• The world health organization classification provides the most complete categorization. The Dixon-Moore classification has provided a general, practical grouping of testis lesions
• Several classifications of testicular carcinoma have been proposed. The Dixon-Moore classification is presented as follows. 1. Germinal neoplasms
  • Seminoma
    • Classic. Pure or "classic" seminoma accounts for approximately 85 percent of seminomas and 30 percent of all testicular germ cell tumors. Approximately 15 percent will also contain syncytiotrophoblastic elements, which can produce human chorionic gonadotropin. Peak incidence is seen in the 4th and 5th decades of life, one decade later than nonseminomatous germ cell tumors (NSGCT). Grossly, seminomas appear as well-defined, yellow-tan tumors.
    • Anaplastic. Account for approximately 10 percent of seminomas. Characterized by increased mitotic activity. Although they usually present at higher stages than classic seminoma, stage for stage, these tumors carry the same prognosis. These tumors account for 30 percent of mortalities due to seminoma.
    • Spermatocytic. Classically seen in an older age group (50 percent are older than 50 years old), it accounts for 1 to 2 percent of all testicular tumors. Only one case of metastasis has been reported, so inguinal orchiectomy is sufficient treatment.
  • Embryonal carcinoma. Represent approximately 3 percent of pure germ cell tumors, but may be a component of up to 25 percent of mixed germ cell tumors.
  • Teratoma (with or without malignant transformation). These tumors can be comprised of endodermal, mesodermal, or ectodermal elements. It is the second most common testicular tumor in children after yolk sac tumor. Treatment is surgical because response to radiotherapy and chemotherapy is poor. Many arise from malignant transformation of NSGCT after chemotherapy.
    • Mature. Cystic areas lined by epithelium that may contain respiratory epithelium, blood vessels, cartilage, or squamous epithelium.
    • Immature. As above but with primitive elements.
  • Choriocarcinoma. Represent less than 1 percent of all NSGCT Usually present with advanced clinical stage and very high serum levels of hCG.
  • Yolk sac tumor. Also referred to as endodermal sinus tumor, it is the most common NSGCT in children. It accounts for roughly 2 percent of all germ cell tumors in its pure form, but may be present in up to 25 percent of mixed germ cell tumors. Cells produce alpha fetoprotein that can be measured in serum.
• Nongerminal neoplasms
  • Gonadal stromal tumors include Leydig cell tumor and gonadoblastoma.
  • Miscellaneous neoplasms include carcinoid, adrenal rests, and mesenchymal neoplasms.
• Intratubular Germ cell Neoplasia. Carcinoma in situ of the testis is a precursor lesion of invasive germ cell tumors. Issues regarding the detection and management of this condition are controversial.
  • General incidence is 0.8% and the finding of CIS in the contralateral testis of a cancer patient is about 5%. Diagnosis is best made by biopsy.
  • Management includes observation, orchiectomy, radiation, or chemotherapy.
  • The approach in the USA is generally conservative, except in higher risk patients [atrophy, cryptorchid testis, infertility]

References

• Baniel J, Foster RS, Rowland RG, Bihrle R, Donahue JP: Testis cancer: Complications of post-chemotherapy retroperitoneal lymph node dissection. J Urol 153:976-980, 1995.
• Donohue JP, Thornhill JA, Foster RS, Bihrle R, Rowland RG, Einhorn LH: The role of retroperitoneal lymphadenectomy in clinical stage B testis cancer: The Indiana University experience (1965 to 1989). J Urol 153:85-89, 1995.
• Einhorn LH: Salvage therapy for germ cell tumors. Semin Oncol 21:47-51, 1994.
• Einhorn LH, Donohue JP: Advanced testicular cancer: Update for urologists. J Urol 160:1964-1969. 1998.
• Moller H, Skakkeback NE: Testicular cancer and cryptorchidism in relation to prenatal factors: Case control studies in Denmark. Cancer Causes Control 8:904-12, 1997.
• Nichols C, Loehrer P Sr: The story of second cancers in patients cured of testicular cancer: Tarnishing success of burnishing irrelevance. J Natl Cancer Inst 89:1304-1305, 1997.
• Wegner HEH, Hubotter A, Andresen R, Miller K: Testicular microlithiasis and concomitant testicular intraepithelial neoplasia. Int Urol Nephrol 30:313-315, 1998.

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