Diagnostic Ultrasound - Abdomen and Pelvis

Testicular Germ Cell Tumors
Diagnoses: Scrotum
• Increased vascularity on color Doppler without
displacement of vessels
• Reactive hydrocele with low-level echoes, scrotal wall
thickening
PATHOLOGY
General Features
• Etiology
○ Associated with cryptorchidism, previous contralateral
cancer; possible association with mumps orchitis,
microlithiasis, and family history of tumor
• Genetics
○ Family history increases risk
• Associated abnormalities
○ Gynecomastia, prepubescent virilization
• 95% of testicular tumors are malignant germ cell tumors
• Single histologic subtype in 65% of tumors (seminoma
most common)
• Multiple subtypes in 35%
Staging, Grading, & Classification
• Stage I (A): Tumor confined to testis
• Stage II (B): Tumor metastatic to nodes below diaphragm
• Stage IIA (B1): Retroperitoneal node enlargement < 2 cm (5
cm³)
• Stage IIB (B2): Retroperitoneal node enlargement > 2 cm x
< 5 cm (10 cm³)
• Stage IIC (B3): Retroperitoneal node enlargement > 5 cm
• Stage III (C): Tumor metastatic to lymph nodes above
diaphragm
• Stage IIIA (C1): Metastases confined to lymphatic system
• Stage IIIB or IV: Extranodal metastases
Gross Pathologic & Surgical Features
• Solid or solid/cystic intratesticular mass
• 10-15% have epididymis or spermatic cord involvement
• Bilateral in 2-3% of cases
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Palpable mass in testis, painless enlarging mass
○ Dull pain (27%)
○ Acute pain (10%)
• Other signs/symptoms
○ Gynecomastia, virilization
• Clinical profile
○ Young male with palpable testicular mass, elevated
serum tumor markers
– 3 serum tumor markers have established roles in
management of men with testicular GCTs
– Beta subunit of human chorionic gonadotropin (betahCG)
□ Elevated inpure or mixed embryonal carcinoma or
choriocarcinoma; also in15-20% of those with
advanced seminoma
– Alpha fetoprotein (AFP)
□ Elevated levels above 10,000 microg/L are found
almost exclusively in patients with NSGCTs (not
seen with pure seminomas)
□ Elevated AFP is most often seen with yolk sac
tumor and less often embryonal tumors
– Lactate dehydrogenase (LDH)
□ Elevated in 40-60% of men with testicular GCTs
Demographics
• Age
○ Seminomatous tumor: Average age 40.5 years
○ Nonseminomatous tumor: 20-30 years
○ Endodermal sinus tumor/teratoma: 1st decade
• Ethnicity
○ Increased incidence in Caucasian and Jewish males
• Epidemiology
○ Most common cancer in men aged 15-34
○ 1% of all cancers in men, 4-6% of all male genitourinary
tumors, 4th most common cause of death from
malignancy between 15-34 years
○ Seminomas most common in men 35-39 years, most
common tumor in undescended testis
○ Seminomas rare before 10 years and after 60 years
Natural History & Prognosis
• 95% 5-year survival rate overall
• Metastases at presentation is seen in 4-14% of individuals
○ Distant spread occurs along testicular lymphatics
○ Hematogenous dissemination (usually late) to lung,
bone, brain
○ Choriocarcinoma has proclivity for early hematogenous
spread especially to brain, death usually within 1 year of
diagnosis
• Growing teratoma syndrome: Evolution of mixed germ cell
tumor into mature teratoma after chemotherapy (in 40%)
followed by interval growth despite maintaining benign
histologic type
Treatment
• Seminoma very sensitive to radiotherapy ± chemotherapy
• Radical orchiectomy; retroperitoneal node dissection for
nonseminomatous tumor
• Radiotherapy or chemotherapy for metastatic disease
SELECTED REFERENCES
1. Kreydin EI et al: Testicular cancer: what the radiologist needs to know. AJR
Am J Roentgenol. 200(6):1215-25, 2013
2. McDonald MW et al: Testicular tumor ultrasound characteristics and
association with histopathology. Urol Int. 89(2):196-202, 2012
3. Sohaib SA et al: Imaging studies for germ cell tumors. Hematol Oncol Clin
North Am. 25(3):487-502, vii, 2011
4. Sohaib SA et al: The role of imaging in the diagnosis, staging, and
management of testicular cancer. AJR Am J Roentgenol. 191(2):387-95,
2008
5. Dalal PU et al: Imaging of testicular germ cell tumours. Cancer Imaging.
6:124-34, 2006
6. Jones RH et al: Part I: testicular cancer--management of early disease. Lancet
Oncol. 4(12):730-7, 2003
7. Woodward PJ et al: From the archives of the AFIP: tumors and tumorlike
lesions of the testis: radiologic-pathologic correlation. Radiographics.
22(1):189-216, 2002
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