• Testis cancer follows classic anatomic pathways in a stepwise pattern of spread. The tunica albuginia resists spread and the escape pathway is through the testicular mediastinum. Lymphatic spread is very common and right sided lesions demonstrate a right to left pattern of dissemination. The exception to this is choriocarcinoma which demonstrates vascular dissemination.
• Whereas pure seminoma is confined to the testis at initial presentation in two thirds to three fourths of cases, up to two thirds of patients with NSGCT may present with metastasis. Lymphatic spread can occur early and usually precedes vascular invasion. Early vascular invasion is noted frequently in pure choriocarcinoma. Sites of hematogenous spread include the lungs, liver, and bones.
• In patients with organ-confined disease after orchiectomy (stage I or A), failure will ultimately occur in 30 percent of patients (80 percent retroperitoneal; 20 percent distant). If a retroperitoneal lymph node dissection is performed for stage I disease, 5 to 8 percent of such patients will have a recurrence, almost exclusively at an extra retroperitoneal site, usually in the chest.
• All germinal cell testis tumors in adults should be treated as malignant. Spontaneous regression of this disease is extremely rare. The majority of patients who die from testicular cancer do so within 3 years of diagnosis.

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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