TESTICULAR SEMINOMA DIAGNOSIS AND TREATMENT:

LITERATURE REVIEW
Jaya Wiratama1, Akhada Maulana2

Abstract
Seminoma is the most common malignant germ cell tumor of the testes. This disease can also
occur in the mediastinum, retroperitoneum, or other extra gonads. Testicular cancer is a curable
cancer. The success of physicians in curing the disease is underpinned by multidisciplinary
advances. Cisplatin-based combination chemotherapy and the refinement of post-chemotherapy
surgical procedures and diagnostic strategies have greatly improved long term survival in most
patients. Despite such excellent outcomes, several controversial dilemmas exist in the
approaches to clinical stage I disease, salvage chemotherapy, post-chemotherapy surgical
procedures, and implementing innovative imaging studies. Relapse after salvage chemotherapy
has a poor prognosis and the optimal treatment is not apparent. Recent research has provided
insight into the molecular mechanisms underlying cisplatin resistance. Phase 2 studies with
targeted agents have failed to show adequate efficacy; however, our understanding of cisplatin
resistant disease is rapidly expanding. This review summarizes recent advances and discusses
relevant issues in the biology and management of testicular cancer. This study aims to review
testicular seminoma diagnosis and treatment based on current literature to refer to other
researchers and clinicians.
Keyword: Testicular seminoma, cancer, urologic disorder, review.
1
Medical professional program, Faculty of Medicine Mataram University/West Nusa Tenggara Province General
Hospital, Mataram, Indonesia
*email: putujayawiratama112000@gmail.com
2
Staff Division of Urology/Department of Surgery, Faculty of Medicine Mataram University/West Nusa Tenggara
Province General Hospital, Mataram, Indonesia
*email: akhada_m@hotmail.com

INTRODUCTION with a survival rate of over 95% if found at an

Testicular cancer is the most common solid tumor early stage2.

among males 15 to 34 years of age 1. The age- Testicular cancer is classified according to its
adjusted annual incidence in the United States is cell of origin: seminoma, non-seminoma,
5.6 cases per 100,000 persons, with a peak of 14.6 Leydig, sertoli, choriocarcinoma, embryonal,
cases per 100,000 persons 30 to 34 years of age. teratoma, and yolk sac. Yolk sac. Seminoma
Includes incidence rates by age and ethnicity. In and non-seminoma lesions are often grouped
2017, there were an estimated 8,850 new cases of
together as germ cell tumors and are known
testicular cancer and 410 deaths. Whites,
to be the most responsive to chemotherapy
Hispanics, and American Indian/Alaska Natives
compared to other types1. Seminomas
have the highest rates of testicular cancer 1. It is
account for approximately one-third of all
one of the most treatable and curable cancers,
testicular germ cell malignancies and are ETIOLOGI AND STONE COMPOSITION
among the most treatable cancers, with a 98%
The exact etiology of seminoma is unknown.
1
to 99% survival rate in early-stage disease .
Recent theories suggest that seminoma is
EPIDEMIOLOGY
caused by estrogenic and/or antiandrogenic
There are around 1400 new cases of testicular
activity, associated with arrested gonocyte
cancer (seminoma and non-seminoma) in the
development. The disease may develop as
UK each year, with a peak incidence in men
carcinoma in situ during the short phase of
aged 25 to 35 years. It is the most common
intrauterine growth. One widely accepted
tumor in young men. By geography, the
concept is testicular dysgenesis syndrome
incidence varies widely; a study in Northern
(TDS). TDS classifies germ cell tumors,
Europe identified a 10-fold variation, with
disorder of permatogenesis, cryptorchidism,
the highest incidence rate in Denmark at 7.8
and hypospadias by reports that the disease
per 100,000 and the lowest in Lithuania at 0.9
has some common risk factors originating
per 100,000. Recent data on testicular cancer
from fetal life. An increased incidence was
incidence has shown an increase in incidence
reported over the last few decades.
over the past 30 years in most industrialized
Approximately 10% of all patients with germ
countries in North America, Europe and
cell tumors have a personal history of
Oceania.
cryptorchidism 3. Men are more at risk of
Testicular tumors generally have a good testicular cancer if they have a history of
prognosis. However, if left untreated, they developmental abnormalities (e.g.,
will progress over time resulting in large maldescent or gonadal dysgenesis); previous
local tumors and distant spread. Initial spread cancer of the opposite testicle; HIV infection,
is to the lymphatic system, especially the AIDS, or both 3.
para-aortic and pelvic lymph nodes.
PATHOPHYSIOLOGY
Hematologic spread to the lungs, liver and
brain metastases are less common with Germ cell tumors develop due to tumorigenic

