Testicular Cancer

TESTICULAR CANCER

Testicular cancer typically presents with a firm, painless testicular mass; non-seminomatous tumours may present with widespread metastasis. Caucasians have a higher incidence than African Americans.

Risk factors include:

•  Cryptorchidism (3–5 times increased risk)
•  Testicular dysgenesis (testicular feminization and Klinefelter syndrome)
•  Positive family history

Clinically, U/S typically shows a hypoechoic intratesticular mass. Serum tumour marker studies can be helpful in confirming the diagnosis. Treatment is radical orchiectomy and possible chemotherapy/radiotherapy. Staging includes an examination of the surgically resected specimen, including a lymph node dissection, along with imaging studies and lab tests.

Serum markers are used to monitor the disease.

• AFP is produced by yolk sac tumours.
• β-hCG is produced by choriocarcinoma and any tumour with syncytiotrophoblasts giant cells.
• LDH is used to measure tumour burden.

Germ Cell Tumors

Germ cell tumours are usually hyperdiploid.

Seminoma is the most common germ cell tumour in adults, with a mean age of 40. It is characteristically sensitive to both chemotherapy and radiation and has an excellent prognosis (early-stage seminoma has a 95% cure rate).

A variant is spermatocytic seminoma, a disease of older men, also with an excellent prognosis. On gross examination, the tumour has a pale tan, bulging cut surface. A microscopic exam shows sheets of monotonous cells (with clear cytoplasm and round nuclei) separated by fibrous septae. Lymphocytes, granulomas, and giant cells may be seen

Choriocarcinoma is a highly malignant tumor that often has widespread metastasis at the time of diagnosis; hematogenous spread to lungs and liver is particularly com-mon. The often small tumor has extensive hemorrhage and necrosis. Microscopi-cally, syncytiotrophoblasts and cytotrophoblasts are seen.

Yolk sac tumor (endodermal sinus tumor) is the most common germ cell tumor in children; in pediatric cases, the prognosis is good. In adults, the prognosis may depend on the other histologic types that are admixed. Microscopically, yolk sac tumors show numerous patterns. Schiller-Duval bodies are glomeruloid structures.

Teratoma often causes cystic masses which may contain cartilage and bone. Micro-scopically, mature teratoma usually contains ectodermal, endodermal, and mesodermal tissue in a haphazard arrangement. Immature elements contain embryonic tissue. Prepubertal cases are benign regardless of immature elements; teratomas in adults have malignant potential.

Mixed germ cell tumours. As many as 60% of germ cell tumours contain >1 component. When both teratoma and embryonal carcinoma are present, the name teratocarcinoma is used.

Sex Cord–Stromal Tumors

Sex cord-stromal tumours include Leydig cell and Sertoli cell tumours.

Leydig cell tumours cause painless testicular masses and have a bimodal distribution (prepubertal and age >50). They may produce androgens and estrogens.

• In adults, the hormonal secretion can produce gynecomastia; in children, it can produce precocious puberty.
• Benign tumours (90%) have an excellent prognosis; malignant tumours (10%) can be refractory to chemotherapy and radiation therapy.
• Tumour cells have abundant pink cytoplasm.

Sertoli cell tumours are rare and usually benign. Microscopically, they show tubule formation.

Other Tumors

• Testicular lymphoma is the most common testicular tumour in men >age 60. Itis most commonly non-Hodgkin lymphoma, diffuse large cell type.
• Scrotal squamous cell carcinoma is associated with exposure to soot (chimneysweeps).