Reproductive: Testicular Cancer Flashcards
Risk factors for testicular cancer
- Cryptorchidism
- Gonadal dysgenesis
- Klinefelters
- Trauma
- ORchitis
- Testicular microlithiasis (maybe)
Does cryptorchidism increase the risk of testicular cancer?
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).
Next step: 18-35 y/o male with retroperitoneal lymphadenopathy on CT
Scrotal ultrasound (possible testicular cancer)
Testicular cancer is most likely to spread to which lymph nodes?
Retroperitoneal (para-aortic and paracaval)
What is the most common method of metastatic spread in testicular cancer?
Lymphatic (to retroperitoneal lymph nodes)
Note: A notable exception is choriocarcinoma, which metastasizes hematogenously.
What are the major categories of testicular cancer?
- Germ cell (90%)
- Non germ cell (10%)
What are the major subtypes of germ cell testicular cancer?
- Seminoma (50%)
- Non-seminoma (50%)
What are the major subtypes of non-seminomatous germ cell testicular cancer?
- Mixed germ cell
- Teratoma
- Yolk sac
- Choriocarcinoma
What are the major subtypes of non germ cell testicular cancer?
- Sertoli
- Leydig
Hypoechoic, solid, intratesticular mass…
Cancer until proven otherwise
Note: If completely avascular and in the setting of trauma, then you can suggest hematoma.
What is the most common testicular tumor?
Seminoma
Note: Over age 60, the most common testicular tumor is lymphoma.
Prognosis of seminoma
Very good (tumor is highly radiosensitive)
Seminoma is 9x more common in…
White people
Most likely diagnosis in this 30 y/o
Seminoma
Note: Hypoechoic intratesticular mass without history of trauma.
Seminomas occur in pts with an average age of 25. Non-seminomatous germ cell tumors tend to occur…
Earlier (~teenage years)
Testicular ultrasound in a 19 y/o
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).
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.
Testicular ultrasound in a 65 y/o
Think lymphoma
Note: Hypoechoic intratesticular mass is likely seminoma in a <40 y/o and lymphoma in a >60 y/o.
Is testicular lymphoma usually unilateral or bilateral?
Unilateral (60%)
Note: Lymphoma is the most common bilateral testicular tumor, but is still more frequently unilateral.
Why is testicular involvement problematic in the setting of systemic lymphoma?
Testicular lymphoma is hard to treat due to the blood-testes barrier (lymphoma can “hide” in the testes)
What is the most common subtype of testicular lymphoma?
Diffuse B-cell lymphoma
Homogenously hypoechoic intratesticular mass with microcalcifications…
Think seminoma
Which type of testicular cancer produces metastases that bleed a lot?
Choriocarcinoma
Which type of testicular cancer is associated with gynecomastia?
Sertoli Leydig tumors
Which type of testicular cancer is associated with Peutz-Jeghers syndrome?
Sertoli tumors
Testicular ultrasound in a pt with congenital adrenal hyperplasia
Think adrenal rests in the bilateral testes
Bilateral solid testicular and epididymal masses
Think testicular sarcoidosis
Pt with Cowden syndrome (multiple hamartomas throughout the body)
Testicular lipomatosis
Note: Hyperechoic, avascular testicular lesions in a pt with Cowden syndrome.
Which testicular cancers are associated with an elevated beta-hCG?
- Seminoma
- Choriocarcinoma (non-seminomatous germ cell)
Which testicular cancers are associated with an elevated AFP?
- Mixed germ cell (non-seminomatous germ cell)
- Yolk sac (non-seminomatous germ cell)
70 y/o M with fever/weight loss and bilateral testicular masses…
Think testicular lymphoma
Scrotal ultrasound demonstrates a single testis
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).
African American male with uveitis and pulmonary disease
Think testicular sarcoidosis
What is the stage of testicular cancer if there is ipsilateral inguinal lymphadenopathy?
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).
What is the stage of testicular cancer is there is ipsilateral paracaval lymphadenopathy?
N1-N3 (spread to regional lymph nodes)
Note: This is not considered distant metastatic disease.
History of scrotal trauma 1 week prior
Global testicular infarction
History of scrotal trauma 3 days prior
Testicular hematoma
Note: Avascular hypoechoic lesions. Follow up imaging will show that they get smaller.
Think testicular epidermoid cyst (benign mass with no malignant potential)
Note: Classic “onion skin” appearance.
Scrotal ultrasound
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).
