Find information on thousands of medical conditions and prescription drugs.


Testicular cancer is a type of cancer that develops in the testicles, a part of the male reproductive system. In the United States, about 8,000 to 9,000 diagnoses of testicular cancer are made each year. Over his lifetime, a man's chance of getting testicular cancer is roughly 1 in 250 (four tenths of one percent). It is most common among males aged 15–40 years. Testicular cancer has one of the highest cure rates of all cancers: in excess of ninety percent; essentially one hundred percent if it has not spread. more...

Sabinas brittle hair...
Sacral agenesis
Saethre-Chotzen syndrome
Salla disease
Sandhoff disease
Sanfilippo syndrome
Say Meyer syndrome
Scarlet fever
Schamberg disease...
Schmitt Gillenwater Kelly...
Scimitar syndrome
Selective mutism
Sensorineural hearing loss
Septo-optic dysplasia
Serum sickness
Severe acute respiratory...
Severe combined...
Sezary syndrome
Sheehan syndrome
Short bowel syndrome
Short QT syndrome
Shprintzen syndrome
Shulman-Upshaw syndrome
Shwachman syndrome
Shwachman-Diamond syndrome
Shy-Drager syndrome
Sickle-cell disease
Sickle-cell disease
Sickle-cell disease
Silver-Russell dwarfism
Sipple syndrome
Sjogren's syndrome
Sly syndrome
Smith-Magenis Syndrome
Soft tissue sarcoma
Sotos syndrome
Spasmodic dysphonia
Spasmodic torticollis
Spinal cord injury
Spinal muscular atrophy
Spinal shock
Spinal stenosis
Spinocerebellar ataxia
Splenic-flexure syndrome
Squamous cell carcinoma
St. Anthony's fire
Stein-Leventhal syndrome
Stevens-Johnson syndrome
Stickler syndrome
Stiff man syndrome
Still's disease
Stomach cancer
Strep throat
Strumpell-lorrain disease
Sturge-Weber syndrome
Subacute sclerosing...
Sudden infant death syndrome
Sugarman syndrome
Sweet syndrome
Swimmer's ear
Swyer syndrome
Sydenham's chorea
Syndrome X
Synovial osteochondromatosis
Synovial sarcoma
Systemic carnitine...
Systemic lupus erythematosus
Systemic mastocytosis
Systemic sclerosis

Even for the relatively few cases in which the cancer has spread widely, chemotherapy offers a cure rate of at least fifty percent.

Symptoms and early detection

Because testicular cancer is curable when detected early, experts recommend regular monthly testicular self-examination after a hot shower, when the scrotum is looser. Men should examine each testicle, first feeling for lumps and then compare the testicles to each other together to see whether one is larger than the other.

Symptoms may include one or more of the following:

  • a lump in one testicle
  • pain and tenderness in the testicles
  • blood in semen during ejaculation
  • build-up of fluid in the scrotum
  • enlargement or tenderness of breasts
  • a dull ache in the lower abdomen or groin
  • an increase, or significant decrease, in the size of one testicle.

Men should report any of these to a doctor as soon as possible.

The extent of testicular cancer and whether the cancer is present are ascertained by ultrasound (of the testicles), X-rays, and/or CT-scans, which are used to locate tumors. For nonseminomas (see below), a blood test is used to identify and measure tumor indicators that are specific to that type of testicular cancer.


Testicular cancer can be caused by any type of cell found in the testes, but more than 95% of all cancers are from germ cells. (Germ cells produce sperm. They are not pathogenic; i.e., they are not to be confused with the "germs" (viruses, bacteria) that cause illness.) In general, the remainder of this article discusses germ-cell testicular cancer.

Germ-cell tumors are classified as either seminomas or nonseminomas. Seminomas are slow-growing, immature germ cells. Seminomas, when found, tend to be localized (i.e., only in the testicles), simply because they spread relatively slowly. Nonseminomas, on the other hand, are more-mature germ cells and spread more quickly. (Nonseminomas are classified as one of three or four subtypes; their rate of spread varies somewhat, but they are treated similarly.) When seminomas and nonseminomas are both present (which is not unusual), the cancer is classified as nonseminoma.

