Testicular seminoma is a malignant germ cell tumor of the testes that is rarely encountered in clinical practice. Painless unilateral testicular swelling is most frequently reported by patients, but because of the indolent clinical course, the diagnosis may often be delayed. A thorough imaging, laboratory, and histological workup is mandatory in determining tumor stage.
Despite the fact that testicular tumors comprise about 1% of all malignancies seen in males, it is the most common solid tumor encountered in males between 15-35 years of age . Cryptorchidism is the most important risk factor for the development of testicular cancers , whereas genetic factors, a positive family history, and unexplained infertility have been associated with an increased incidence of this tumor  . The clinical presentation in virtually all patients starts with the appearance of a painless lump or swelling within the testes that is incidentally discovered by the patient himself  . Swelling is usually unilateral, and only a small number of males report bilateral symptoms . The presence of pain is noted in approximately a third of patients, most commonly in the form of a dull ache, whereas acute pain is seen in only 10% of cases . Fortunately, the majority of individuals are diagnosed in early stages of the disease, but abdominal or back pain, headaches, hemoptysis and other signs of distant tumor spread are seen in 25-35% of cases .
Entire Body System
Computed tomography in the emergency department showed haemoperitoneum and a torted large left testicular mass, likely malignant. The patient underwent laparotomy and excision of the mass. [ncbi.nlm.nih.gov]
Testicular pain from malignancy is relatively rare but still should be included in the differential diagnosis. On physical exam, there is usually a unilateral, firm to hard palpable mass in the scrotum which is localized to the testis. [ncbi.nlm.nih.gov]
Lymphoma in a 72-year-old man with right testicular pain and swelling. [pubs.rsna.org]
In summary, in patients presenting with manifestations of extragonadal germ cell tumor or lymphoma, it is important to rule out a primary tumor in the testes, even when they do not present with symptoms such as testicular pain or mass. [ispub.com]
Testicular pain is reported in up to one fifth of cases. [en.wikipedia.org]
Leydig cell neoplasm in a 24-year-old man with a palpable right scrotal mass and new-onset gynecomastia. [pubs.rsna.org]
Genitourinary Radiology Male Pelvis Testis Seminoma Seminoma Seminomas are the most common malignancy of males age 15-30, usually presenting as a painless scrotal mass. [med-ed.virginia.edu]
Testicular tumors often clinically appear with a painless scrotal mass. At the time of diagnosis retroperitoneal metastases can be detected in some patients. Abdominal, flank and back pain depending on retroperitoneal metastases can be seen. [turkiyeklinikleri.com]
Ultrasonography may be helpful in confirming the presence of a scrotal mass within the testicle. Intratesticular masses are considered malignant until proved otherwise. Radical orchiectomy is the treatment for the primary tumor. [aafp.org]
Painless Testicular Mass
The most common presentation is with a painless testicular mass although some 45% will report a degree of testicular discomfort. Bilateral tumors are rare ( 2%) and are almost always asynchronous 1. [radiopaedia.org]
A painless testicular mass is the classic presentation for testicular cancer, although a number of patients present with diffuse pain or swelling. Ultrasonography may be helpful in confirming the presence of a scrotal mass within the testicle. [aafp.org]
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 Cleveland Clinic [my.clevelandclinic.org]
Patients presenting with a swelling in the scrotum should be examined carefully and an attempt made to distinguish between lumps arising from the testis and other intrascrotal swellings. [patient.info]
An extensive diagnostic workup is necessary if signs and symptoms are suggestive of a testicular tumor. A thorough patient history that will confirm the onset of swelling and accompanying symptoms (if present) should be performed, followed by a detailed physical examination of the scrotum. Testicular ultrasonography must be conducted immediately if swelling or a lump is observed, which may be sufficient to make an initial diagnosis . In order to classify the tumor into its appropriate stage, the following criteria should be used    :
- Invasiveness of the tumor (T) - Seminomas can be limited to the testis and/or epididymis with or without infiltration of the tunica albuginea and vaginalis (T1 and T2, respectively), they can invade the spermatic cord (T3) or the scrotal wall (T4).
- Nodal spread (N) - In early stages of the disease (stage I), tumor spread to the lymph nodes does not occur (N0), but stages II and III are distinguished by a varying degree of lymph node enlargement (≤ 2 cm, between 2-5 cm, and > 5 cm).
- Metastatic spread (M) - Dissemination of the tumor into the non-regional lymph nodes and the lungs (M1a) or distant spread (M1b) may occur in later stages of the disease (III).
- Laboratory values (S) - Lactate dehydrogenase (LDH), beta human chorionic gonadotropin (βhCG) and alpha-fetoprotein (AFP) are well-established tumor markers of testicular cancer, and their values should be obtained in a prompt fashion, as they are vital constituents of seminoma staging.
Such criteria can only be obtained after a detailed imaging and histopathological workup, indicating that computed tomography (CT) and magnetic resonance imaging (MRI) of the pelvis, abdomen, and thorax, as well as microscopic examination of the tumor (most frequently performed after a sample is obtained during radical orchiectomy), are essential in order to make a definite diagnosis . For patients in whom metastatic spread is suspected, positron emission tomography (PET) scanning can be useful as well .
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- Ferguson L, Agoulnik AI. Testicular Cancer and Cryptorchidism. Front Endocrinol (Lausanne). 2013;4:32.
- Coursey Moreno C, Small WC, Camacho JC, et al. Testicular tumors: what radiologists need to know--differential diagnosis, staging, and management. Radiographics. 2015;35(2):400-415.
- Hayes-Lattin B, Nichols CR. Testicular Cancer: A Prototypic Tumor of Young Adults. Semin Oncol. 2009;36(5):432-438.
- Schmoll HJ, Jordan K, Huddart R, et al. Testicular seminoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2010;21(5):v140-146.