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Inguinal exploration with early vascular control of the spermatic cord structures is the initial intervention to exclude neoplasm If cancer cannot be excluded by examination of the testis, radical orchiectomy is warranted Scrotal approaches and open testicular biopsies should be avoided Further therapy is dependent upon the histology of the tumor as well as the clinical stage The 5-year disease-free survival rates for stage I and IIa (retroperitoneal disease < 10 cm in diameter) seminomas treated by radical orchiectomy and retroperitoneal irradiation are 98% and 92 94%, respectively High-stage seminomas of stage IIb (> 10 cm retroperitoneal involvement) and stage III receive primary chemotherapy (etoposide and cisplatin or cisplatin, etoposide, and bleomycin) Ninety-five percent of patients with stage III disease will attain a complete response following orchiectomy and chemotherapy Surgical resection of residual retroperitoneal masses is warranted only if the mass is larger than 3 cm in diameter, under which circumstances 40% will harbor residual carcinoma Up to 75% of stage A nonseminomas are cured by orchiectomy alone Currently, such patients may be treated by modified retroperitoneal lymph node dissections designed to preserve the sympathetic innervation required for ejaculation Selected patients who meet specific criteria may be offered surveillance These criteria are as follows: (1) tumor is confined within the tunica albuginea; (2) tumor does not demonstrate vascular invasion; (3) tumor markers normalize after orchiectomy; (4) radiographic imaging shows no evidence of disease (chest x-ray and CT); and (5) the patient is reliable Patients most likely to experience relapse on a surveillance regimen include those with predominantly embryonal cancer and those with vascular or lymphatic invasion identified in the orchiectomy specimen Surveillance should be considered an active process both by the physician and by the patient Patients are followed monthly for the first 2 years and bimonthly in the third year Tumor markers are obtained at each visit, and chest radiographs and CT scans are obtained every 3 4 months Follow-up continues beyond the initial 3 years; however, the majority of relapses will occur within the first 8 10 months With rare exceptions, patients who relapse can be cured by chemotherapy or surgery The 5-year diseasefree survival rate for patients with stage A disease ranges from 96% to 100% For low-volume stage B disease, 90% 5-year disease-free survival is attainable Patients with bulky retroperitoneal disease (> 3 cm nodes) or metastatic nonseminomas are treated with primary cisplatin-based combination chemotherapy following orchiectomy (etoposide and cisplatin or cisplatin, etoposide, and bleomycin) If tumor markers normalize and a residual mass greater than 3 cm is apparent on imaging studies, resection of that mass is mandatory because 20% of the time
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Clinical Findings
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A Symptoms and Signs
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The most common symptom of testicular cancer is painless enlargement of the testis Sensations of heaviness are not unusual Patients are usually the first to recognize an abnormality, yet the typical delay in seeking medical attention ranges from 3 to 6 months Acute testicular pain resulting from intratesticular hemorrhage occurs in approximately 10% of cases Ten percent of patients are asymptomatic at presentation, and 10% manifest symptoms relating to metastatic disease such as back pain (retroperitoneal metastases), cough (pulmonary metastases), or lower extremity edema (vena cava obstruction) A testicular mass or diffuse enlargement of the testis is found in the majority of cases on physical examination Secondary hydroceles may be present in 5 10% of cases In advanced disease, supraclavicular adenopathy may be detected, and abdominal examination may palpate a retroperitoneal mass Gynecomastia is seen in 5% of germ cell tumors
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B Laboratory Findings
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Several biochemical markers are important in the diagnosis and treatment of testicular carcinoma, including human chorionic gonadotropin (hCG), -fetoprotein, and lactate dehydrogenase (LDH) -Fetoprotein is never elevated in seminomas, and while hCG is occasionally elevated in seminomas, levels tend to be lower than those seen in nonseminomas LDH may be elevated in either type of tumor Liver function tests may be elevated in the presence of hepatic metastases, and anemia may be present in advanced disease
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