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DOI: 10.1542/pir.26-9-3412005;26;341Pediatrics in Review
William P. Adelman and Alain JoffeConsultation with the Specialist : Testicular Masses/Cancer
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Pediatrics. All rights reserved. Print ISSN: 0191-9601.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2005 by the American Academy of published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1979. Pediatrics in Review is owned,Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
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Author Disclosure
Drs Adelman and Joffe did not
disclose any financial relationships
relevant to this article.
Testicular Masses/CancerWilliam P. Adelman, MD,* Alain Joffe, MD, MPH†
Objectives After completing this article, readers should be able to:
1. Describe the presentation, epidemiology, clinical aspects, management, and
preventive measures associated with testicular tumors in adolescents.
2. Discuss the differential diagnosis of scrotal masses in the adolescent.
Case A 19-year-old college sophomore pre-
sents to the University Health Service
with a complaint of a “painful left testicle.” He noted gradually worsen-
ing testicular pain over the past 2 to
3 days. He is sexually active, with his
last encounter occurring 8 weeks prior
to the visit. He denies dysuria, penile
discharge, back pain, flank pain, fe-
ver, chills, or sweats. He denies recent
trauma or any history of testicular
problems. The family and social history
are noncontributory.
On physical examination, he has no
gynecomastia, and findings on his lung and heart examinations are nor-
mal. He is sexually mature (Sexual
Maturity Rating 5) and is circum-
cised. He has no skin lesions or appre-
ciable lymphadenopathy. The contents
of his right scrotum are normal; his left
epididymis is palpable and nontender;
his left spermatic cord is without visual
or palpable varicosity; and his left tes-
ticle is palpable and normal in size,
lie, and shape, but is markedly tender
to palpation at the inferior pole. It does
not transilluminate. Pain does not de-
crease with elevation of the testis.
Ultrasonography reveals a testicu-
lar tumor at the lower pole, with bleed- ing into the tumor. Following appro-
priate staging evaluation, he undergoes
orchiectomy followed by radiation and
chemotherapy and recovers fully.
EpidemiologyTumor of the Testis
Testicular cancer, predominantly of
germ cell origin (95%), is the most
common cancer of young men be-
tween 15 and 34 years of age, ac-
counts for 3% of all cancer deaths inthat age group, and may affect as
many as 1 in 10,000 teens. It is pro-
jected that in 2005, 8,010 new cases
of testicular cancer will be diagnosed,
and 390 men will die of the disease in
the United States. Forty percent of
germ cell tumors are seminomas,
making this the most common testic-
ular cancer of single cell type. The
incidence of seminoma peaks in the
25- to 45-year-old age group; that of
nonseminoma (embryonal cell, cho-riocarcinoma, teratoma, yolk sac, and
mixed forms) peaks in the 15- to
30-year-old age group. Bilateral tu-
mors occur in 2% to 4% of patients.
Risk FactorsTesticular cancer is a disease of young
men. It is 4.5 times more common
among Caucasian men than African-
American men; Hispanics, American
Indians, and Asians have intermedi-
ate incidence rates. Males who have
*Head, Department of Adolescent Medicine,
National Naval Medical Center; Assistant Professor
of Pediatrics, Uniformed Services University of the
Health Sciences, Bethesda, Md.†Director, Student Health and Wellness Center,
Johns Hopkins University; Associate Professor of
Pediatrics, Johns Hopkins School of Medicine,
Baltimore, Md.
The views expressed in this article are those of the
authors and do not reflect the official policy or
position of the United States Army, United States
Navy, United States Department of Defense, or the
United States government.
consultation with the specialist
Pediatrics in Review Vol.26 No.9 September 2005 341
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cryptorchidism have an increased risk
of testicular cancer, and 12% of men
who have testicular cancer have a his-
tory of cryptorchidism. Because 1%
to 5% of boys who have a history of
an undescended testicle later develop
germ cell tumors, any history of cryp-
torchidism should prompt careful
long-term follow-up that may in-
clude teaching of testicular self-
examination (TSE). Orchiopexy of a
testis that is located in the embryo-
logic pathway and not in the abdo-
men reduces the risk of cancer in
inverse relation to age. Orchiopexy usually is performed in the United
States around 1 year of age primarily
to preserve fertility. A testicle made
palpable by surgery also can be mon-
itored better for changes. Males
who have gonadal dysgenesis and
Klinefelter syndrome also have an in-
creased risk for testicular cancer. Tes-
ticular atrophy is associated with can-
cer. Men who have a family history of
testicular cancer may be at higher risk
for this disease. A history of testicularcancer is associated with a higher risk
of a contralateral tumor.
