.com]

  Patients with symptoms of metastatic disease (about 5 percent of patients with testicular cancer) may present with a neck mass, abdominal mass, lumbar back pain, cough, hemoptysis, dyspnea, or gastrointestinal symptoms. [aafp.org]

  […] finding in 5% of testicular cancer cases Supraclavicular adenopathy, which may be a finding in advanced disease Lung examination in patients with widespread lung metastases may reveal areas of decreased breath sounds, or these patients may present with hemoptysis [emedicine.medscape.com]

• Dyspnea

  Patients with symptoms of metastatic disease (about 5 percent of patients with testicular cancer) may present with a neck mass, abdominal mass, lumbar back pain, cough, hemoptysis, dyspnea, or gastrointestinal symptoms. [aafp.org]

  […] of the gonads, anywhere along the body's midline from the pineal gland to the coccyx Epidemiology: 5–10% of all germ cell tumors; mostly affects young males Location: midline organs; mediastinal > retroperitoneal > intracranial Symptoms : Chest pain, dyspnea [amboss.com]

  […] of testicular cancer cases Supraclavicular adenopathy, which may be a finding in advanced disease Lung examination in patients with widespread lung metastases may reveal areas of decreased breath sounds, or these patients may present with hemoptysis, dyspnea [emedicine.medscape.com]

• Abdominal Pain

  We describe a new unique case of acute myeloid leukemia (AML) in a 21-yr-old male presenting with abdominal pain, bilateral testicular masses and gynecomastia. [ncbi.nlm.nih.gov]

  In the later stages, as cancer spreads to other organs, a person may notice: lower back pain, if cancer spreads to the lymph nodes difficulty breathing, if it affects the lungs abdominal pain, if it affects the liver headaches and confusion, if it reaches [medicalnewstoday.com]

  In a very small percentage of patients, the first symptoms are from metastases, including neck mass, problems with breathing (cough or shortness of breath), difficulty eating, abdominal pain, back pain or pain in the bones. [ufhealth.org]

  Testicular pain and/or abdominal pain. Dragging sensation. Recent history of trauma; it is probably the trauma that leads the man to examine himself and find the tumour rather than being the cause of malignant change. Hydrocele. [patient.info]

  Acute abdominal pain could be the initial symptom with torsion of an abdominal undescended testicle containing a tumor. Some children with hormonally active tumors may have small intratesticular lesions that are not palpable on physical examination. [indianjcancer.com]

• Constipation

  These side effects include: increased risk of infections bleeding or bruising fatigue diarrhea or constipation Several drugs are available to assist in treating these side effects, most of which will disappear after the treatment is completed. [medical-dictionary.thefreedictionary.com]

• Vascular Disease

  Cardiovascular late side effects have been termed radiation-induced heart disease (RIHD) and radiation-induced vascular disease (RIVD).[27] Symptoms are dose dependent and include cardiomyopathy, myocardial fibrosis, valvular heart disease, coronary artery [en.wikipedia.org]

  vinblastine, or both. 121, 122 Microalbuminuria, a proposed marker of systemic vascular disease reflecting generalized endothelial dysfunction, 139 is also present in up to 22% of long-term testicular cancer survivors treated with cisplatin. 123 This [doi.org]

• Tingling

  […] hair loss nausea sore mouth and mouth ulcers loss of appetite fatigue breathlessness and lung damage infertility ringing in your ears ( tinnitus ) skin that bleeds or bruises easily low blood counts increased vulnerability to infection numbness and tingling [nhsinform.scot]

  […] cardiovascular disease; high blood pressure (hypertension); lung disease including scarring of the lungs; reduced production of hormones by the testicles (hypogonadism), which can cause infertility and sexual dysfunction; damage to the nerves including tingling [rarediseases.org]

• Cryptorchidism

  In terms of risk factors, cryptorchidism is shown to substantially increase the risk of testicular neoplasia. [symptoma.com]

  […] risk is greatest in cases of bilateral cryptorchidism. [aafp.org]

  Because of this, some doctors conclude that cryptorchidism doesn’t actually cause testicular cancer, but that there's something else that leads to both testicular cancer and abnormal positioning of one or both testicles. [cancer.org]

  Wood and Elder conducted an extensive review of the data about cryptorchidism as it related to testicular cancer. The relative risk of testicular cancer in cryptorchidism is 2.75 to 8. [cancernetwork.com]

