Seminoma

Robert C. Susil and Neha Vapiwala

 Background

Clinically, what are the 2 main subgroups of testicular germ cell tumors (GCTs)?

Seminomatous and nonseminomatous germ cell tumors (NSGCTs) are the 2 main subgroups of testicular GCTs. 60% are pure seminoma, 30% are NSGCTs, and 10% are mixed (pts with mixed histology are typically considered to have NSGCTs).

What is the estimated annual incidence and mortality from testicular cancer in the U.S.? Has the incidence been increasing or decreasing?

In the U.S., the annual testicular cancer incidence is ~8,000 and mortality is ~380. From 1973–1998, the incidence in testicular GCTs rose 44% in the U.S. (mostly seminoma).

What is the most common age group for testicular seminoma?

Testicular seminoma is most common in those age 25–40 yrs.

In the U.S., what is the relative incidence of testicular tumors in white men vs. black men?

Testicular cancer is 5.4 times more common in white men than black men.

What is the best established risk factor for testicular cancer?

A Hx of cryptorchidism increases the risk of testicular cancer by ~5 times. The higher the undescended testicle (inguinal canal vs. intra-abdominal), the higher the risk. Orchiopexy prior to puberty lowers this risk. 5%–20% of tumors in pts with a Hx of cryptorchidism develop in the contralat, normally descended testis. The risk is greatest in cases of bilat cryptorchidism.

In a pt with a prior Dx of testicular cancer, what is the cumulative incidence (at 25 yrs) of contralat testicular seminoma?

At 25 yrs following the primary Dx, the cumulative incidence of contralat testicular seminoma is 3.6%.

What is the most common chromosomal abnormality in testicular GCTs?

A 12p isochromosome (i.e., a chromosome with 2 copies of the short arm of chromosome 12) is the most common testicular GCT chromosomal abnormality.

Name the layers of tissue surrounding the testes from outer to inner.

Layers of tissue surrounding the testes (outer to inner):

1. 
   

   Skin

   
   
2. 
   

   Tunica dartos

   
   
3. 
   

   External spermatic fascia

   
   
4. 
   

   Cremaster muscle

   
   
5. 
   

   Internal spermatic fascia

   
   
6. 
   

   Parietal layer of tunica vaginalis

   
   
7. 
   

   Visceral layer of tunica vaginalis

   
   
8. 
   

   Tunica albuginea

Compare and contrast lymphatic drainage of the left vs. right testis.

Lymphatic drainage from testicular tumors goes directly to the para-aortic (P-A) nodes. The left testicular vein drains to the left renal vein, and nodal drainage is primarily to the P-A nodes, directly below the left renal hilum. The right testicular vein drains to the IVC; paracaval and interaortocaval nodes are most commonly involved. Lymphatic drainage from the right testes commonly crosses over to the left, but the reverse is rare.

What is the chance of pelvic/inguinal nodal involvement from testicular cancer? What increases this risk?

Pelvic/inguinal nodes are rarely (<3%) involved by testicular cancer. Risk of involvement increases with:

1. 
   

   Prior scrotal or inguinal surgery

   
   
2. 
   

   Tumor invasion of the tunica vaginalis or lower one third of epididymis

   
   
3. 
   

   Cryptorchidism

What is the DDx of a testicular mass?

The DDx of a testicular mass includes tumor, torsion, hydrocele, varicocele, spermatocele, and epididymitis.

What is the classic presentation of testicular cancer?

A painless testicular mass is the classic presentation of testicular cancer. However, up to 45% of pts will present with pain.

 Workup/Staging

What imaging modality is preferred for primary evaluation of a testicular mass?

Transscrotal US is preferred for primary evaluation of a testicular mass. Testicular tumors are typically hypoechoic.

What is the preferred primary surgical Tx for a unilat testicular tumor?

Transinguinal orchiectomy is the preferred surgical Tx for unilat testicular tumor.

What are 3 tumor markers that should be drawn before orchiectomy for testicular tumor?

Before orchiectomy for a testicular tumor, levels of β-HCG, AFP, and LDH should be drawn.

What are the half-lives of β-HCG and AFP?

The half-life for β-HCG is 22 hrs. The half-life for AFP is 5 days.

How commonly are β-HCG and AFP elevated in testicular seminoma vs. NSGCT? What are unrelated etiologies for elevated β-HCG and AFP?

β-HCG is elevated in 15% of seminomas. AFP is never elevated in seminoma. 1 or both markers will be elevated in 85% of NSGCTs. The use of marijuana can elevate β

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