Clinical AspectsPresentation
Tumor of the testis presents most
commonly as a circumscribed, non-
tender area of induration within the
testis that does not transilluminate.
Swelling is noted in up to 73% of
cases at presentation, but most cases
are asymptomatic and discovered by the patient. Patients may present
with a sensation of fullness or scrotal
heaviness. Often, there is a history of
recent trauma, which draws attention
to pre-existing pathology in the scro-
tum. It is not unusual for a patient to
present with a painless mass in the
traumatized testicle. Testicular pain
is the presenting symptom in 18% to
46% of patients who have germ cell
tumors.
Acute pain, as in this case, may be
associated with torsion of the neo-
plasm, infarction, or bleeding into
the tumor. Signs and symptoms in-
distinguishable from acute epididy-
mitis have been observed in up to
25% of patients who have testicular
neoplasms. Less common presenta-
tions include gynecomastia due to
human chorionic gonadotropin-
secreting tumors or back or flank
pain from metastatic disease.
In most cases of testicular tumor,
the epididymis and cord feel normal.
In this case, the epididymis and cord
were normal in position and shape. With more advanced tumors, the tes-
tis may be diffusely enlarged and rock
hard. Secondary hydroceles may oc-
cur. New onset of a hydrocele is
highly suspicious for a testicular tu-
mor and warrants careful evaluation.
If the testis cannot be palpated ade-
quately, due to tenderness, hydro-
cele, or limitation in examination
skills, ultrasonography is indicated to
allow sufficient visualization of the
testis to rule out a tumor.The presentation of seminoma
may be unique in that the testis may
be uniformly enlarged to 10 times its
normal size without loss of normal
shape. Therefore, size comparison
with the contralateral testis is impor-
tant or a seminoma may be missed on
casual examination. Of particular
note in sexually active adolescents,
testicular cancer, which in advanced
stages may be characterized by a
swollen, tender testicle with occa-sional fever and pyuria, can be mis-
taken for epididymitis. Also, epididy-
mitis and testicular cancer can
coexist. Significant delays in treat-
ment have been observed in patients
treated for presumed epididymitis.
Thus, following an appropriate
course of antibiotics for epididymitis,
the patient should be re-examined to
ensure that no residual mass is palpa-
ble. If the diagnosis is not clear-cut,
ultrasonography is indicated.
Differential DiagnosisThe differential diagnosis of a testic-
ular mass includes testicular torsion,
hydrocele, varicocele, spermatocele,
epididymitis (can coexist with germ
cell tumors), or other malignancies,
such as lymphoma. Rarely, genital
tuberculosis, sarcoidosis, mumps, or
inflammatory disease also can mimic
cancer. Any delay in diagnosis can
affect the prognosis negatively.
Therefore, the clinician must have a
high index of suspicion for this en-
tity. Because 25% of patients who
have seminomas and 60% to 70% of those who have nonseminomatous
germ cell tumors have metastatic dis-
ease at the time of presentation, any
of the following symptoms should
prompt examination of the testis:
back or abdominal pain, unexplained
weight loss, dyspnea (pulmonary me-
tastases), gynecomastia, supraclavic-
ular adenopathy, urinary obstruc-
tion, or a “heavy” or “dragging”
sensation in the groin.
ManagementEvaluation of a testicular mass should
begin with ultrasonography, a sensi-
tive and specific test that can discrim-
inate between a testicular neoplasm
and the nonmalignant processes in-
cluded in the differential diagnosis.
Even if an obvious mass is palpated
on physical examination, ultrasonog-
raphy should be performed on both
testicles to rule out bilateral disease
(2% to 4%). Once a tumor is sus-pected, measurement of tumor se-
rum markers such as lactate dehydro-
genase, beta human chorionic
gonadotropin (elevated in choriocar-
cinoma and seminoma), and alpha-
fetoprotein (produced by yolk sac
cells) is indicated. Further evaluation
for staging should be performed in
consultation with an oncologist and
may include additional laboratory
studies; computed tomography scan
of the chest, abdomen, and pelvis;
consultation with the specialist
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and other imaging as needed (eg,
imaging of the brain in the case of a
pure choriocarcinoma). Similarly,
testicular cancer should be managed
by an appropriately trained oncolo-
gist and urologist because treatments
vary by grade and stage of tumor. All
patients undergo radical orchiec-
tomy, followed by close surveillance
for certain early stage tumors or che-
motherapy and radiation, usually
with a positive prognosis.