A case of testicular cancer is categorized as being in one of three stages (which have subclassifications). Stage one is that in which the cancer remains localized to the testicle. In stage two, the cancer has spread to the nearest lymph nodes, which are small, bean-shaped structures that produce and store infection-fighting cells, in the abdomen. In stage three, the cancer has spread farther, to locations that may include the kidneys, liver, bones, lungs, or brain. The majority of cases are stage 1 when first identified; stage 3 is relatively rare.


[List your site here Free!]

Metastatic seminoma with cervical lymphadenopathy as the initial manifestation
From Ear, Nose & Throat Journal, 5/1/04 by Lee M. Akst


Advanced testicular germ cell tumors commonly involve cervical lymph nodes. In most circumstances, the diagnosis of germ cell tumor is established before the neck disease is noted. In rare cases, these tumors have been found along with cervical lymphadenopathy in patients with a previously undiagnosed primary tumor. In this article, we report the unusual case of a 71-year-old man whose metastatic seminoma initially manifested as an asymptomatic neck mass. This finding reinforces the need to include metastatic disease in the differential diagnosis of neck masses. Our discussion of this case focuses on the appropriate management of cervical metastases of germ cell tumors.


The incidence of testicular tumors in the United States is approximately 6 per 100,000 males; these neoplasms are the most common tumors in males in the 15-to-34-year age group. (1) Germ cell tumors account for 98% of all testicular malignancies. (1) Among patients with testicular carcinoma, the incidence of neck metastasis has been reported to range from 4.5 to 15%; in an estimated 5% of these cases, a neck mass is the initial sign. (2,3) Although the presence of cervical metastasis is believed to be a marker for advanced disease, even advanced testicular cancer is thought to be curable with appropriate therapy. (4) Overall cure rates for germ cell tumors are in the range of 90 to 95%, but maintenance of these cure rates requires structured and timely approaches to therapy. (5)

When a cervical metastasis is present especially when the germ cell tumor manifests as a neck mass--the otolaryngologist may play a central role in the structured management of such a patient. In this article, we report an unusual case of metastatic seminoma that initially manifested as a neck mass. Our discussion of this case focuses on the evaluation and management of germ cell tumors with cervical metastases.

Case report

A 71-year-old white man presented with a chief complaint of a neck mass. The patient had noted a left supraclavicular neck mass 2 days earlier. The mass was asymptomatic. The patient had a history of papillary carcinoma of the thyroid, which had been treated with thyroidectomy 2 years earlier. The pathology report at that time indicated that there was no vascular invasion. When postoperative scanning identified some residual disease in the right lower neck and left upper neck, the patient was treated with radioactive iodine. The history and a review of systems also revealed that the patient had a congenitally atrophic right testicle as well as recent fatigue and weight loss. Findings on a head and neck review of systems were negative. The patient had not used any tobacco products for more than 35 years.

On physical examination, the patient was noted to be well developed and well nourished, and he communicated easily without assistance. His voice was somewhat hoarse and rather high-pitched. Findings on examination of the ears, nose, and oral cavity were normal. Further examination detected no suspicious lesions in the nasopharynx, oropharynx, or hypopharynx. Mirror examination revealed hypomobility of the right true vocal fold. The neck mass measured 5 cm in diameter and was located at the base of the neck just above the left clavicle. It was nontender and fixed. The carotid artery remained palpable medial to this mass. No other cervical lymphadenopathy was noted. Computed tomography (CT) at the level of the left clavicle revealed that the mass had displaced the trachea (figure 1).

