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Testis Cancer: Diagnosis and Management in the Outpatient Clinic

Benjamin Patel

Testicular cancer (TC) is the most common solid cancer in men aged 20–45 with around 2400 new cases in 2016 in the UK. It constitutes 1% of male cancers and 5% of urological tumours. Since the early 1990s, the incidence has increased by 28% in males in the UK. The incidence is projected to further rise by 12% in the UK between 2015 and 2035 to 10/10 000 males. There is a peak incidence between 30 and 34 and it is rarely found in those below 15 years and above 60 years. (See Figure 22.1.) Encouragingly, mortality has fallen since the introduction of platinum‐based chemotherapy, with a 98% 10‐year survival in the UK. Indeed, in 2016 there were less than 60 deaths.

Aetiology

Aetiological factors are largely non‐modifiable. TC is more common in white western Caucasians. The most commonly affected age group is 20–45 years and there is a variable histological pattern of disease according to age. Non‐seminomatous germ cell tumours (NSGCTs) affect a slightly younger cohort (20–35 years) compared to seminomas (35–45 years). Infants and children below 10 years most commonly develop yolk sac tumours and 50% of TCs in those >60 years are lymphoma.

A previous diagnosis of TC is associated with a 12‐fold increased risk of metachronous TC, with bilateral TCs occurring in 1–2% of cases. 5–10% of TC patients have a history of cryptorchidism. In unilateral cryptorchidism, TC risk is 6 times greater in the undescended testicle and 1.7 times increased in the descended testicle. One large study indicated that those who undergo early orchidopexy (<13 years) have a twofold increased risk of TC, compared to a fivefold increased risk in those undergoing late orchidopexy (>13 years).

Bar chart depicts the average number of new cases per year per 100,000 males, UK. — **Figure 22.1** Average number of new cases per year per 100,000 males, UK.

*Source*: Based on graphic created by Cancer Research UK.

Genetic factors have also been identified. TC is 5 times higher in men with an affected father and 8–9 times higher in men with an affected brother. Additionally, Kleinfelter’s syndrome and Kallman’s syndrome are associated with increased TC risk.

In general, TC is not clearly linked to preventable factors. Human immunodeficiency virus HIV appears to increase risk of TC by 30–40%. There is weak evidence for chemical carcinogens and rural residence increasing risk. However, there is no strong evidence for smoking, alcohol, vasectomy, or trauma increasing risk.

Finally, Testicular carcinoma in situ, also known as intratubular germ cell neoplasia (ITGCN) or testicular intraepithelial neoplasia (TIN), is a precursor for TC; around 50% of men with cancer in situ (CIS) will develop TC within five years without treatment.

Symptoms and Signs

Testicular cancer most commonly presents as a hard, painless lump. It is slightly more common on the right side and bilateral in 1–2% of cases. Five percent of TCs present with acute scrotal pain, secondary to intra‐tumoral haemorrhage. Ten percent unfortunately present with symptoms of advanced disease, including weight loss, lumps in the neck, bone pain, chest symptoms and neurological symptoms. Lumbar back pain may occur if the psoas muscles and nerve roots are affected.

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