• Painless Testicular Mass

  Patients presenting with a painless testicular mass, scrotal heaviness, a dull ache, or acute pain should receive a thorough examination. Testicular masses should be examined with scrotal ultrasonography. [ncbi.nlm.nih.gov]

  At a Glance When a patient discovers a usually painless testicular mass, either unintentionally or by self-examination, or when a testicular mass is discovered by routine physical examination, testicular cancer should be suspected. [cancertherapyadvisor.com]

  So, knowing the signs and symptoms of testicular cancer plays an important role in the treatment process at an early stage. Dr Ahluwalia says that testicular cancer may develop painless testicular mass. [timesofindia.indiatimes.com]

  However, ITGCN does not appear to occur in testes harboring prepubertal yolk sac tumors. [8] A painless testicular mass is the most common finding in a child with a testicular tumor. [indianjcancer.com]

  Most common germ cell tumor Mean age is 40 yrs Very rare in children Patients present with painless testicular mass 30 % have metastases at presentation, but only 3% have symptoms related to metastases. 11. [slideshare.net]

• Swelling of the Scrotum

  Consult a doctor if you have any of these symptoms: Swelling in the scrotum A lump or swelling in either testicle Build-up of fluid on the scrotum Dull ache in the groin or lower abdomen Pain or discomfort in the scrotum or a testicle Get useful, helpful [my.clevelandclinic.org]

  Look for swelling in the scrotum or any changes in appearance. Gently feel the scrotal sac to find a testicle. Examine the testicles one at a time. [urologyhealth.org]

  […] mass Negative transillumination test Solid mass with variable echogenicity Hydrocele testis Fluctuant swelling of the scrotum Palpation of an elastic soft swelling Positive transillumination test Hypoechoic mass around the testis Varicocele testis Usually [amboss.com]

  Heat relaxes the scrotum, making it easier to spot anything abnormal. The National Cancer Institute recommends following these steps every month: Stand in front of a mirror. Check for any swelling on the scrotum skin. [washington.edu]

• Testicular Swelling

  A 19 year old man presented with unilateral testicular swelling and pain. An initial diagnosis of epididymo-orchitis was modified to a presumed testicular neoplasm following ultrasonography. [ncbi.nlm.nih.gov]

  When symptoms do appear, they can include: testicular pain or discomfort testicular swelling lower abdominal or back pain enlargement of breast tissue Make an appointment with your doctor if you have any of these symptoms. [healthline.com]

  […] painless ; swelling may be reduced when supine Visible or palpable strands and “bag of worms” sensation Negative transillumination test Dilated hypoechoic pampiniform vessels Spermatocele testis Fluctuant swelling of the upper testicular pole Positive [amboss.com]

  Patients present with unilateral testicular swelling or recurrent hydrocele. Only rarely is the presentation incidental in a hernia sac or is there a palpable mass clinically suggestive of a neoplasm. [nature.com]

• Sexual Dysfunction

  At present none of the existing treatment modalities for life-long androgen replacement ensure constant physiological testosterone levels, and patients can suffer from disturbances in their libido and sexual dysfunction.7 Due to the risk of malignancy [pmj.bmj.com]

  These risks can include chronic fatigue; cardiovascular disease; high blood pressure (hypertension); lung disease including scarring of the lungs; reduced production of hormones by the testicles (hypogonadism), which can cause infertility and sexual dysfunction [rarediseases.org]

  […] be responsible of sexual dysfunctions (erectile dysfunction or premature ejaculation). [cancerindex.org]

The initial diagnosis can be made upon palpation of a painless mass, but to support this finding, both laboratory and imaging studies need to be conducted. Serum levels of β-hCG are elevated in 100% of patients with choriocarcinoma, while 90% mixed tumors have both β-hCG and AFP elevations [2]. On the other hand, embryonal carcinomas never give increased values of these markers, which may further help in making the diagnosis prior to microscopic confirmation [2]. Although nonspecific, lactate dehydrogenase (LDH) is also a valuable parameter, as it is often elevated in the presence of virtually all forms of testicular neoplasia. In terms of imaging studies, testicular ultrasonography may be performed to differentiate between testicular and benign testicular masses, as the latter may not require immediate intervention [4]. If a suspicion of metastatic disease is made, X-ray or computed tomography (CT) may be performed. Because biopsy may cause tumor dissemination, a radical orchiectomy is indicated for all patient in whom a painless mass is observed [10]. Once orchiectomy is performed, the mass is sampled for histopathological analysis and confirms the tumor subtype depending on morphological characteristics.