[FIGURE 1 OMITTED] Needle aspiration biopsy yielded a moderate amount of mucoid material. Cytology demonstrated malignant cells consistent with a poorly differentiated epithelial malignancy (figure 2, A); on this basis, melanoma and lymphoma were ruled out. Immunohistochemical analysis revealed that the malignant cells were negative for pankeratin (AE1/AE3), S-100, HMB-45, CD30, and chromogranin; these cells were positive for keratin (CAM 5.2) and vimentin. Numerous lymphoid cells in the background were positive when stained for CD45, CD3, and CD20.

[FIGURE 2A OMITTED] Given the diagnosis of poorly differentiated epithelial malignancy on needle aspiration, excisional biopsy was performed to establish a definitive diagnosis. Upon exploration, it was noted that the mass was deep to the sternocleidomastoid and omohyoid muscles. The jugular vein was displaced anterior to the mass. The mass extended laterally into zone V and inferiorly beneath the clavicle; it appeared to partially encapsulate the carotid artery. Given the anticipated difficulty and morbidity associated with complete excision, representative portions of the mass were excised for pathologic diagnosis and the remainder of the mass was left in place.

Findings on histologic examination of the excised tumor were consistent with seminoma with atypical features (figure 2, B). The specimen contained large epithelioid malignant cells with large vesicular nuclei and prominent nucleoli. A moderate amount of variably vacuolated cytoplasm surrounded the nuclei. Mitotic figures were conspicuous. The neoplasm had a consistent lymphoid and granulomatous stroma. Nuclear pleomorphism was more striking than is the case in classic seminoma. The diagnosis of seminoma was confirmed by further immunohistochemical studies (figure 2, C), although the negative staining for placental alkaline phosphatase and CD 117 are considered to be atypical for seminoma.

[FIGURE 2B, 2C OMITTED] Following the diagnosis of the neck mass, testicular examination revealed the presence of an occult seminoma in the patient's atrophic right testicle. Further investigation revealed a collection of matted retroperitoneal lymph nodes as well as metastases beyond the retroperitoneum. The patient was diagnosed with stage-3 seminoma and began appropriate chemotherapy. He experienced a complete response to therapy, and at the 6-month follow-up, he had no evidence of disease. He subsequently died of an unrelated myocardial infarction. An autopsy was not performed.


Testicular germ cell tumors can be split into two broad categories: seminomas and nonseminomatous germ cell tumors (NSGCTs). Seminomas account for approximately 60% of all testicular germ cell tumors. (6) The incidence of seminoma is highest among men aged 30 to 39 years, and it declines steadily with advancing age. (6) Such a tumor in a 71-year-old is exceedingly unusual; seminoma is rarely diagnosed in this age group. Treatment strategies are different for seminomas and NSGCTs; treatment can also vary according to the tumor stage in both categories. Clinicopathologic studies suggest that patients who have seminomas with atypical features tend to present at more advanced stages and that their tumors may behave more aggressively than seminomas without atypia. (7) Our patient was diagnosed with seminoma with atypical features. In light of the CT finding of a 5-cm collection of matted retroperitoneal lymph nodes and evidence of supradiaphragmatic disease, he was diagnosed as having a stage-3 seminoma.

The presence of cervical involvement is believed to be a marker for advanced disease, and most patients with testicular carcinomas present with other symptoms, such as a scrotal mass. When a neck mass is found to be a metastatic germ cell tumor, it is usually in the setting of a known primary tumor and other known metastatic disease, particularly beneath the diaphragm. (8)

Although some authors have estimated that as many as 5% of germ cell tumors initially manifest as a neck mass, (2,3) case reports of such a phenomenon are rare. Our superficial search of the MEDLINE database dating from 1966 turned up only a handful of previously reported cases of a metastatic germ cell tumor that initially manifested as a neck mass. Such a finding was described by Soboroff and Lederer (9) in a single case report, by Zeph et al (3) in 1 of 5 patients, and by Lee and Caleaterra (10) in 2 of 6 patients. None of these four patients was older than 34 years.

