Artikel Seminoma 3
Artikel Seminoma 3
Artikel Seminoma 3
Testicular cancer is the most common solid tumor among males 15 to 34 years of age, with an estimated 8,850 new cases
and 410 deaths during 2017 in the United States. With effective treatment, the overall five-year survival rate is 97%. Risk
factors for testicular cancer include undescended testis (cryptorchidism), personal or family history of testicular cancer,
age, ethnicity, and infertility. The U.S. Preventive Services Task Force recommends against routine screening in asymp-
tomatic men. Men with symptoms should receive a complete history and physical examination. Scrotal ultrasonography is
the preferred initial imaging study. If a solid intratesticular mass is discovered, orchiectomy is both diagnostic and ther-
apeutic. Staging through chest radiography, chemistry panel, liver function tests, and tumor markers guides treatment.
Active surveillance, chemotherapy, retroperitoneal lymph node dissection, and radiation therapy are treatment options
following orchiectomy. For patients desiring future fertility, sperm banking should be discussed early in the course of
treatment. Family physicians often play a role in the care of cancer survivors and should be familiar with monitoring for
recurrence and future complications, including secondary malignant neoplasms, cardiovascular risk, and infertility and
subfertility. (Am Fam Physician. 2018;97(4):261-268. Copyright © 2018 American Academy of Family Physicians.)
Testicular cancer is the most common solid tumor personal or family history of testicular cancer, age, and
among males 15 to 34 years of age. The age-adjusted annual ethnicity (Figure 11).
incidence in the United States is 5.6 cases per 100,000 persons, In patients with cryptorchidism, the relative risk of
with a peak of 14.6 cases per 100,000 persons 30 to 34 years developing testicular cancer ranges from 2.9 to 6.3; the risk
of age. Figure 1 includes incidence rates by age and ethnic- is increased in both testes, although the risk is much higher
ity.1 In 2017, there were an estimated 8,850 new cases of in the ipsilateral testis (6.3 vs. 1.7).4,5 Among these patients,
testicular cancer and 410 deaths. Whites, Hispanics, and the risk of cancer increases when orchiopexy is delayed
American Indian/Alaska Natives have the highest rates of until after puberty or never performed (odds ratio = 5.8)
testicular cancer.1 The incidence of testicular cancer has compared with early orchiopexy.6,7 Even after early orchio-
increased over the past several decades for unclear reasons. pexy, the risk of testicular cancer remains elevated (relative
With effective treatment, the overall five-year survival rate risk = 2.2) compared with the general population.8
is 97%.2 Table 1 presents an overview of the World Health Patients with a personal history of testicular cancer have
Organization classification of testicular tumors, with prev- a 12-times greater risk of developing a contralateral tes-
alence of the most common histologic types.3 ticular cancer than the general population. However, the
greatest risk is in the first five years after diagnosis, and
Risk Factors the 15-year cumulative risk is 1.9%.9 Patients with a father
Well-established risk factors for testicular cancer include or brother with testicular cancer have a 3.8- and 8.6-times
history of an undescended testis (cryptorchidism), greater risk, respectively.10
Men with infertility have an increased risk of testicular
cancer, with a standardized incidence ratio of 1.6 to 2.8,
Additional content at http://www.aafp.org/afp/2018/0215/
although the underlying mechanism is unclear.11-13 Human
p261.htm.
immunodeficiency virus infection/AIDS increases the risk
CME This clinical content conforms to AAFP criteria for
continuing medical education (CME). See CME Quiz on
of seminoma, but this is negated with highly active antiret-
page 235. roviral treatment.14 Associations between testicular cancer
Author disclosure: No relevant financial affiliations. and marijuana use, inguinal hernia, diet, maternal smok-
Patient information: A handout on this topic is available at
ing, and body size are inconclusive.15-17 Testicular micro-
http://www.aafp.org/afp/2018/0215/p261-s1.html. lithiasis, vasectomy, and scrotal trauma are not risk factors
for testicular cancer.16
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TESTICULAR CANCER
Screening Recommendations
The U.S. Preventive Services Task SORT: KEY RECOMMENDATIONS FOR PRACTICE
Force, National Cancer Institute, and
American Academy of Family Physi- Evidence
cians recommend against screening Clinical recommendation rating References
for testicular cancer (by a clinician or Routine screening for testicular cancer in asymp- C 18, 19, 21
through self-examination) in asymp- tomatic men is not recommended.
tomatic adolescents and adults because
of its low incidence and high survival Confirmation of an alternative diagnosis is required C 24-26
to exclude testicular cancer in patients with a scrotal
rate.18-20 The American Cancer Society mass.
states that a testicular examination
should be part of a routine cancer- Scrotal ultrasonography is the preferred initial imag- C 24-26
related checkup but does not include a ing study for evaluating a testicular mass.
recommendation on regular testicular Active surveillance (orchiectomy without additional B 24-26, 33,
self-examinations for all men.21 therapy) is a reasonable treatment option for stage I 34, 37, 39
germ cell tumors with no risk factors for relapse.