Treatment encompasses surgery, radiation, and chemotherapy, as well as surveillance and long-term follow-up [11]. Radical orchiectomy, with or without retroperitoneal lymph node dissection, is indicated in early clinical stages, while adjunctive therapy is recommended in patients with evidence of advanced and metastatic disease [4]. Cisplatin, etoposide, and bleomycin are chemotherapeutic agents that are used in stages II, III, and IV and show very high rates of success [5]. Regardless of the subtype, a combination of surgery and adjuvant therapy provides very high success rates, especially in early stages of the disease.

The overall prognosis of testicular tumors is very good, as they are quite sensitive to current therapeutic principles. According to TNM classification, tumors are divided into four stages [4]:

• Stage I - The tumor is confined to the testis and epididymis without dissemination through vascular and lymphatic pathways, as well as a possible invasion into the tunica albuginea.
• Stage II - Vascular or lymphatic dissemination of the tumor, although still confined to the testis, with the invasion of both tunica albuginea and tunica vaginalis.
• Stage III - Invasion of the spermatic cord is observed that may or may not be accompanied by either lymphatic or vascular dissemination.
• Stage IV - The tumor invades the scrotum, while distant metastases are not necessary.

For nonseminomas, cure rates for stages I and II extend over 95%, while 80-85% of patients with the advanced metastatic disease are effectively treated, implying that therapy is quite successful against this type of tumor. Similar cure rates have been observed in seminomas and fortunately, the majority of patients are diagnosed in the initial stages of the disease (stage I), which significantly improves chances of complete cure [5]. Relapses may occur but are adequately managed with chemotherapy [4].

The cause of testicular neoplasia remains unknown, although several findings regarding its etiology have been established. In almost all germ cell tumors, an isochromosome of the short arm of chromosome 12 is found, while alterations in chromosomes 7 and 8 have also been identified in numerous cases [6]. The role of genetic factors further includes a much frequent appearance of testicular tumors in individuals with a positive family history, indicating that some inherited defects may play a role as well [2]. However, exact mutations and gene alterations are yet to be determined. 95% of testicular tumors arise from germ cells and are divided into two main categories: seminoma and nonseminoma, with approximately equal distributions. Nonseminomas are further classified into embryonal carcinomas, choriocarcinomas, and teratomas, while yolk sac and mixed tumors are also mentioned in literature [2].

Testicular neoplasia comprises only 1% of all tumors in males, but it is the most common tumor between 15-35 years of age in men, with marked increases in its appearance over the last 40 years [3]. In the United States, the incidence rates have risen between 40-60% [7], depending on the subtype of tumor, and today, approximately 8000 males are diagnosed every year [2]. Incidence rates significantly vary depending on the geographical region, with lowest rates seen in Africa, Asia and South America (0.5 cases per 100 000 males in Egypt and 1.6 per 100 000 in China, Hong Kong) compared to Europe (5.3 cases per 100 000 in Sweden, 7.6 per 100 000 in the United Kingdom, 9.2 cases per 100 000 in Denmark and 9.6 per 100 000 in Norway) [3] [8]. Additionally, a significant predilection toward Caucasians compared to African Americans and Asians has been observed, with potential reasons being hormonal variations, mainly in testosterone and other androgens [3]. In terms of risk factors, cryptorchidism is shown to substantially increase the risk of testicular neoplasia. It is seen in approximately 10% of patients and causes a two-fold to even five-fold increased risk for testicular neoplasia according to various studies [1]. Other risk factors include both personal and family history of a previous testicular tumor and male infertility, while numerous other environmental, genetic and hormonal factors have been mentioned sporadically as potential contributors [3] [9].

The pathogenesis model of testicular neoplasia is currently not known and only limited information exist regarding its development. Aside from documented alterations in short arm of chromosome 12, evidence that cryptorchidism open link and previous testicular neoplasia substantially increase the risk for this tumor, little is known in this field. In situ carcinomas (or intratubular germ cell neoplasia) are considered to be prerequisite lesions for this tumor and are thought to occur as a result of varying levels of testicular dysgenesis [2] [3]. Moreover, it is thought that virtually all patients who develop this lesion will eventually result in testicular neoplasia, especially during the younger age.