In extraordinarily unusual cases, a neck mass is the only manifestation of a germ cell tumor; no other primary tumor is ever found. In such a case, it is possible that the neck mass itself is the primary tumor or that the neck mass represents a metastatic deposit with spontaneous regression of the primary elsewhere; only four such cases have been described. (11) With respect to these cases, it is important to remember that as many as 10% of seminomas may be extragonadal in origin; such tumors typically occur in the anterior mediastinum, retroperitoneum, or pineal region. (12)

When germ cell tumors do metastasize to the cervical lymph nodes, such deposition may occur through either lymphatic or hematogenous channels. While all germ cell tumors have a propensity for lymphatic spread, NSGCTs are much more likely than seminomas to demonstrate hematogenous spread. (13,14) When lymphatic spread does occur, it follows characteristic lymphatic pathways. Both right-and left-sided testicular tumors spread first to the retroperitoneal nodes and then move superiorly along the thoracic duct. As a consequence, lymphatic metastases tend to be contiguous, spreading from the abdomen into the chest and finally into the neck. (14) Based on thoracic duct anatomy, cervical metastases from germ cell tumors are found almost exclusively within the left supraclavicular fossa, although aberrant crossover may occur. As for hematogenous spread, one possible mechanism includes metastatic reflux through Batson's paraspinal venous plexus, driven by transient increases in intra-abdominal and intrathoracic pressure. (15) This mechanism has been presumed to allow retroperitoneal renal cell cancers to metastasize to the head and neck. (16) The phenomenon of hematogenous spread may also explain the metastatic spread of seminoma to other areas of the head and neck, such as the orbit, sphenoid sinus, temporal bone, and jaw. (13)

Treatment strategies for advanced germ cell tumors continue to evolve. The treatment plan depends on the histology of the tumor (seminoma vs. NSGCT), the site of metastasis, and serum concentrations of tumor markers. (4,5,17) Once cervical lymph nodes are involved, the tumor is classified as stage 3 and initial treatment is generally chemotherapy. For NSGCTs, tumor markers may be followed; when tumor markers such as human chorionic gonadotropin or alpha-fetoprotein remain elevated, salvage chemotherapy is indicated. When tumor markers normalize but the neck mass persists, surgical resection is indicated to remove any recurrent disease, thereby eliminating the possibility of a reversion of mature teratoma to a more malignant phenotype and preventing further tumor spread. (2,3,10,18) In most cases, selective neck dissection is sufficient to provide adequate exposure for safe and aggressive resection of cervical disease. (2,3,18) Such neck dissection may be accompanied by simultaneous resection of retroperitoneal or thoracic disease if metastases persist in these areas as well. (19)

The management of seminoma is less clear and may be more controversial than that for NSGCT. (20) In seminoma, tumor markers may be negative at presentation (as was the case with our patient) and there fore may not be available to guide therapy. Also, seminomas tend to be more radiosensitive than are NSGCTs. Consequently, postchemotherapy management of residual masses (as studied in the retroperitoneum) might include radiotherapy, observation, or surgical resection; no studies address cervical seminoma specifically. However, researchers who did consider seminoma together with NSGCT in the more general category of germ cell tumors continue to recommend surgical resection of residual neck masses following chemotherapy. (2,10) Whether or not postchemotherapy resection is pursued, proper diagnosis necessitates that an otolaryngologist be aware that a metastatic germ cell tumor might manifest as a neck mass. As the case of our patient demonstrates, these tumors are occasionally found in an unexpected age group and even in the absence of a previously diagnosed primary tumor.


(1.) National Cancer Institute. SEER * Stat version 4.1: SEER cancer incidence public use database, 1973-1998. Bethesda, Md.: National Cancer Institute, 2001.

(2.) See WA, Laurenzo JF, Dreicer R, Hoffman HT. Incidence and management of testicular carcinoma metastatic to the neck. J Urol 1996;155:590-2.

(3.) Zeph RD, Weisberger EC, Einhorn LH, et al. Modified neck dissection for metastatic testicular carcinoma. Arch Otolargyngol 1985;111:667-72.

