What are the clinical features of testicular cancer?

Clinical Features of Testicular Cancer

The classic presentation of testicular cancer is a painless solid testicular mass, though patients may also present with testicular discomfort, swelling, or a sensation of heaviness in the scrotum. 1

Primary Clinical Presentation

• Testicular mass characteristics:

  • Painless solid mass (most pathognomonic sign) 1
  • Testicular enlargement or induration (hardening) 1
  • Unilateral presentation (most common) 1

• Associated symptoms:

  • Scrotal pain (occurs in approximately 27% of cases) 1
  • Back or flank pain (occurs in approximately 11% of cases) 1
  • Sensation of heaviness in the scrotum 1
  • Gynaecomastia (occurs in approximately 1% of cases) 1

Risk Factors

• Age: Most common in males between 15-40 years 1, 2
• Cryptorchidism (undescended testicle) - increases risk up to 11-fold 3
• Personal or family history of testicular cancer 1
• Infertility 1, 4
• White race 4
• Testicular atrophy 1
• Genetic conditions (e.g., Klinefelter syndrome) 2

Diagnostic Findings

Physical Examination

• Palpable testicular abnormality
• Examination should include both testes, abdomen, and supraclavicular fossae 1
• Assessment for gynaecomastia 1

Laboratory Findings

Serum tumor markers are critical for diagnosis, staging, and monitoring:

• Alpha-fetoprotein (AFP):

  • Elevated in non-seminomatous germ cell tumors
  • Never elevated in pure seminoma 1

• Beta-human chorionic gonadotropin (β-hCG):

  • May be elevated in both seminoma and non-seminoma
  • Half-life of 1-3 days 1

• Lactate dehydrogenase (LDH):

  • Less specific marker but correlates with tumor burden
  • Prognostic value 1

Important note: Normal tumor marker levels do not exclude testicular cancer, as markers have limited sensitivity, especially in seminoma 1

Imaging Findings

• Testicular ultrasound:
  • High-frequency (>10 MHz) with Doppler assessment
  • Differentiates intratesticular from extratesticular masses
  • Evaluates contralateral testis 1

Disease Presentation by Stage

• Stage I (70-75% of cases): Localized to testicle 2

  • 85% of seminomas present as stage I
  • 60% of non-seminomas present as stage I 1

• Stage II (20% of cases): Metastatic to retroperitoneal lymph nodes only 2

• Stage III (10% of cases): Widely metastatic disease 2

  • May present with symptoms related to metastatic sites (e.g., back pain, respiratory symptoms)

Histological Types

• Seminoma (55-60% of cases): 1

  • Generally slower growing
  • More responsive to radiation therapy
  • Cannot have elevated AFP

• Non-seminoma (40-45% of cases): 1

  • More aggressive clinical course
  • Includes embryonal carcinoma, yolk sac tumor, choriocarcinoma, and teratoma
  • May have mixed histology

Common Pitfalls in Diagnosis

1. Misdiagnosis as epididymitis or orchitis:

   • Persistent symptoms despite antibiotic treatment warrant ultrasound evaluation 1

2. Delay in diagnosis:

   • Associated with higher stage at presentation and potentially worse outcomes 1

3. Failure to obtain appropriate tumor markers:

   • Markers should be obtained before orchiectomy as they support diagnosis and provide baseline for monitoring 1

4. Scrotal approach for biopsy:

   • Should be avoided as it increases risk of local recurrence 1

Early diagnosis and prompt referral to a urologist are essential for optimal outcomes, as testicular cancer has excellent cure rates when detected early, with 5-year survival rates of 99% for stage I disease 2.