Testicular cancer

Overview

•Most common solid malignancy in males aged 15-34 years; >95% cured when caught early

•90-95% are germ cell tumours (GCTs); split ~50:50 seminoma vs non-seminomatous GCT (NSGCT)

•If any NSGCT element is present in a mixed tumour, manage as NSGCT

Risk factors

Cryptorchidism - most important; 3-5x risk even after orchidopexy

Previous contralateral GCT - 2-5% lifetime risk of second tumour

Family history - first-degree relatives 6-10x increased risk

Klinefelter syndrome (47,XXY) - mediastinal GCTs in particular

HIV infection - modestly increased risk, especially seminoma

Gonadal dysgenesis - dysgenetic gonads carry significant risk

Presentation

•Painless testicular lump - firm, hard, intratesticular; does not transilluminate (classic presentation)

•Dull ache or heaviness - minority of cases; ~10-20% have some discomfort

•Gynaecomastia - hCG secretion (especially choriocarcinoma); hCG has LH-like activity stimulating oestrogen

•Back/flank pain - para-aortic lymphadenopathy; late/metastatic feature

•Supraclavicular lymphadenopathy (Virchow's node) - advanced disease

•Respiratory symptoms / haemoptysis - pulmonary metastases

⚠️

Testicular cancer can mimic epididymo-orchitis. Any patient not responding to antibiotics within 2-4 weeks must have urgent scrotal ultrasound to exclude malignancy.

Investigations

🥇 First-line

•Scrotal ultrasound with Doppler - investigation of choice for any scrotal mass; distinguishes intra- from extratesticular, solid from cystic

•Before orchidectomy: Tumour markers (AFP, hCG, LDH) - baseline for diagnosis support, risk stratification, and post-treatment monitoring

•Staging: CT chest, abdomen, and pelvis - para-aortic lymphadenopathy and distant metastases

🏆 Gold standard

•Histological examination of orchidectomy specimen - definitive diagnosis and classification

🚨

Percutaneous (transscrotal) biopsy is contraindicated - it violates the tunica albuginea, alters lymphatic drainage to include inguinal pathways, and worsens staging. Always use radical inguinal orchidectomy.

Management

•Sperm banking must be offered before any treatment - critical given young age at presentation

•Surgery: Radical inguinal orchidectomy (never transscrotal) - universal first step

•Lymphatic drainage is to para-aortic/interaortocaval nodes (L1-L2), not inguinal nodes - inguinal lymphadenopathy only if scrotal skin breached

Prognosis

•Overall >95% cure at early stage; seminoma generally better prognosis than NSGCT

•Pure choriocarcinoma - worst prognosis of all subtypes; early haematogenous spread, very high hCG

Tumour markers

Tumour markers in seminoma vs NSGCT

Marker	Seminoma	NSGCT
AFP	Never elevated (pure seminoma)	Elevated (yolk sac / mixed)
hCG	Mildly elevated (10-30%)	Elevated (choriocarcinoma especially)
LDH	Elevated - bulk of disease marker	Elevated - bulk of disease marker

🎯

AFP is NEVER elevated in a pure seminoma. If AFP is raised and histology appears to be seminoma, the tumour contains NSGCT elements and must be managed as NSGCT.

Complications of treatment

•Infertility - chemotherapy/radiotherapy; sperm banking critical pre-treatment

•Peripheral neuropathy - cisplatin-related; may be permanent

•Ototoxicity (hearing loss) - cisplatin directly toxic to cochlear hair cells

•Raynaud's phenomenon - bleomycin and cisplatin toxicity

•Secondary malignancies - etoposide associated with 2-4x increased risk; leukaemia also recognised

•Cardiovascular disease - increased ischaemic heart disease risk following chemotherapy and radiotherapy