seminoma; 75% of men present with stage 1 events in the uterus leading to intratubular

disease. Overall survival in the good germ cell neoplasia. Intratubular germ cell

prognosis category is expected to be in the neoplasia originates from gonocytes that fail

order of 86% at 5 years. to differentiate into spermatogonia, These

cells do not reach invasive potential until
after hormonal changes occur during puberty. with a hydrocele that obstructs palpation, so
Seminomas consist of transformed germ cells a testicular ultrasound may be warranted 8.
and are blocked in their differentiation.
Testicular cancer may present as a painless
Embryonal carcinoma cells resemble
scrotal mass, an incidental radiologic finding,
undifferentiated stem cells, their gene
posttraumatic symptom, or scrotal pain. Less
expression is similar to that of stem cells and
commonly, presenting symptoms may
intratubular germ cell neoplasms.
indicate metastatic disease or retroperitoneal
Choriocarcinomas and yolk-sac tumors have
lymphadenopathy 1. Testicular changes may
extraembryonic differentiation, while
be detected by the patient or by a sex partner.
teratomas have somatic differentiation.
Epididymitis is an important part of the
Seminomas can be divided into one of three
differential diagnosis of a scrotal mass 1. If
categories based on histology: classic,
tenderness, swelling, or examination
anaplastic and spermatocytic. In testicular
abnormalities persist after antibiotic
seminomas, alpha-fetoprotein (AFP) is
treatment, further evaluation is necessary. 23
within the normal range. If AFP is elevated
Confirmation of an alternative diagnosis is
and noseminomatous elements are present in
required to exclude testicular cancer in
the histopathology specimen, a diagnosis of
patients with a scrotal mass 1.
nonseminotaous germ cell tumor can be
made 3. Germ cell carcinoma in situ (CIS) is HISTORY AND PHYSICAL

a precancerous condition Evaluation should be guided by a complete

DIAGNOSE history of the presenting symptoms and

assessment for risk factors. Testicular
Patients usually present with an
examination should include the affected and
asymptomatic testicular mass that may be
unaffected testis for comparison. The normal
associated with infertility. Testicular pain
testis is 3.5 to 5 cm in length, smooth,
due to malignancy is relatively rare but
homogenous, movable, and detached from
should be included in the differential
the epididymis. Hard, firm, or fixed areas
diagnosis. On physical examination, there is
within or adjacent to the testes are abnormal
usually a firm unilateral mass in the scrotum
and warrant further evaluation. Physical
localized to the testis. This may be associated
examination should also include evaluation
of the inguinal and supraclavicular lymph
nodes, the abdomen, and the chest for cytotrophoblastic subtype. Such elevations
gynecomastia 1. tend to be associated with metastatic disease,
but the beta-HCG elevation by itself has no
EVALUATION
connection with overall survival.
In testicular seminoma, there is a unilateral
As noted earlier, a plain chest film may reveal
hard mass in the scrotum that is localized to
metastatic disease, and chest CT-Scan is only
the testicles because there is a hydrocele that
indicated to evaluate abnormalities on the
prevents palpation, so a testicular ultrasound
plain abnormalities. Ultrasound is typically
is needed to identify the mass. The spread of
the most useful diagnostic method for the
this disease occurs in the lymphatic system,
follow-up of metastatic masses.
especially the para-aortic and pelvic beta
gening glands so that it is necessary to have MEDICAL MANAGEMENT
testicular ultrasound as an initial examination
Several treatment options are available for
and CT scan of the abdomen and pelvis to be
these patients, but surgery, radical
the initial stage modalities, but there may be
orchiectomy, is almost always the main
failure to retroperitoneal nodes in 15-20%.
intervention. This surgical approach usually
PET scanning is not usually art of the initial
requires an incision in the groin with removal
workup but may be useful in tracking activity
of the entire testicle and most of the spermatic
and growth in residual masses following
cord which is called a radical inguinal
definitive chemotherapy ⁵ ⁶ ⁷
orchiectomy and is a therapy as well as part
Several laboratory values may be useful in of the staging procedure. The scrotal incision
following tumor burdens. These include approach should be avoided in orchiectomy
AFP, B-HCG, and LDH. Alpha-fetoprotein or surgical testicular exploration if
(AFP) elevation indicates at least some non- malignancy is suspected.
seminomatous disease, and those patients are
Stage 1 disease may offer monotherapy with
then treated as non-seminomonas, germ cell
carboplatin, and for more advanced disease,
patients, LDH may be used to follow the
bleomycin, etoposide, and cisplatin (BEP) or
overall seminomatous tumor burden. Beta-
etoposide and cisplatin (EP) may be used ⁶
human chorionic gonadotropin (HCG) is
present in 5-10% of seminoma patients; these Most men do not experience a significant

