Revised 08 May 2013

3.1 Clinico-pathologic considerations

Presentation is often as a painless mass or swelling in the testis (70-80% of cases). Pain can occur if there is torsion, hemorrhage, and swelling. In rare cases, there may be simultaneous bilateral tumours. Spread occurs by either vascular or lymphatic routes. Metastatic disease leads to presenting complaints in approximately 15% of cases overall with testicular tumours, with metastatic presentation being more frequent with non seminoma than with seminoma. This will lead to symptoms specific to the affected organ or adjacent tissues. Patients may develop back pain due to large retroperitoneal lymphadenopathy, gynecomastia due to elevation of HCG (germ cell tumours), and other hormonal functional elements may be present (stromal tumours).

3.2 Diagnostic pathology

Basic diagnostic Work Up for patients with suspected or confirmed testis cancer

• History and physical examination
• CT Chest/abdomen/pelvis
• Chest X-ray may be sufficient in patients with early stage disease
• CBC, LDH, bHCG, AFP, creatinine (both prior to , and after, orchiectomy)
• Testicular ultrasound (pre-orchiectomy)

Pathological diagnosis is then obtained by a radical inguinal orchiectomy with high ligation of the spermatic cord. Needle or incisional biopsy through the scrotum is contraindicated. An orchiectomy can be delayed until after chemotherapy in patients with metastatic disease with a clinical (marker positive) diagnosis of germ cell tumour and an urgent need for systemic therapy.

Gross Description

Gross description of radical orchiectomy specimens should include:

• The length of spermatic cord attached
• The external dimensions of the testis
• The preservation or loss of normal testicular contour
• The presence or absence of a mass
• Size of the mass(es)
• The presence of satellite nodules or not
• The texture of all nodules
• The relationship of all nodules to the tunical albuginea, the tunica vaginalis, rete testis, epididymis and cord

Microscopic Description

The following features should be included:

• Tumour size
• Enumeration of the cell type(s) present: if more than once cell type is present, some indication should be given of the proportions
• A statement should be made regarding the relationship to the tunica albuginea, tunica vaginalis, rete testis, the epididymis and the spermatic cord
• The presence or absence of lymphatic and/or venous invasion within the testes and within the cord should be commented upon
• The presence of in-situ germ cell neoplasia should be noted
• The presence/absence of spermatogenesis and Leydig cell hyperplasia in the residual testis should be commented upon
• Margin status.

Because of its clinical importance, it is highly recommended that all histological specimens are assessed by a reference pathologist experienced in testis cancer pathology.

The BC Cancer Agency employs the TNM system (UICC 2009) and the Classification of the International Germ Cell Collaborative Group (J Clin Oncol 1997).

3.3 Classification criteria

• Intratubular germ cell neoplasia, unclassified