Testicular tumors most commonly present as a firm to hard painless mass. Occasionally, scrotal swelling and acute pain (10%) may be present. The presence of acute pain increases the likelihood of infection, trauma, torsion, and infarction, but does not rule out tumor or tumor in addition to another diagnosis. A history of trauma is present in 30% of cases. Carcinoma in situ most commonly presents in patients being evaluated for infertility. Germ-cell tumors present more commonly in patients with a history of cryptorchidism and testicular atrophy. Patients with either condition should have both testicles carefully evaluated periodically. Carcinoma in situ occurs in 5% of testes corrected for non-descent and in 5% of the contra-lateral testes in patients with a primary testicular germ-cell tumor. In children, up to 20% of cases are associated with hernia or hydrocele. Tran-sillumination will assist with diagnosis of the hydrocele, but does not rule out the co-existence of tumor.
Patients with small or even occult primary testicu-lar tumors may present with symptoms of large metastases (10%). These most commonly occur in the retro-peritoneum and may cause low-back pain, small bowel or ureteral obstruction, and even compression of the inferior vena cava. Anterior mediastinal tumors may be extra-gonadal primaries and may present with superior vena cava syndrome and associated testicular atrophy and Klinefelter's syndrome. Enlarged, firm, non-tender supraclavicular lymph nodes in an adolescent or young adult male should also prompt a thorough evaluation of the testes.
Radiographic evaluation of the testicle has improved the pre-operative diagnosis rates for these tumors. Such evaluation allows for the accurate determination of the correct surgical approach and procedure. Ultrasound may be used to evaluate scrotal masses, the contralateral testes when a tumor has been detected, and both testes when determining whether an extra-gonadal germ cell tumor is a primary or metastatic lesion from an occult testicular primary.
Abdominal computed tomography (CT) scan is currently the gold standard for evaluation of the abdomen and retroperitoneum, the most common site for metastases. CT scan of the chest should be performed in the staging of all patients. Magnetic resonance imaging (MRI) of the brain should be performed when symptoms indicate. Bone metastases are usually painful and may be evaluated with plain radiographs, bone scan, or MRI.
The role for positron emission tomography (PET) scan has yet to be determined, but may be most useful in the evaluation of residual masses. Germ-cell tumors actively take up 18-fluoro-2-deoxyglucose and, thus, PET scanning deserves further evaluation to determine its ultimate usefulness in these diseases.
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