Tumors of the testis are quite rare (around 1% of all tumors in male) and usually affect young men, with a peak of incidence between 15 and 35 years of age. There is an increasing trend of testis cancer incidence in western countries.
Fifty years ago mortality for testis cancer was extremely high. Today, thanks to the introduction of effective chemotherapeutic protocols and to new surgical techniques, 5 years survival exceeds 90%.
The main risk factor is a testis undescended (or descended after puberty) in the scrotum. Other risk factors are some chromosome abnormalities and exposition to x-ray during pregnancy.
Testis cancer is often asymptomatic. The first sign is a hard enlargement of the testis, palpable at the scrotum. However, in up to 25-30% of cases the tumor clinical onset may be a painful enlargement with fever, due to inflammatory reaction inside the tumor. In such cases the diagnosis can be difficult and the tumor can be confused with an orchitis (testis inflammation, usually infective). Orchitis usually is successfully treated by antibiotic therapy with fever disappearing within 2-3 days and enlargement regression in 7-15 days.
Early diagnosis is essential because testis cancer is rapidly proliferating (doubling time of 10-30 days).
Scrotal ultrasound is a valuable test to show tumor changes in the testis parenchyma. Since some testis tumors produce specific substances, like beta-HCG and alpha-feto-protein, or less specific ones, like LDH, these tumor markers must be measured in every patient with a suspect of tumor testis, especially before surgical approach.
The first approach to a testis cancer is surgical removal of the testis and the spermatic cord. The operation must be performed via inguinal incision. The scrotal approach should be avoided, for the risk of oncological dissemination and of altering the normal pathways of lymphatic spread of the tumor. After the removal of the primary tumor, the treatment depends upon the stage and the histology type of the disease. Most testis tumors are derived from germ cells, like seminoma (nearly 40%), or nonseminomatous germ cells testis tumors (NSGCTT), like embryonal carcinoma, teratocarcinoma, choriocarcinoma. Non germ cell tumors are rare.

TNM staging
Primary tumor extension is defined after inguinal orchidectomy.

Primary tumor (T)
The extent of primary tumor is classified after radical orchiectomy, and for this reason, a pathologic stage is assigned.

• pTX: Primary tumor cannot be assessed*
• pT0: No evidence of primary tumor (e.g., histologic scar in testis)
• pTis: Intratubular germ cell neoplasia (carcinoma in situ)
• pT1: Tumor limited to the testis and epididymis without lymphatic/vascular invasion; tumor may invade into the tunica albuginea but not the tunica vaginalis
• pT2: Tumor limited to the testis and epididymis with vascular/lymphatic invasion, or tumor extending through the tunica albuginea with involvement of the tunica vaginalis
• pT3: Tumor invades the spermatic cord with or without vascular/lymphatic invasion
• pT4: Tumor invades the scrotum with or without vascular/lymphatic invasion

Regional lymph nodes (N)

• NX: Regional lymph nodes cannot be assessed
• N0: No regional lymph node metastasis
• N1: Metastasis with a single lymph node mass 2 cm or less in greatest dimension; or multiple lymph nodes, none more than 2 cm in greatest dimension
• N2: Metastasis with a single lymph node mass more than 2 cm but not more than 5 cm in greatest dimension; or multiple lymph nodes, none more than 5 cm in greatest dimension
• N3: Metastasis with a lymph node mass more than 5 cm in greatest dimension

Distant metastasis (M)

• MX: Presence of distant metastasis cannot be assessed
• M0: No distant metastasis
• M1: Distant metastasis
  • M1a: Non-regional nodal or pulmonary metastasis
  • M1b: Distant metastasis other than to non-regional lymph nodes and lungs

Serum tumor markers (S)

• SX: Marker studies not available or not performed
• S0: Marker study levels within normal limits
• S1: LDH < 1.5 X N* AND
  • hCG (mIu/ml) < 5000 AND
  • AFP (ng/ml) < 1000
• S2: LDH 1.5-10 X N* OR
  • hCG (mIu/ml) 5000-50,000 OR
  • AFP (ng/ml) 1000-10,000
• S3: LDH > 10 X N* OR
  • hCG (mIu/ml) > 50,000 OR
  • AFP (ng/ml) > 10,000

Stage grouping

• Stage 0
  • pTis, N0, M0, S0
• Stage I
  • pT1-4, N0, M0, SX
• Stage IA
  • pT1, N0, M0, S0
• Stage IB
  • pT2, N0, M0, S0
  • pT3, N0, M0, S0
  • pT4, N0, M0, S0
• Stage IS
  • Any pT/Tx, N0, M0, S1-3
• Stage II
  • Any pT/Tx, N1-3, M0, SX
• Stage IIA
  • Any pT/Tx, N1, M0, S0
  • Any pT/Tx, N1, M0, S1
• Stage IIB
  • Any pT/Tx, N2, M0, S0
  • Any pT/Tx, N2, M0, S1
• Stage IIC
  • Any pT/Tx, N3, M0, S0
  • Any pT/Tx, N3, M0, S1
• Stage III
  • Any pT/Tx, any N, M1, SX
• Stage IIIA
  • Any pT/Tx, any N, M1a, S0
  • Any pT/Tx, any N, M1a, S1
• Stage IIIB
  • Any pT/Tx, N1-3, M0, S2
  • Any pT/Tx, any N, M1a, S2
• Stage IIIC
  • Any pT/Tx, N1-3, M0, S3
  • Any pT/Tx, any N, M1a, S3
  • Any pT/Tx, any N, M1b, any S

After surgical removal of the primary tumor, the treatment ranges from watchful waiting for early stage cancer, to radiotherapy for seminoma, to open or laparoscopic removal of retroperitoneal lymph nodes, or to chemotherapy and subsequent surgical removal of residual bulky lymph nodes. Though laparoscopic retroperitoneal lymph node dissection is a less invasive procedure, it should be performed in laparoscopic trained centers. With modern surgical schemes, usually retrograde ejaculation, common in the past, is unusual after retroperitoneal lymph nodes dissection

Stage	Tumor	Treatmen
I	Seminoma	Radiotherapy to retroperitoneum and to inguinal lymph nodes on tumor side
	Non seminoma	RPLND or surveillance
IIa (no enlarged lymph nodes)	Seminoma	Radiotherapy to retroperitoneum and to inguinal lymph nodes
	Non seminoma	RPLND, possibly with platinum-based polichemotherapy
IIb (enlarged lymp nodes)	Seminoma	Radiotherapy to retroperitoneum. to inguinal lymph nodes, possibly to mediastine and supraclavear lymph nodes ORplatinum-based polichemotherapy
	Non seminoma	platinum-based polichemotherapy followed by surgical removal of bulky disease
III	Seminoma	platinum-based polichemotherapy followed by surgical removal of bulky disease
	Non seminoma	platinum-based polichemotherapy followed by surgical removal of bulky disease

Thanks to improved therapeutic approach, survival has greatly increased also for aggressive tumors, like noseminomatous gem cell cancer. Five years survival is 94% for low risk cancers, 83% for intermediate risk, and 50-71% for advanced tumors.
For stage I seminoma, after orchidectomy alone 80% of patients remain disease free without further treatments.
Recent studies have suggested that chemotherapy and radiotherapy regimens used in testis cancer might increase the risk of a second tumor with time.
Testis cancer is today a disease with high healing rate, but the patients must follow strictly the treatment and follow-up protocols