History and exam

Key diagnostic factors

common

presence of risk factors

Key risk factors include cryptorchidism, positive family history, previous diagnosis of testicular cancer, testicular atrophy, and white ethnicity.

age 20 to 34 years

Incidence peaks at 20 to 34 years of age (around 50% of cases).[13]

testicular mass

On palpation, location, shape, and consistency of the mass are assessed. About 55% of cases occur on the right side. In up to 2% of cases, testicular cancer is bilateral.[57]

The mass is usually painless (>85%). About 10% present with acute pain.[42]

Other diagnostic factors

uncommon

extratesticular manifestation

Around 5% to 10% of patients have extratesticular manifestations at the time of presentation with or without apparent primary tumour in the testes.[44] These include bone pain (skeletal metastasis), lower extremity swelling (venous occlusion), supraclavicular lymph node enlargement, symptoms and/or signs of hyperthyroidism,​ and gynaecomastia.[9]

Lumbar back pain may occur if there is involvement of the psoas muscles and nerve roots. Spinal cord and cerebral metastasis may cause neurological symptoms.

Risk factors

strong

cryptorchidism

Relative risk of 3.7 to 7.5 times for malignancy.[28]​​

Highest risk in abdominal and bilateral undescended testes.

Around 10% of all germ cell tumour cases occur in men with a history of cryptorchidism.[29]

Seminoma appears to be the predominant tumour type associated with an undescended tests.[28]​​

gonadal dysgenesis

Link with changes in the gonadotrophin feedback regulation is suggestive but inconclusive.[30]

family history of testicular cancer

Familial clustering of testicular cancer illustrates polygenic variation, with no major susceptibility gene.[31]

Family history in father-son pairs showed a 10-fold increase in risk and testicular cancer tended to appear earlier in the son in at least three studies.[32][33][34]

Monozygotic twins have the highest risk compared with dizygotic twins, followed by siblings and father.[32][33][34]

personal history of testicular cancer

Up to 5% of men who have had previous testicular cancer may develop a second primary cancer in the contralateral testis.[35] Approximately 35% of these men present within the first 6 months of diagnosis (synchronous), with around 65% of diagnoses occurring after that period (metachronous).[35]

testicular atrophy

Can be secondary to trauma, hormones, and viral orchitis.

Considered moderate-to-high risk, but only at a younger age.[36]

Severe trauma has been linked to testicular cancer, but the evidence is weak regarding post-vasectomy cases.

Fluctuations in sex hormones, with relative risk rates between 2.8% and 5.3% for testicular tumours commonly observed in male offspring of diethylstilbestrol-treated mothers.[37]

Mumps orchitis has been suggested as an indirect causative factor.

white ethnicity

White men have the highest incidence compared to men of African and Asian descent.

In the US, incidence in white men is four times that in black men.[18]

HIV infection

The relative risk of seminoma is 5-fold higher in men with HIV than in age-matched controls without HIV.[38]

weak

occupational exposures

Chemical carcinogens are weakly associated with testicular cancer and are thought to be secondary risk factors.

Agricultural pesticide exposure, particularly organochloride pesticide, is associated with an up to threefold increased risk of testicular cancer.[29]

inguinal hernia

Associated with childhood hernia.[39]​​

genetic abnormality

Several single nucleotide polymorphisms associated with an increased risk of developing testicular germ cell tumours have been detected, in particular an isochromosome of the short arm of chromosome 12, but multiple susceptibility loci have been identified in genome‐wide association studies.​[21][24]

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