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Testicular Seminoma

Testicular Embryonal Carcinoma and Seminoma

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.


Presentation

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 [1]. Cryptorchidism is the most important risk factor for the development of testicular cancers [2], whereas genetic factors, a positive family history, and unexplained infertility have been associated with an increased incidence of this tumor [2] [3]. 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 [1] [4]. Swelling is usually unilateral, and only a small number of males report bilateral symptoms [1]. 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 [1]. 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 [4].

Noncompliance
  • Responders with a higher perceived noncompliance rate are more likely to recommend adjuvant therapy (Fisher's exact p CONCLUSIONS: Many US ROs over-estimate the likelihood that stage I testicular seminoma patients will be noncompliant with surveillance[ncbi.nlm.nih.gov]
Mediastinal Lymphadenopathy
  • We report on two men treated for testicular seminoma who on follow-up developed mediastinal lymphadenopathy, which was initially assumed to be metastatic seminoma.[ncbi.nlm.nih.gov]
Testicular Mass
  • 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]
  • A 60-year-old male presented with painless gross hematuria and a left testicular mass. The bladder tumor was deeply infiltrating muscular tissue and had histologic features of both carcinoma and sarcoma.[ncbi.nlm.nih.gov]
  • A 33-year-old male presented to hospital with a painless right testicular mass measuring 2 x 3 cm and no systemic symptoms. The patient had no relevant medical history.[ncbi.nlm.nih.gov]
  • Eleven months later the patient discovered a testicular mass which was found to be a stage I seminoma upon excision and metastatic evaluation. His proteinuria rapidly normalized after orchectomy and regional lymph node radiotherapy.[ncbi.nlm.nih.gov]
Testicular Pain
  • 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]
Scrotal Mass
  • 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]
  • 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]
  • Consult a doctor if you have any of these symptoms: Swelling in the scrotum 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 News[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]

Workup

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 [1]. In order to classify the tumor into its appropriate stage, the following criteria should be used [1] [3] [4] [5]:

  • 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 [5]. For patients in whom metastatic spread is suspected, positron emission tomography (PET) scanning can be useful as well [5].

Colitis
  • The patient started a systemic induction chemotherapy with high dose cytarabine and idarubicin that was complicated by an infectious pneumonia and colitis, and a grade IV thrombocytopenia leading to a brain subdural hemorrhage and quickly to patient's[ncbi.nlm.nih.gov]

Treatment

  • More reliable predictive factors are needed to make treatment decisions.[ncbi.nlm.nih.gov]
  • To minimize the burden of treatment, there has been a shift away from adjuvant treatments for stage I testicular seminomas toward surveillance protocols for seminoma survivors.[ncbi.nlm.nih.gov]
  • BACKGROUND/AIM: Although radiotherapy is considered to be a standard treatment of stage A testicular seminoma, an increasing number of studies have reported encouraging results of the treatment by carboplatin monochemotherapy (CBDCA).[ncbi.nlm.nih.gov]
  • INTRODUCTION: Orchiectomy followed by infradiaphragmatic radiotherapy is a common treatment for stage I-II testicular seminoma.[ncbi.nlm.nih.gov]
  • AIM: This study aims to identify clinical features, treatment outcomes, and prognostic factors for relapse and survival in patients with testicular seminoma.[ncbi.nlm.nih.gov]

Prognosis

  • Accurate staging is crucial in planning the treatment and follow up of seminoma and determines the prognosis.[ncbi.nlm.nih.gov]
  • AFP 1000 ng/mL hCG 5000 IU/L (1000 ng/mL) LDH 1.5x ULN Seminoma (90% of cases) All of the following criteria: 5-year PFS 82% 5-year survival 86% Any primary site No non-pulmonary visceral metastases Normal AFP Any hCG Any LDH Intermediate prognosis group[esmo.org]
  • The abnormal expression of clusterin is closely related to the occurrence, progression, and prognosis of tumors. Up to now, few studies have focused on clusterin in human testicular cancer.[ncbi.nlm.nih.gov]
  • BACKGROUND Myeloid sarcoma is a rare extramedullary soft tissue neoplasm composed of myeloblastic cells, usually associated to hematologic tumor disorders and a poor prognosis. Its diagnosis is very difficult as radiological images are not specific.[ncbi.nlm.nih.gov]
  • Prognosis Prognosis is good but depends on the stage of disease with 5- year survival rates as high as 99% in stage 1 disease.[orpha.net]

