Scrotal Mas 3

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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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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 bleeding 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








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;


342 Pediatrics in Review Vol.26 No.9 September 2005








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

J Urol. 2001;8:1184–1192Thomas R. Testicular tumors. Adolescent

Medicine State of the Art Reviews. 1996;7:149–155

Wan J, Bloom DA. Genitourinary problemsin adolescent males. Adolescent Medicine

State of the Art Reviews. 2003;14:717–731


Pediatrics in Review Vol.26 No.9 September 2005 343








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.


344 Pediatrics in Review Vol.26 No.9 September 2005








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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