Diagnosis
After primary treatment for testicular cancer, primary C 24-26,
CLINICAL PRESENTATION care physicians should routinely monitor patients 43, 47-51,
Testicular cancer may present as a for recurrence, secondary malignancy, infertility, 53-55
painless scrotal mass, an inciden- cardiovascular disease, and other complications of
tal radiologic finding, posttraumatic chemotherapy and radiotherapy.
symptom, or scrotal pain. Less com- For patients desiring future fertility, sperm banking C 24-26, 47
monly, presenting symptoms may should be discussed early in the course of treatment.
indicate metastatic disease or retro-
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality
peritoneal lymphadenopathy. Table 2 patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert
presents the signs and symptoms of opinion, or case series. For information about the SORT evidence rating system, go to http://
www.aafp.org/afpsort.
testicular cancer.22
Testicular changes may be detected
by the patient or by a sex partner.
Epididymitis is an important part of
the differential diagnosis of a scrotal FIGURE 1
mass. The management of epididymi-
18
tis was previously reviewed in Amer-
Incidence rates (per 100,000 persons)
16 All ethnicities
ican Family Physician (http://www. White
aafp.org/afp/2016/1101/p723.html). If 14
Black
tenderness, swelling, or examination 12 Asian/Pacific islander
abnormalities persist after antibiotic 10 American Indian/
Alaska Native
treatment, further evaluation is neces- 8 Hispanic
sary.23 Confirmation of an alternative
6
diagnosis is required to exclude testic-
4
ular cancer in patients with a scrotal
mass.24-26 2
0
HISTORY AND PHYSICAL
<1
1-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
≥ 85
EXAMINATION
Evaluation should be guided by a Age group (years)
complete history of the presenting
symptoms and assessment for risk fac-
tors. Testicular examination should Annual incidence of testicular cancer in the United States.
include the affected and unaffected Information from reference 1.
testis for comparison. The normal
262 American Family Physician www.aafp.org/afp Volume 97, Number 4 ◆ February 15, 2018
TABLE 1 TABLE 2
February 15, 2018 ◆ Volume 97, Number 4 www.aafp.org/afp American Family Physician 263
TESTICULAR CANCER
TABLE 3
Stage Description
Serum biomarkers
Lactate dehydrogenase Human chorionic gonadotropin Alpha fetoprotein
SX Biomarkers not available or not measured
S0 Normal Normal Normal
S1† < 1.5 times normal < 5,000 mIU per mL (5,000 IU per L) < 1,000 ng per mL (1,000 mcg per L)
S2‡ 1.5 to 10 times normal 5,000 to 50,000 mIU per mL (5,000 1,000 to 10,000 ng per mL (1,000 to 10,000
to 50,000 IU per L) mcg per L)
S3‡ > 10 times normal > 50,000 mIU per mL > 10,000 ng per mL
LN = lymph node; LVI = lymphovascular invasion; TNMS = tumor, nodes, metastasis, serum biomarkers.
*—Subclassification of pT1 applies only to pure seminoma.
†—All markers must be in the stated range for S1.
‡—Only one of the markers must be in the stated range for S2/S3.
Adapted with permission from American Joint Committee on Cancer. AJCC Cancer Staging Handbook. 8th ed. New York, NY: Springer; 2017:732-733.
Active surveillance involves more frequent monitor- This article reviews treatment (Table 525) and surveillance
ing than adjuvant therapy and is associated with higher (eTables A through J) for germ cell tumors.
recurrence rates, but it avoids the risks of radiation and
chemotherapy.24,25 The risk of testicular cancer recurrence SEMINOMA TREATMENT
is greatest within two to three years of primary treat- One-half of germ cell tumors are seminomas, and 80% to
ment, and surveillance is continued for up to five years. 85% are stage I at diagnosis.32 Among men with a stage I
264 American Family Physician www.aafp.org/afp Volume 97, Number 4 ◆ February 15, 2018
TABLE 4
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TESTICULAR CANCER
TABLE 5
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TESTICULAR CANCER
February 15, 2018 ◆ Volume 97, Number 4 www.aafp.org/afp American Family Physician 267
TESTICULAR CANCER
15. Gurney J, Shaw C, Stanley J, Signal V, Sarfati D. Cannabis exposure and 36. Giannatempo P, Greco T, Mariani L, et al. Radiotherapy or chemother-
risk of testicular cancer:a systematic review and meta-analysis. BMC apy for clinical stage IIA and IIB seminoma:a systematic review and
Cancer. 2015;15:897. meta-analysis of patient outcomes. Ann Oncol. 2015;26(4):657-668.
