Pure testicular teratomas account for only 4-9% of all testicular tumours. A similar number are seen in the context of testicular mixed germ cell tumours (approximately 50% of these tumours contain teratomatous components, and they make up approximately 15% of all testicular germ cell tumours) 3.
The former is more commonly found in very young children (<2 years of age) whereas teratomas in the context of mixed germ cell tumours are more common in young adults (typically 20-30 years of age) 2.
The most common presentation of pure teratomas is with a painless testicular mass.
Testicular teratomas are non-seminomatous germ-cell tumours and should be divided by age of the patient and by the degree of differentiation (into mature and immature).
Mature teratomas contain well-differentiated tissues and should be biologically indolent. In pre-pubertal cases, this is born out, whereas in post-pubertal males it is believed that mature teratomas represent fully differentiated teratocarcinomas with a precursor of embryonal carcinoma 3. As such, in post-pubertal males, even mature teratomas should be regarded as potentially aggressive. In fact, if the seminiferous tubules of the adjacent seemingly uninvolved testis are examined, cellular atypia and carcinoma in situ are often identified 3.
Immature teratomas are more common in the testes, although they are rare as pure tumours, usually associated with other non-seminomatous cell types (e.g. embryonal cell carcinoma, choriocarcinoma, yolk sac tumour) as part of a testicular mixed germ cell tumour 1-2.
In both cases, they contain cell populations derived from all three embryonal layers (ectoderm, mesoderm and endoderm) although the proportion of each need not be even remotely equal.
It is interesting to note that in addition to biological behaviour, the chromosomal makeup of these tumours also depends on the age of the patients. Tumours in pre-pubertal patients are typically diploid, whereas in adults they tend to be hypotriploid 2.
This is the modality of choice for direct imaging of the testes with teratomas in the testes being similar in appearance to other locations. Mature teratomas tend to be cystic with heterogeneous echoes in the fluid representing a mixture of mucinous or sebaceous material with or without hair follicles. Solid components are present of variable echogenicity, including hyper-echoic and shadowing fatty components.
Immature teratomas tend to be more solid, but still heterogeneous on account of areas of haemorrhage and necrosis.
CT is required to assess for nodal and distant metastatic disease.
The spread of testicular tumours is both lymphatic and haematogenous.
Testicular lymphatics ascends along the gonadal arteries such that right-sided tumours involve pericaval nodes (aortocaval nodes, precaval nodes, and right paracaval and retrocaval nodes) whereas left-sided tumours typically ascend to pre-aortic and left para-aortic nodes 1.
Haematogenous spread is typically to the lungs, as well as brain, bone and liver 1.
Treatment and prognosis
Treatment depends of the age of the patient, the stage and histology of the tumour.
In cases of entirely mature benign teratomas, orchidectomy may suffice, although in adults even apparently completely mature teratomas can have aggressive behaviour, largely due to the potential of small components of embryonal carcinoma cells 1-3. In fact metastases of histologically mature tissues are sometimes seen (mature metastasising teratoma).
Conversely in infants and young children, even though a tumour may contain foci of immature teratoma, mature teratomas have a benign clinical course 2. Overall age is thus the most important prognostic factor.
In cases of immature teratoma, treatment depends on the stage. For stage I tumours orchidectomy and surveillance may suffice. Alternatively, retroperitoneal nodal dissection and chemotherapy may be recommended 1.
In adults, approximately 30% of cases have metastases at the time of diagnosis 2.
- growing teratoma syndrome
- malignant degeneration of a mature teratoma:
- malignancy of any of the components, e.g. squamous cell carcinoma
- mature metastasising teratoma
- 1. Sohaib SA, Koh DM, Husband JE. The role of imaging in the diagnosis, staging, and management of testicular cancer. AJR Am J Roentgenol. 2008;191 (2): 387-95. doi:10.2214/AJR.07.2758 - Pubmed citation
- 2. Petersen RO, Sesterhenn IA, Davis CJ. Urologic pathology. Farrar, Straus, and Giroux. (2009) ISBN:0781753430. Read it at Google Books - Find it at Amazon
- 3. Raghavan D. Germ cell tumors. Pmph USA Ltd. (2003) ISBN:1550090828. Read it at Google Books - Find it at Amazon
- 4. Maizlin ZV, Belenky A, Baniel J, Gottlieb P, Sandbank J, Strauss S. Epidermoid cyst and teratoma of the testis: sonographic and histologic similarities. (2005) Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine. 24 (10): 1403-9; quiz 1410-1. Pubmed
Germ cell tumours
germ cell tumours
- general discussion
- germ cell tumours by location
- gonadal germ cell tumours
- ovarian germ cell tumour
- ovarian dysgerminoma
- non-seminomatous germ cell tumours
- ovarian embryonal cell carcinoma
- ovarian yolk sac tumour
- ovarian choriocarcinoma
- ovarian mixed germ cell tumour
- ovarian teratoma
- testicular germ cell tumour
- ovarian germ cell tumour
intracranial germ cell tumours
- intracranial germinoma
- non-germinomatous germ cell tumours
mediastinal germ cell tumours
- mediastinal germinoma
- mediastinal non-germinomatous germ cell tumours
- gonadal germ cell tumours
Ultrasound - testicular and scrotal
- ultrasound (introduction)
testicular and scrotal ultrasound
unilateral testicular lesion
- testicular torsion
- testicular rupture
- germ cell tumours of the testis
- sex cord / stromal tumours of the testis
- testicular cyst
- bilateral testicular lesion
- paratesticular lesions
- tubular ectasia of the rete testis
- cystadenoma of the rete testis
- testicular sarcoidosis
- testicular tuberculosis
- spermatic cord
- fibrous pseudotumour of the scrotum
- scrotal leiomyosarcoma
- testicular adrenal rest tumours (TARTs)
- tunica vaginalis testis mesothelioma
- splenogonadal fusion
- unilateral testicular lesion