usually demonstrate the syncytial decrease in testosterone or symptoms of low

testosterone sexual dysfunction with the single therapy with carboplatin, and for more
removal of one testicle. This procedure advanced disease, bleomycin, etoposide, and
usually does not cause infertility, and 25% of cisplatin, or etoposide and cisplatin may be
men with testicular malignancy were infertile used. This activity describes the evaluation
prior to their diagnosis of testicular cancer. and treatment of testicular seminomas and
highlights the interprofessional team's role in
Sperm count may increase after removal of
caring for affected patients.
the affected testicle. Reconstructive surgery
with prosthetic testicles is an option that can TREATMENT AND PROGNOSE
be performed with primary surgery delayed
until active treatment is instituted or refused Radical inguinal orchiectomy, including

completely. Retroperitoneal lymph node removal of the spermatic cord to the internal

dissection is more complex and invasive. It is inguinal ring, is the primary treatment for any

used for staging and is usually open, but malignant tumor found on surgical

laparoscopic approaches are being exploration of a testicular mass. Testis-

developed. Complications include urgent sparing surgery is generally not

problems, such as intestinal infection or recommended but may be performed for a

blockage, and loss of the ability to ejaculate. small tumor in one testis or for small bilateral

For this reason, retroperitoneal lymph node tumors. Orchiectomy may be delayed if life-

dissection is rarely performed for seminomas threatening metastases require more urgent

except perhaps for growing, residual attention1. Treatment after orchiectomy is

abdominal masses that have not responded to based on histology, staging, prognosis, and

other treatments. Radiation or chemotherapy an individualized discussion with the patient

is generally indicated for the treatment of on the benefits and harms of treatment

positive lymph nodes.. options.24 As treatment has advanced and

survival rates have improved, efforts have
SURGICAL THERAPY increasingly focused on decreasing
treatment-associated morbidity through more
Testicular seminomas are cancers that can
active surveillance and selecting therapies
usually be managed with surgical resection,
tailored to individualized risk (i.e., risk-
although radiation is added for advanced-
adapted therapy). Risk-adapted therapy is
stage disease. Stage 1 disease may be offered
used in nonseminoma treatment but has not and Management. Med Clin North Am. 2018
Mar;102(2):251-264.
been validated in seminoma treatment1.
doi: 10.1016/j.mcna.2017.10.003. Epub 2017
Dec 21. PMID: 29406056.
Active surveillance involves more frequent
3. Chovanec M, Cheng L. Advances in
monitoring than adjuvant therapy and is
diagnosis and treatment of testicular cancer.
associated with higher recurrence rates, but it BMJ. 2022 Nov 28;379:e070499. doi:
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chemotherapy. The risk of testicular cancer PMID: 36442868.
4. Stephenson A, Eggener SE, Bass EB,
recurrence is greatest within two to three
Chelnick DM, Daneshmand S, Feldman D,
years of primary treatment, and surveillance
Gilligan T, Karam JA, Leibovich B, Liauw
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Sharma R, Sheinfeld J. Diagnosis and
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5. Leveridge MJ, Siemens DR, Brennan K,
Seminoma is the most common malignant
Izard JP, Karim S, An H, Mackillop WJ,
germ cell tumor of the testis. Seminomas Booth CM. Temporal trends in management
account for approximately one-third of all and outcomes of testicular cancer: A

testicular germ cell malignancies and are population-based study. Cancer. 2018Jul
01;124(13):2724-2732.
among the most treatable cancers, with a 98%
doi:10.1002/cncr.31390. Epub 2018 Apr16.
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PMID: 29660851
Seminomas can be classified into one of three 6. Chovanec M, Hanna N, Cary KC, Einhorn L,
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