In terms of preventing the development of this tumor, little can be done having in mind the fact that the cause remains to be discovered. However, studies have established a significantly reduced risk of testicular neoplasia if prior management of cryptorchidism and undescended testes was performed [12]. Additionally, self-examination may be a helpful preventive measure, particularly during the adolescent period when these tumors most commonly appear.

Testicular neoplasm comprises only 1-2% of all tumors seen in men, but it is the most common malignancy seen in males between 15-35 years of age. Almost 95% of tumors arise from germ cells, but a very small proportion of tumors arise from either Leydig or Sertoli cells and are usually benign in nature [1]. Based on histological differentiation, testicular neoplasms derived from germ cells are divided into seminomas and nonseminomas, but there are four malignant subtypes: seminomas, choriocarcinomas, embryonic cell carcinomas and teratomas [2]. The pathogenesis of testicular tumors remain unknown, but various risk factors have been identified. Cryptorchidism is shown to increase the risk by several-fold and is present in around 10% of all patients, while gonadal dysgenesis and hormonal factors are also considered to be associated factors [2]. Current data show that the incidence ranges from 1-9 per 100,000 males, depending on the geographical region [1], but more importantly, rates of this tumor have doubled in the past few decades [3]. In the United States, approximately 8000 new cases occur every year [2]. The main clinical presentation is the appearance of a painless mass in the scrotum, while pain and tenderness in the testes are rarely seen. Findings during the physical examination may be sufficient to make a presumptive diagnosis, but both laboratory and imaging studies may be used to support these findings. β-Human chorionic gonadotropin (β-hCG), α-fetoprotein (AFP) and lactate dehydrogenase (LDH) are serum markers that are often elevated in testicular neoplasms, while ultrasonography of the palpated mass, as well as plain chest radiography may be useful. A biopsy is rarely indicated for this type of cancer, as it may cause dissemination of the tumor, which is why radical inguinal orchiectomy is performed with subsequent histopathological analysis. Testicular cancers respond very well to all forms of therapy and strategies somewhat vary depending on tumor staging. According to the tumor, node, metastasis, or TNM classification, tumors are stages from 1 to 4, 1 being testicular involvement only and 4 invasions of the scrotum with or without distant metastases [4]. Surgery, chemotherapy, radiation therapy and close monitoring are modalities used in managing testicular cancer. Cure rates are very high, exceeding 95% for almost all types of cancers in milder stages, whereas 75-80% of patients with evidence of disseminated disease are effectively treated [5].

Testicular neoplasia is not commonly encountered, as it comprises of about 1% of all tumors seen in males, but it is established to be the most common tumor in males between 15-35 years of age. There are various subtypes, and more than 95% of tumors are malignant in nature. The cause remains unknown, but several risk factors have been established. Undescended testicles (cryptorchidism), male infertility and family history of testicular cancer are all shown to be important risks. Additionally, an ethnic predilection toward Caucasians has been observed throughout various studies. This tumor appears in approximately 8000 males every year in the United States, whereas epidemiological data from Europe suggest that the number of new cases ranges from about 3-9 per 100,000 males. The main symptoms of testicular neoplasia are the appearance of a painless mass in the testicle that is either palpated by the patient himself or during the physical examination. In rare cases, the mass may be tender and painful, while other symptoms are very rare. To confirm the diagnosis of a testicular neoplasia, laboratory studies that evaluate levels of β-Human chorionic gonadotropin (β-hCG), α-fetoprotein (AFP) and lactate dehydrogenase (LDH) may be of significant value, as these parameters are almost always elevated in these patients. Because biopsy is contraindicated due to the risk of disseminating the tumor, an ultrasound of the mass may be performed to potentially differentiate between a testicular and extratesticular mass, that is most often benign. If a testicular mass is confirmed, radical testicular removal is indicated and the mass is further analyzed to confirm the subtype of the tumor. Fortunately, the vast majority of patients present in early stages of the tumor and current treatment modalities result in almost 100% cure for some subtypes of testicular neoplasia. In patients with advanced disease, such as the presence of metastases, cure rates are between 80-85%, but the overall prognosis is very good. In addition to surgical treatment, chemotherapy and radiation are often used, especially in advanced stages of the disease and show a marked success. Relapses may occur, but the little risk exists with the proper use of chemotherapy.

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