Reproductive: Testicular Cancer

Question 1

Risk factors for testicular cancer

Answer 1

• Cryptorchidism
• Gonadal dysgenesis
• Klinefelters
• Trauma
• ORchitis
• Testicular microlithiasis (maybe)

Question 2

Does cryptorchidism increase the risk of testicular cancer?

Answer 2

Yes, for both testes (even if only unilateral cryptorchidism)

Note: Orchiepexy does not reduce the risk of testicular cancer (but does make it easier to detect earlier).

Question 3

Next step: 18-35 y/o male with retroperitoneal lymphadenopathy on CT

Answer 3

Scrotal ultrasound (possible testicular cancer)

Question 4

Testicular cancer is most likely to spread to which lymph nodes?

Answer 4

Retroperitoneal (para-aortic and paracaval)

Question 5

What is the most common method of metastatic spread in testicular cancer?

Answer 5

Lymphatic (to retroperitoneal lymph nodes)

Note: A notable exception is choriocarcinoma, which metastasizes hematogenously.

Question 6

What are the major categories of testicular cancer?

Answer 6

• Germ cell (90%)
• Non germ cell (10%)

Question 7

What are the major subtypes of germ cell testicular cancer?

Answer 7

• Seminoma (50%)
• Non-seminoma (50%)

Question 8

What are the major subtypes of non-seminomatous germ cell testicular cancer?

Answer 8

• Mixed germ cell
• Teratoma
• Yolk sac
• Choriocarcinoma

Question 9

What are the major subtypes of non germ cell testicular cancer?

Answer 9

• Sertoli
• Leydig

Question 10

Hypoechoic, solid, intratesticular mass…

Answer 10

Cancer until proven otherwise

Note: If completely avascular and in the setting of trauma, then you can suggest hematoma.

Question 11

What is the most common testicular tumor?

Answer 11

Seminoma

Note: Over age 60, the most common testicular tumor is lymphoma.

Question 12

Prognosis of seminoma

Answer 12

Very good (tumor is highly radiosensitive)

Question 13

Seminoma is 9x more common in…

Answer 13

White people

Question 14

Most likely diagnosis in this 30 y/o

Answer 14

Seminoma

Note: Hypoechoic intratesticular mass without history of trauma.

Question 15

Seminomas occur in pts with an average age of 25. Non-seminomatous germ cell tumors tend to occur…

Answer 15

Earlier (~teenage years)

Question 16

Testicular ultrasound in a 19 y/o

Answer 16

Think non-seminomatous germ cell cancer

Note: Heterogeneous cystic and solid with macrocalcifications (seminomas tend to be more homogeneously hypoechoic solid masses with no calcifications or with microcalcifications).

Question 17

Answer 17

Burned-out testicular tumor

Note: Germ cell tumors can outgrow their blood supply, “burning out” and then regressing to a smaller mass or calcification. There may still be viable tumor cells, so these are still usually removed.

Question 18

Testicular ultrasound in a 65 y/o

Answer 18

Think lymphoma

Note: Hypoechoic intratesticular mass is likely seminoma in a <40 y/o and lymphoma in a >60 y/o.

Question 19

Is testicular lymphoma usually unilateral or bilateral?

Answer 19

Unilateral (60%)

Note: Lymphoma is the most common bilateral testicular tumor, but is still more frequently unilateral.

Question 20

Why is testicular involvement problematic in the setting of systemic lymphoma?

Answer 20

Testicular lymphoma is hard to treat due to the blood-testes barrier (lymphoma can “hide” in the testes)

Question 21

What is the most common subtype of testicular lymphoma?

Answer 21

Diffuse B-cell lymphoma

Question 22

Homogenously hypoechoic intratesticular mass with microcalcifications…

Answer 22

Think seminoma

Question 23

Which type of testicular cancer produces metastases that bleed a lot?

Answer 23

Choriocarcinoma

Question 24

Which type of testicular cancer is associated with gynecomastia?

Answer 24

Sertoli Leydig tumors

Question 25

Which type of testicular cancer is associated with Peutz-Jeghers syndrome?

Answer 25

Sertoli tumors

Question 26

Testicular ultrasound in a pt with congenital adrenal hyperplasia

Answer 26

Think adrenal rests in the bilateral testes

Question 27

Bilateral solid testicular and epididymal masses

Answer 27

Think testicular sarcoidosis

Question 28

Pt with Cowden syndrome (multiple hamartomas throughout the body)

Answer 28

Testicular lipomatosis Note: Hyperechoic, avascular testicular lesions in a pt with Cowden syndrome.

Question 29

Which testicular cancers are associated with an elevated beta-hCG?

Answer 29

- Seminoma - Choriocarcinoma (non-seminomatous germ cell)

Question 30

Which testicular cancers are associated with an elevated AFP?

Answer 30

- Mixed germ cell (non-seminomatous germ cell) - Yolk sac (non-seminomatous germ cell)

Question 31

70 y/o M with fever/weight loss and bilateral testicular masses...

Answer 31

Think testicular lymphoma

Question 32

Scrotal ultrasound demonstrates a single testis

Answer 32

Think testicular cancer of an undescended testis Note: Look for an ipsilateral draining vein that empties into the IVC (if rights) or left renal vein (if left).

Question 33

African American male with uveitis and pulmonary disease

Answer 33

Think testicular sarcoidosis

Question 34

What is the stage of testicular cancer if there is ipsilateral inguinal lymphadenopathy?

Answer 34

M1 (metastatic disease) Note: Pelvic, external iliac, and inguinal lymph nodes are considered "non regional" for testicular cancer (which spreads to para-aortic and paracaval lymph nodes first).

Question 35

What is the stage of testicular cancer is there is ipsilateral paracaval lymphadenopathy?

Answer 35

N1-N3 (spread to regional lymph nodes) Note: This is not considered distant metastatic disease.

Question 36

History of scrotal trauma 1 week prior

Answer 36

Global testicular infarction

Question 37

History of scrotal trauma 3 days prior

Answer 37

Testicular hematoma Note: Avascular hypoechoic lesions. Follow up imaging will show that they get smaller.

Question 38

Answer 38

Think testicular epidermoid cyst (benign mass with no malignant potential) Note: Classic "onion skin" appearance.

Question 39

Scrotal ultrasound

Answer 39

Tubular ectasia of the rete testis (benign finding, no follow up) Note: This is common in pts with partial or complete obstruction of the efferent ducts (e.g. older men).