Testicular tumors are generally developed in young men during their third to fourth decade of life. In 78 % of the cases, the disease appears in men aged 20–40 years, 20 % in men >40 years, and 2 % in boys under 18 years. Usually patients present with a painless, unilateral mass in the scrotum, found incidentally. In 20 % of cases the first symptom is pain in the scrotum or feeling of heaviness in the area, while up to 30 % of patients have local pain when palpating the testis. More rarely the disease is diagnosed by physical examination for accidental injury of the scrotum. Pain in loins occurs in a10 % of cases (due to retroperitoneal metastases). In a percentage of 10 % the tumor mimics orcheoepididymitis often resulting in delayed diagnosis, while rarely gynecomastia may occur, mostly in choriocarcinoma cases. Often the tumor can be accompanied by hydrocele and this why, if in doubt, a scrotum ultrasound should be prescribed. In case of metastases, the first manifestation of the disease may be shortness of breath or cough (pulmonary metastasis), skeletal pain (bone metastases), headache, neurological signs or symptoms in the central nervous system (brain metastases). The differential diagnosis of testicular cancer involves ruling out epidydimitis or orcheoepididymitis, hydrocele, spermatocele, haemocele, granulomatous orchitis, varicocele and epidermoid testis cyst or epididymis.

After the diagnosis, the surgical resection (radical orchectomy) and the histological characterization of the tumor, the complete staging of disease follows. A complete staging requires both imaging exams to ascertain if there are enlarged para-aortic, retroperitoneal and mediastinal lymph nodes or lesions of liver or lung, as well as the evaluation of tumor markers, beta- human chorionic gonadotropin and alpha – fetoprotein both preoperatively and postoperatively. Notably that beta – chorionic gonadotropin (β-hCG) increases in cases of non seminomatous tumors since rarely a seminoma contains syncytiotrophoblastic and cryptotrophoblast elements, while the alpha- fetoprotein increases only in case of non seminomatous tumors containing elements of embryonic-cell carcinoma or yolk sac tumor. The half-life for alpha – fetoprotein is 5–7 days and for beta – human chorionic gonadotropin is 2–3 days. Thus the detection of high levels after orchiectomy is indicative of residual disease. Brain CT and bone scans are performed only when clinically indicated. Based on these criteria, the disease is classified as stage I, II or III, as shown in Table 25.1. Stage I disease refers to cancer limited to the testis, stage II disease refers to the presence of enlarged subdiaphragmatic lymph nodes and stage III refers to disease that has spread to the diaphragm or parenchymal sites.

It is acknowledged that patients with stage II and III disease are a heterogeneous group with different prognosis and that the integration of tumor marker tests in this classification could provide better distinction between prognostic groups. One of the most important steps in this field was the international classification of the International Germ Cell Cancer Collaborative Group (IGCCCG). This group designated the relevant outcomes to each group of patients and has made the treatment approach more rational: Young patients who belong to low-risk group will take less aggressive therapy with emphasis on preventing toxicity from unnecessary treatments, while patients in high risk group should receive more toxic treatment, with a higher threshold of acceptance risks of late effects, in order to provide the best chances for long-term survival (Table 25.2).