Any mass originating from the testicle must be presumed to be testicular cancer until otherwise proven, because of the explosive growth and metastatic potential of germ cell testicular cancers. While rare, testis cancers are the most common solid tumor of young adult males. Germ cell tumors make up approximately 95% of all testis tumors and are seminoma, yolk sac, choriocarcinoma, embryonal, and teratoma. Stromal testis tumors are rare and are found almost exclusively in prepubertal individuals. These mostly exhibit

12.5. Torsion of the appendix of testis

benign behavior but undifferentiated stromal tumors may exhibit metastatic behavior. Men with a testis mass in their 50s are more likely to have a testicular lymphoma. Benign tumors of the testis are rare, less than 1%. These include an intratesticular cyst, tunica cyst, dermoid cyst, and epidermoid cyst (different from epidermoid tumor of the epididymis, which is also benign.

Testis cancers usually present as an incidental finding of a painless lump, nodule, swelling, or abnormality in the scrotum in men in their 20s to 40s. A feeling of dull aching or heaviness may also be present. A hydro-cele may co-exist on physical exam, which may make testicular palpation difficult. Exceedingly rapidly growing testis cancers, which are hemorrhaging, may cause the patient to present with a painful scrotal mass (see Table 12.1). Palpation will usually reveal a hard testis mass and very often a significant size discrepancy. Metastatic adenopathy is rarely palpable, but huge ret-roperitoneal adenopathy may cause nausea, vomiting, or early satiety. Rarely, supraclavicular lymphadenopa-thy will be palpable with massive supradiaphragmatic disease. Scrotal ultrasound will show a heterogeneous testis mass (Fig. 12.6).

Treatment is standard and should invariably be an inguinal radical orchiectomy (Fig. 12.7). Tumor markers consisting of alpha fetoprotein (AFP), beta human chorionic gonadotropin (B-HCG), and lactate dehydrogenase (LDH) should be sent prior to orchiectomy. Chest x-ray and contrast CT scan of the abdomen and pelvis should be obtained. Patients should be risk-stratified and counseled for the need for repeating tumor markers after orchiectomy, as well as the fact that testis cancer represents the most curable solid organ malignancy presently.

12.6. Ultrasound showing heterogenous echotexture of a testis cancer

12.7. Intraoperative picture of bivalved specimen from a radical orchiectomy. Note the thin rim of normal tissue seen on the ultrasound of the same patient in Fig. 12.6
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