PrognosisOverall, the 5-year survival rate is
92%; even among those who have
advanced disease at diagnosis, 5-year
survival is almost 70%. Because ad-
vances in treatment have afforded an
overall excellent prognosis, it is un-
known what impact preventive mea-
sures have on mortality.
PreventionTSE is simple to teach, simple to
perform, of negligible cost, and morelikely to be practiced if taught by a
practitioner. Therefore, many na-
tional organizations, including The
American Academy of Pediatrics, the
American Medical Association, the
American Urological Association,
and the American Cancer Society,
recommend teaching TSE or per-
forming annual professional testicu-
lar examination for teenage boys.
It is unknown, however, whether
screening by either physician exami-
nation or patient self-examination
actually affects the stage of cancer at
detection or morbidity or reduces
mortality. Therefore, organizations
that rely on large controlled trials for
evidence-based recommendations,
such as the United States Preventive
Services Task Force and the Cana-
dian Task Force on the Periodic
Health Examination, make no rec-
ommendations for or against routinescreening of asymptomatic males for
testicular cancer. The American
Academy of Family Practice takes a
selective approach, recommending
clinical testicular examination for
men ages 13 to 39 years of age who
have the known risk factors of crypt-
orchidism, orchiopexy, or testicular
atrophy.
ConclusionTesticular cancer remains an impor-tant public health problem that af-
fects young men uniquely. A high
level of suspicion for testicular cancer
is warranted in adolescent males, and
ultrasonography is a simple, reliable
technique to define scrotal anatomy
when questions arise. TSE remains
an undertaught and underperformed
“screen,” even among high-risk indi-
viduals, but its universal application
remains controversial.
Suggested Reading Adelman WP, Joffe A. The adolescent male
genital examination: what’s normal and
what’s not. Contemp Pediatr. 1999;16:
76–92
Adelman WP, Joffe A. The adolescent with a
painful scrotum. Contemp Pediatr.
2000;17:111–128
Henderson BE, Benton B, Jing J, et al. Risk
factors for cancer of the testis in youngmen. Int J Cancer . 1979;23:598– 602
HerrintonLJ, Zhao W, Husson G. Manage-ment of cryptorchidism and risk of tes-ticular cancer. Am J Epidemiol . 2003;157:602–605
Richie JP, Steele GS. Neoplasms of the tes-tis. In: Walsh PC, Retik AB, VaughanED, et al, eds. Campbell’s Urology. 8thed. Philadelphia, Pa: Saunders; 2002:2876–2910
Segal R, Lukka H, Klotz LH, et al. Surveil-lance programs for early stage non-seminomatous testicular cancer: a prac-
tice guideline. Cancer Care OntarioPractice Guidelines Initiative Genitouri-nary Cancer Disease Site Group. Can
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consultation with the specialist
Pediatrics in Review Vol.26 No.9 September 2005 343
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PIR Quiz
Quiz also available online at www.pedsinreview.org.
10. The parents of a 12-year-old boy come to you because his cousin developed testicular cancer when hewas 15 years old. They are concerned about the risk to their son and have been confused by their searchfor information on the Internet. Which of the following statements is correct?
A. Nonseminoma tumors peak in the 15- to 30-year-old age group.B. Testicular cancer occurs primarily in those who have cryptorchidism.C. Testicular self-examination has been proven to decrease the mortality of testicular cancer.D. The mortality of testicular cancer is more than 90%.E. The most common form of testicular cancer is a teratoma.
11. A 6-year-old African-American boy who has received minimal health maintenance care is found to havecryptorchidism. Which of the following most accurately reflects the risks for this child?
A. He is at increased risk for neuroblastoma.B. His risk of developing a germ cell tumor is 1% to 5%.C. His risk for testicular cancer is greater than for a white male.D. His risk for testicular cancer is greatest in the fourth and fifth decades of life.E. His risk for testicular leukemia is increased.
12. A 16-year-old boy presents with right scrotal pain of 2 days’ duration following minor trauma. The testisis enlarged to twice the size of the left. Of the following, the most appropriate next step is:
A. Computed tomography scan of the testes and pelvis.B. Measurement of beta human chorionic gonadotropin.C. Orchiectomy.D. Radionuclide scan of the testes.
E. Ultrasonography of the testes.
consultation with the specialist
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DOI: 10.1542/pir.26-9-3412005;26;341Pediatrics in Review
William P. Adelman and Alain JoffeConsultation with the Specialist : Testicular Masses/Cancer
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