16. Manecksha RP, Fitzpatrick JM. Epidemiology of testicular cancer. BJU 37. Daugaard G, Gundgaard MG, Mortensen MS, et al. Surveillance for
Int. 2009;104(9 pt B):1 329-1333. stage I nonseminoma testicular cancer:outcomes and long-term
17. Lerro CC, McGlynn KA, Cook MB. A systematic review and meta- follow-up in a population-based cohort. J Clin Oncol. 2014;32(34):
analysis of the relationship between body size and testicular cancer. Br 3817-3823.
J Cancer. 2010;103(9):1467-1474. 38. Tandstad T, Ståhl O, Håkansson U, et al.;SWENOTECA. One course of
18. Screening for testicular cancer:U.S. Preventive Services Task Force adjuvant BEP in clinical stage I nonseminoma mature and expanded
reaffirmation recommendation statement. Ann Intern Med. 2011; results from the SWENOTECA group. Ann Oncol. 2014;25(11):
154(7):483-486. 2167-2172.
19. American Academy of Family Physicians. Clinical preventive service 39. Gumus M, Bilici A, Odabas H, et al. Outcomes of surveillance versus
recommendation. Testicular cancer. http:// w ww.aafp.org/patient- adjuvant chemotherapy for patients with stage IA and IB nonsemino-
care/clinical-recommendations/all/testicular-cancer.html. Accessed matous testicular germ cell tumors. Word J Urol. 2017;35(7):1 103-1110.
April 26, 2017. 40. Lerner SE, Mann BS, Blute ML, Richardson RL, Zincke H. Primary che-
motherapy for clinical stage II nonseminomatous germ cell testicular
20. National Cancer Institute. Testicular cancer screening (PDQ)—health
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professional version. http: //www.cancer.gov/types/testicular/hp/
70(9):821-828.
testicular-screening-pdq. Accessed December 4, 2016.
41. Horwich A, Norman A, Fisher C, Hendry WF, Nicholls J, Dearnaley
21. American Cancer Society. Can testicular cancer be found early? http://
DP. Primary chemotherapy for stage II nonseminomatous germ cell
www.cancer.org/cancer/testicularcancer/detailed g uide/testicular-
tumors of the testis. J Urol. 1994;151(1):72-77.
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42. Fung C, Fossa SD, Williams A, Travis LB. Long-term morbidity of testic-
22. Shaw J. Diagnosis and treatment of testicular cancer. Am Fam Physi-
ular cancer treatment. Urol Clin North Am. 2015;42(3):393-408.
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43. Travis LB, Fosså SD, Schonfeld SJ, et al. Second cancers among 40,576
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24. Albers P, Albrecht W, Algaba F, et al.;European Association of Urology. 44. Djaladat H, Burner E, Parikh PM, Beroukhim Kay D, Hays K. The asso-
Guidelines on testicular cancer:2015 update. Eur Urol. 2015;68(6): ciation between testis cancer and semen abnormalities before orchi-
1054-1068. ectomy:a systematic review. J Adolesc Young Adult Oncol. 2014;3(4):
25. National Comprehensive Cancer Network. NCCN clinical practice 153-159.
guidelines in oncology. Testicular cancer. December 8, 2016. http:// 45. Ostrowski KA, Walsh TJ. Infertility with testicular cancer. Urol Clin
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registration required]. Accessed December 29, 2016.
46. Brydøy M, Fosså SD, Klepp O, et al. Paternity following treatment for
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https://uroweb.org/guideline/testicular-cancer. Accessed September 47. Loren AW, Mangu PB, Beck LN, et al. Fertility preservation for patients
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28. Coursey Moreno C, Small WC, Camacho JC, et al. Testicular tumors: 49. Sonnenburg DW, Brames MJ, Case-Eads S, Einhorn LH. Utilization of
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64(3):182-197. 54. Haugnes HS, Wethal T, Aass N, et al. Cardiovascular risk factors
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268 American Family Physician www.aafp.org/afp Volume 97, Number 4 ◆ February 15, 2018
BONUS DIGITAL CONTENT
TESTICULAR CANCER
eTABLE A
1 2 3 4 5
CT = computed tomography.
*—Serum tumor markers are optional.
†—Testicular ultrasound for any equivocal exam.
‡—Without contrast.
Reprinted with permission from National Comprehensive Cancer Network. Clinical practice guidelines in oncology. Testicular cancer. December
8, 2016. http://www.nccn.org/professionals/physician_gls/PDF/testicular.pdf [free registration required]. Accessed December 29, 2016.
eTABLE B
1 2 3 4 5
February 15, 2018 ◆ Volume 97, Number 4 www.aafp.org/afp American Family Physician 268A
TESTICULAR CANCER
eTABLE C
1 2 3 4 5
eTABLE D
1 2 3 4 5
CT = computed tomography.