(4.) Shahidi M, Norman AR, Deanaley DP, et al. Late recurrence in 1263 men with testicular germ cell tumors: Multivariate analysis of risk factors and implications for management. Cancer 2002:95: 520-30.

(5.) Raghavan D. Testicular cancer: Maintaining the high cure rate. Oncology (Huntingt) 2003; 17:218-28.

(6.) McGlynn KA, Devesa SS, Sigurdson AJ, et al. Trends in the incidence of testicular germ cell tumors in the United States. Cancer 2003;97:63-70.

(7.) Tickoo SK, Hutchinson B, Bacik J. et al. Testicular seminoma: A clinicopathologic and immunohistochemical study of 105 cases with special reference to seminomas with atypical features. Int J Surg Pathol 2002;10:23-32.

(8.) Lynch DF, Jr., Richie JP. Sapraclavicular node biopsy in staging testis tumors. J Urol 1980; 123:39-40.

(9.) SoboroffBJ, Lederer FL. The lanthanic neck mass. Arm Otol Rhinol Laryngol 1968;77:547-57.

(10.) Lee JT, Calcaterra TC. Testicular carcinoma metastatic to the neck. Am J Otolaryngol 1998;19:325-9.

(11.) Berdjis N, Offergeld C, Lossnitzer A, et al. Solitary cervical lymph node manifestation of a seminoma without detectable primary. Urol Int 2001;67:165-7.

(12.) Slevin N J, James PD, Morgan DA. Germ cell tumours confined to the supra-clavicular fossa: A report of two cases. Eur J Surg Oncol 1985;11:187-90.

(13.) Bhalla RK, Jones TM, Errington D, Roland NJ. Metastatic testicular seminoma--case report. Auris Nasus Larynx 2002;29:219-22.

(14.) WoodA, Robson N, Tung K, Mead G. Patterns of supradiaphragmatic metastases in testicular germ cell tumours. Clin Radiol 1996;51: 273-6.

(15.) Batson OV. The function of the vertebral veins and their role in the spread of metastases. Ann Surg 1940; 112:138-49.

(16.) Cheng ET, Greene D, Koch RJ. Metastatic renal cell carcinoma to the nose. Otolaryngol Head Neck Surg 2000;122:464.

(17.) Law TM, Motzer RJ, Bajorin DF, Bosl GJ. The management of patients with advanced germ ceil tumors. Seminoma and nonseminoma. Urol Clin North Am 1994;21:773-83.

(18.) Weisberger EC, McBride LC. Modified neck dissection for metastatic nonseminomatous testicular carcinoma. Laryngoscope 1999;109: 1241-4.

(19.) Brenner PC, Herr HW, Morse M J, et al. Simultaneous retroperitoheal, thoracic, and cervical resection of postchemotherapy residual masses in patients with metastatic nonseminomatous germ cell tumors of the testis. J Clin Oncol 1996;14:1765-9.

(20.) Fleshner N, Warde P. Controversies in the management of testicular seminoma. Semin Urol Oncol 2002;20:227-33.

From the Department of Otolaryngology and Communicative Disorders, The Cleveland Clinic, Cleveland, Ohio (Dr. Akst and Dr. Discolo), and the Division of Pathology and Laboratory Medicine (Dr. Dipasquale) and the Department of Otolaryngology and Communicative Disorders (Dr. Greene and Dr. Roberts), The Cleveland Clinic, Naples, Fla.

Reprint requests: David Greene, MD, Head, Department of Otolaryngology and Communicative Disorders, Cleveland Clinic Florida, 6101 Pine Ridge Rd., Naples FL 34119. Phone: (239) 348-4081; fax: (239) 348-4355; e-mail:

COPYRIGHT 2004 Medquest Communications, LLC
COPYRIGHT 2004 Gale Group

Return to Seminoma
Home Contact Resources Exchange Links ebay