Germ Cell Tumors of the Testis Clinical Findings

A. Symptoms
The most common symptom of testicular cancer is a painless enlargement of the testis. Enlargement is usually gradual, and a sensation of testicular heaviness is not unusual. The typical delay in treatment from initial recognition of the lesion by the patient to definitive therapy (orchiectomy) ranges from 3 to 6 months. The length of delay correlates with the incidence of metastases. The importance of patient awareness and self-examination is apparent. Acute testicular pain is seen in approximately 10% of cases and may be the result of intratesticular hemorrhage or infarction.

Approximately 10% of patients present with symptoms related to metastatic disease. Back pain (retroperitoneal metastases involving nerve roots) is the most common symptom. Other symptoms include cough or dyspnea (pulmonary metastases); anorexia, nausea, or vomiting (retroduodenal metastases); bone pain (skeletal metastases); and lower extremity swelling (venacaval obstruction).

Approximately 10% of patients are asymptomatic at presentation, and the tumor may be detected incidentally following trauma, or it may be detected by the patient's sexual partner.

B. Signs
A testicular mass or diffuse enlargement is found in most cases. The mass is typically firm and nontender, and the epididymis should be easily separable from it. A hydrocele may accompany the testicular tumor and help to camouflage it. Transillumination of the scrotum can help to distinguish between these entities.

Palpation of the abdomen may reveal bulky retroperitoneal disease; assessment of supraclavicular, scalene, and inguinal nodes should be performed. Gynecomastia is present in 5% of all germ cell tumors but may be present in 30-50% of Sertoli and Leydig cell tumors. Its cause seems to be related to multiple complex hormonal interactions involving testosterone, estrone, estradiol, prolactin, and hCG. Hemoptysis may be seen in advanced pulmonary disease.

C. Laboratory Findings and Tumor Markers
Anemia may be detected in advanced disease. Liver function tests may be elevated in the presence of hepatic metastases. Renal function may be diminished (elevated serum creatinine) if ureteral obstruction secondary to bulky retroperitoneal disease is present. The assessment of renal function (creatinine clearance) is mandatory in patients with advanced disease who require chemotherapy.

Several biochemical markers are of importance in the diagnosis and management of testicular carcinoma, including AFP, hCG, and LDH. Alpha-fetoprotein is a glycoprotein with a molecular mass of 70,000 daltons and a half-life of 4-6 days. Although present in fetal serum in high levels, beyond the age of 1 year it is present only in trace amounts. While present to varying degrees in many NSGCTs (), it is never found in seminomas.