*—Serum tumor markers are optional.
†—Testicular ultrasound for any equivocal exam.
‡—Without contrast.
Reprinted with permission from National Comprehensive Cancer Network. Clinical practice guidelines in oncology.
Testicular cancer. December 8, 2016. http://www.nccn.org/professionals/physician_gls/PDF/testicular.pdf [free regis-
tration required]. Accessed December 29, 2016.
268B American Family Physician www.aafp.org/afp Volume 97, Number 4 ◆ February 15, 2018
TESTICULAR CANCER
eTABLE E
1 2 3 4 5
CT = computed tomography.
*—Assuming no residual mass or residual mass < 3 cm and normal tumor markers.
†—Serum tumor markers are optional.
‡—Testicular ultrasound for any equivocal exam.
§—With contrast.
||—Chest x-ray may be used for routine follow-up, but chest CT with contrast is preferred in the presence of thoracic
symptoms.
Reprinted with permission from National Comprehensive Cancer Network. Clinical practice guidelines in oncology.
Testicular cancer. December 8, 2016. http://www.nccn.org/professionals/physician_gls/PDF/testicular.pdf [free regis-
tration required]. Accessed December 29, 2016.
eTABLE F
Bulky Clinical Stage IIB, IIC and Stage III Seminoma: Surveillance
Post-Chemotherapy with No Residual Mass or Residual Mass ≤ 3 cm
and Normal Tumor Markers
Year (at month intervals)
1 2 3 4 5
February 15, 2018 ◆ Volume 97, Number 4 www.aafp.org/afp American Family Physician 268C
TESTICULAR CANCER
eTABLE G
1 2 3 4 5
eTABLE H
1 2 3 4 5
CT = computed tomography; NSGCT = nonseminomatous germ cell tumor; RPLND = retroperitoneal lymph node
dissection.
*—Testicular ultrasound for any equivocal exam.
†—With contrast.
‡—Patients who undergo RPLND and are found to have pN0 disease (no tumor or teratoma) need only 1 CT scan at
postoperative month 4.
§—Chest x-ray may be used for routine follow-up, but chest CT with contrast is preferred in the presence of thoracic
symptoms.
||—Chest CT with contrast if supradiaphragmatic disease at baseline.
¶—Chest x-ray is optional at months 36 and 48.
Reprinted with permission from National Comprehensive Cancer Network. Clinical practice guidelines in oncology.
Testicular cancer. December 8, 2016. http://www.nccn.org/professionals/physician_gls/PDF/testicular.pdf [free regis-
tration required]. Accessed December 29, 2016.
268D American Family Physician www.aafp.org/afp Volume 97, Number 4 ◆ February 15, 2018
TESTICULAR CANCER
eTABLE I
1 2 3 4 5
CT = computed tomography; NSGCT = nonseminomatous germ cell tumor; RPLND = retroperitoneal lymph node
dissection.
*—Testicular ultrasound for any equivocal exam.
†—With contrast.
‡—Chest x-ray may be used for routine follow-up, but chest CT with contrast is preferred in the presence of thoracic
symptoms.
Reprinted with permission from National Comprehensive Cancer Network. Clinical practice guidelines in oncology.
Testicular cancer. December 8, 2016. http://www.nccn.org/professionals/physician_gls/PDF/testicular.pdf [free regis-
tration required]. Accessed December 29, 2016.
eTABLE J
1 2 3 4 5
CT = computed tomography; NSGCT = nonseminomatous germ cell tumor; RPLND = retroperitoneal lymph node
dissection.
*—Patients with clinical stage II-A/II-B nonseminoma who undergo primary RPLND and are found to have pN0 disease
(no tumor or teratoma, pathologic stage I) should revert to the surveillance schedule for low-risk NSGCT with the
exception that only 1 CT scan is needed postoperatively around month 4 (eTable B).
†—Testicular ultrasound for any equivocal exam.
‡—With contrast.
§—This schedule assumes a complete resection has taken place.
||—Chest x-ray may be used for routine follow-up, but chest CT with contrast is preferred in the presence of thoracic
symptoms.
Reprinted with permission from National Comprehensive Cancer Network. Clinical practice guidelines in oncology.
Testicular cancer. December 8, 2016. http://www.nccn.org/professionals/physician_gls/PDF/testicular.pdf [free regis-
tration required]. Accessed December 29, 2016.
February 15, 2018 ◆ Volume 97, Number 4 www.aafp.org/afp American Family Physician 268E