PANCE Blueprint Genitourinary (5%)

Testicular cancer (Lecture)

Patient will present as → a 32-year-old male who noticed a mass on his right testicle while showering. He reports this has never happened before and denies any pain or discomfort. On physical examination, there is a firm and fixed mass on the left testicle. Bilateral scrotal ultrasound is performed and significant findings are seen here.

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What are the tumor markers for testicular tumors?

  1. Beta-human chorionic gonadotropin (βHCG)
  2. Alpha-fetoprotein (α-fetoprotein )
  3. LDH

Presents as a firm, painless, nontender testicular mass

  • Most common solid tumor in young men ages 15-40 (average age 32 years old)
  • 5-year survival is 90% in most cases
  • The most common type of testis cancer is a germ cell tumor
    • There are two main types of germ cell tumors: seminoma and non-seminomatous germ cell tumors (NSGCT)
    • Both seminoma and NSGCT occur at about the same rate, and men can have seminoma, NSGCT, or a combination of both
      • Subtypes of seminoma include:
        • Classic seminoma (95%)
        • Spermatocytic seminoma
      • There are four main types of NSGCT that can appear alone, but most often appear as a “mixed” NSGCT, with more than one type present:
        • Embryonal carcinoma
        • Yolk sac carcinoma
        • Choriocarcinoma
        • Teratoma
  • Risk factors include a history of cryptorchidism

Diagnostic studies include

  • Scrotal ultrasound
  • Radiologic studies to look for metastases (common metastases to the belly, brain, and lung)

There are three important tumor markers for testicular cancer:

  • Alpha-fetoprotein (AFP)(+) in NSGCT not seminomas
    • AFP can be elevated in patients with a number of other malignancies, including hepatocellular (liver) carcinoma, cancer of the stomach, pancreas, biliary tract, and lung
  • Beta-Human chorionic gonadotropin (beta-hCG)  – both seminomas and NSGCT
    • beta-hCG can be elevated in a number of other malignancies, including cancers of the liver, lung, pancreas, and stomach
  • Lactate dehydrogenase (LDH) – LDH is less specific for testis cancer than HCG or AFP. However, elevated LDH levels are correlated to high tumor burden in seminoma and recurrence in NSGCT

Orchiectomy with or without chemotherapy and radiation depending on cell type.

  • Seminomatous tumors are radiosensitive and can be treated with radiation therapy
  • Nonseminomatous tumors are radioresistant
  • **Alpha-fetoprotein (AFP) can be used to identify early relapse in testicular cancer

osmosis Osmosis
Testicular carcinoma

Testicular carcinoma is the most common form of cancer in young males between 15-35 years old. The two main categories of testicular cancer are germ cell tumors (including seminomas and non-seminoma germ cell tumors) and sex cord-stromal tumors (including Leydig and Sertoli cell tumors). Germ cell tumors are most common. Cryptorchidism or undescended testes is a common risk factor of testicular cancer. Clinical manifestations include a painless scrotal mass, testicular swelling, and elevated serum tumor markers. Instruct the patient to perform a testicular self-examination once a month beginning at puberty. Treatment includes surgery, chemotherapy, and radiation. Since testicular carcinoma is one of the most curable types of cancers, early treatment yields good prognosis for long-term survival rates.

Testicular carcinoma assessment
Play Video + Quiz
Play Video + Quiz
Play Video + Quiz

Question 1
Which of the following is the most appropriate intervention for a stage I testicular seminoma?
Watchful waiting
Surveillance is an option in stage I disease of a nonseminoma testicular tumor.
Chemotherapy initially
Patients with stage IIC and stage III are treated with chemotherapy.
Orchiectomy and radiation
Orchiectomy and chemotherapy
Chemotherapy is used for later stage tumors (II/III) and followed by surgery in stage III tumors.
Question 1 Explanation: 
Inguinal orchiectomy followed by retroperitoneal radiation therapy cures about 98% of patients with stage I seminoma.
Question 2
Which of the following increases the risk of developing testicular cancer?
Low socioeconomic status
High socioeconomic status, not low, is a risk factor.
History of cryptorchidism
Multiple episodes of epididymitis
Multiple episodes of epididymitis are unrelated to the development of testicular cancer.
Being of African-American ethnicity
The incidence of testicular cancer is much lower in African-American men than in Caucasian men.
Question 2 Explanation: 
The major predisposing risk factor is cryptorchidism unrepaired until after age two.
Question 3
A 20 year-old male presents with a hard mass on the testicle. There has been no previous infection or trauma to the area. Which of the following is the initial diagnostic evaluation to pursue?
serum alpha fetoprotein levels
Although tumor markers are useful to follow patients with testicular cancer, they are not used as the initial screen.
serum human chorionic gonadotropin hormone
See A for explanation.
CT scan of the pelvis
CT scanning of the pelvis is most commonly used in the evaluation for metastatic disease and not used in the initial screen for testicular cancer.
ultrasound of the testicles
Question 3 Explanation: 
An ultrasound of the testes will enable the clinician to discriminate between testicular tumors and epididymitis, orchitis, hematomas, hydroceles, and infiltrative diseases of the testes.
Question 4
A 28 year-old man comes to the office for his yearly follow up of testicular cancer. He was successfully treated with an orchiectomy two years ago. Which of the following tumor markers can be used to identify early relapse in testicular cancer?
Carcinoembryonic antigen (CEA)
Carcinoembryonic antigen can be elevated in multiple conditions including colon cancer, gastritis, peptic ulcer disease, diverticulitis, liver disease, chronic obstructive pulmonary disease, and diabetes.
Prostate specific antigen (PSA)
Prostate specific antigen is a sensitive marker for prostate cancer.
CA 125 glycoprotein
CA 125 glycoprotein is a marker in epithelial ovarian cancer and can be used for post-treatment surveillance.
Alpha fetoprotein (AFP)
Question 4 Explanation: 
Periodic surveillance of alpha fetoprotein is a sensitive method for detecting early relapse of testicular cancer.
There are 4 questions to complete.
Shaded items are complete.

References: Merck Manual · UpToDate

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