Etiology

  • Tumor induction by therapeutic irradiation remains the most likely etiology. Other possibilities include a natural association between seminoma and angiosarcoma, and perhaps the use of chemotherapy.[ncbi.nlm.nih.gov]
  • Etiology Etiology is unknown but tumors are thought to arise from an embryonic germ cell leading to testicular intraepithelial neoplasia (the precursor to classical seminoma).[orpha.net]
  • Etiology The exact etiology of seminoma is unknown. The most current theory is that environmental endocrine disrupters exert estrogenic and/or antiandrogenic activities, contributing to the arrested development of the gonocyte.[ncbi.nlm.nih.gov]
  • Etiology Based on the presumed origin of spermatocytic seminoma from mature (postpubertal) germ cells, it has been hypothesised that the increased proliferation of these cells causes the growth of the tumours, but the etiology has long been unknown.[atlasgeneticsoncology.org]

Epidemiology

  • METHODS: One thousand one hundred and fifty-two stage I testicular seminoma patients with normal alpha-fetoprotein levels were identified in the Surveillance, Epidemiology, and End Results (SEER) database between 1998 and 2005.[ncbi.nlm.nih.gov]
  • MATERIALS AND METHODS: Two hundred and forty-one patients with stage IIA and IIB testicular seminoma were identified between 1988 and 2003 using the Surveillance, Epidemiology, and End Results (SEER) database. RESULTS: Median follow-up was 10 years.[ncbi.nlm.nih.gov]
  • MATERIALS AND METHODS: A total of 8,151 men diagnosed with stage I testicular seminoma from 2000 to 2009 were identified in the national SEER (Surveillance, Epidemiology, and End Results) registry.[ncbi.nlm.nih.gov]
  • METHODS: Data were obtained from the Surveillance, Epidemiology, and End Results program of the National Cancer Institute from 1973 to 2003. The primary end points were overall survival (OS) and cause-specific survival (CSS).[ncbi.nlm.nih.gov]
  • Abstract Testicular germ cell cancers are the most common solid malignancies in young men, but their pathogenesis remains undetermined although some epidemiological data have implicated both environmental and genetic factors.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology Testicular seminoma originates in the germinal epithelium of the seminiferous tubules. The disease is thought to result from the proliferation of immature spermatogonia.[ncbi.nlm.nih.gov]
  • Pathophysiology Testicular seminoma is a pathologic diagnosis in which only seminomatous elements are observed upon histopathologic review after a radical orchiectomy and in which serum alpha-fetoprotein (AFP) is within the reference range.[emedicine.medscape.com]

Prevention

  • Thus, precautions for preventing further complications could be initiated.[ncbi.nlm.nih.gov]
  • Supportive Care: Supportive care refers to treatments designed to prevent and control the side effects of cancer and its treatment.[cancer.unm.edu]
  • Side effects not only cause patients discomfort, but also may prevent the optimal delivery of therapy at its planned dose and schedule.[texasoncology.com]
  • If so, orchidopexy would not prevent testicular cancer; and orchidectomy would be required. The surgical treatment of cryptorchidism to prevent testicular cancer remains unclear.[alliedacademies.org]

References

Article

  1. Boujelbene N, Cosinschi A, Boujelbene N, et al. Pure seminoma: A review and update. Radiat Oncol. 2011;6:90.
  2. Ferguson L, Agoulnik AI. Testicular Cancer and Cryptorchidism. Front Endocrinol (Lausanne). 2013;4:32.
  3. 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.
  4. Hayes-Lattin B, Nichols CR. Testicular Cancer: A Prototypic Tumor of Young Adults. Semin Oncol. 2009;36(5):432-438.
  5. 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.

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Last updated: 2019-07-11 21:17