Presentation, Management, and Outcomes of Testicular Germ Cell Tumors by Age

Testicular germ cell tumors (TGCTs) have long been considered a disease primarily of young men, typically affecting those between 15 and 45 years of age. However, over the past few decades, there has been a meaningful epidemiological shift with a growing proportion of TGCT diagnoses in older men.

Despite this trend, comprehensive data characterizing how these older patients differ from their younger counterparts in terms of clinical presentation, management, and survival outcomes remain limited. In our study, we aimed to comprehensively characterize the clinicopathologic features, management patterns, and survival outcomes in a contemporary population-based cohort of men diagnosed with TGCTs across different age groups.

Using the Surveillance, Epidemiology, and End Results (SEER) database, we identified 34,738 patients aged 15-70 years who were diagnosed with TGCTs by radical orchiectomy between 2004 and 2021. We stratified patients into a younger and older group (15-44 and 45-70, respectively) and systematically compared their clinicopathologic features, management patterns, and cancer-specific survival (CSS).

Several important findings emerged from our analysis. First, older men were significantly more likely to present with seminoma (78.7% versus 49.9%) and clinical stage I disease (72.9% versus 70%) compared to younger men. Despite this seemingly more favorable presentation, older patients had larger tumors on average, which may reflect delays in diagnosis or presentation. Second, we found no significant differences in histology-specific management patterns between younger and older men with clinical stage I disease, suggesting that current clinical practice does not routinely differentiate treatment by age at this stage. Third, while outcomes were excellent across both age groups for clinical stage I and II disease, older age was significantly associated with worse CSS in the setting of metastatic (clinical stage III) disease, for both seminoma (86% versus 92.2%) and non-seminoma GCTs (65.7% versus 81.6%). These associations persisted in multivariable competing risks regression analysis after adjusting for relevant confounders.

The survival disparity observed in metastatic disease likely reflects a combination of higher comorbidity burden, reduced tolerance for platinum-based chemotherapy regimens, and potentially distinct tumor biology in older men. Tailored management strategies are imperative for older TGCT patients, particularly those presenting with advanced disease. Our findings support the need for prospective studies investigating outcomes in this growing patient population and underscore the importance of age-conscious decision-making in the clinical management of TGCTs.

Written by: Soum D. Lokeshwar, MD, MBA, Joseph G. Cheaib, MD, and Nirmish Singla, MD, MSCS, The Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD

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