Testicular Tumour
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Direct answer
A painless, firm, non-tender testicular swelling in a man of fifteen to thirty-five is a malignant tumour until excluded — the commonest solid malignancy of that age group and among the most curable of all cancers. Ultrasound confirms an intratesticular lesion, tumour markers (AFP, beta-hCG, LDH) are drawn before surgery, and the definitive operation is radical inguinal orchidectomy with high ligation of the cord — the transscrotal route is banned because scrotal skin drains to inguinal nodes and seeding corrupts the lymphatic map. Seminoma, radiosensitive and cisplatin-sensitive, is managed after orchidectomy with surveillance, single-dose carboplatin or radiotherapy in early stages; non-seminomatous germ cell tumours add retroperitoneal lymph node dissection and BEP chemotherapy, which cures the great majority even when metastatic.
What you must remember
- Types: seminoma accounts for about half of pure germ-cell tumours (peak 35-40 years); non-seminomatous types are embryonal carcinoma, yolk sac tumour (infants, AFP-producing), choriocarcinoma (beta-hCG, gynaecomastia) and teratoma; in men over sixty think lymphoma.
- Markers: AFP (half-life 5-7 days) from yolk sac and embryonal elements — never elevated in pure seminoma; beta-hCG (half-life 24-36 hours) from choriocarcinoma and some seminomas; LDH reflects tumour bulk; falling markers after surgery chart the cure.
- The inguinal rule: orchidectomy through a groin incision with early clamping of the cord at the deep ring; a transscrotal biopsy contaminates the scrotum and changes lymphatic drainage — if it has been done, the scrotal scar and hemiscrotum are excised with the subsequent management.
- Lymphatic map: right testis drains to aortocaval nodes, left to left para-aortic nodes below the renal vessels — hence staging CT of abdomen and pelvis, with chest imaging next.
- Stage I seminoma menu: surveillance (increasingly preferred), a single cycle of carboplatin, or para-aortic radiotherapy — all with excellent long-term survival near 99% for stage I disease.
- NSGCT pathway: stage I — surveillance in low-risk, retroperitoneal lymph node dissection (RPLND) or one cycle of BEP when vascular invasion marks high risk; metastatic disease — three to four cycles of BEP (bleomycin, etoposide, cisplatin), then resection of residual masses, because teratoma does not respond to chemotherapy.
- Fertility and follow-up: offer sperm banking before chemotherapy — cisplatin is gonadoxic; surveillance pairs markers and imaging for five years.
A young man's painless lump
A 26-year-old notices a hard, painless enlargement of the left testis over six weeks. It does not transilluminate, does not reduce, and feels stony compared with the right. Ultrasound shows a hypoechoic intratesticular mass with microlithiasic background. Before theatre: AFP, beta-hCG and LDH (AFP mildly raised — already signalling non-seminomatous elements), chest and abdominal CT (no nodes), and a sperm-banking conversation. Operation: radical inguinal orchidectomy, cord clamped at the deep ring, prosthesis offered.
Histology returns mixed germ-cell tumour with embryonal carcinoma and vascular invasion — stage I non-seminomatous, high risk. The options are laid honestly: surveillance with intensive follow-up, one cycle of BEP, or primary RPLND. He chooses chemotherapy. Markers fall on schedule (AFP halves every 5-7 days), and follow-up markers plus CT continue for five years. Had the histology been pure seminoma, the conversation would have offered surveillance, single-dose carboplatin, or para-aortic radiotherapy — and theAFP would never have risen.
Why the scrotal route is banned
The examiner's reasoning question is anatomical: the testis drains to para-aortic nodes, while scrotal skin drains to inguinal nodes — a transscrotal biopsy opens a second lymphatic field, seeds scrotal skin, and makes both staging and radiotherapy planning unreliable. The paired pharmacology questions are the markers: AFP never rises in pure seminoma (an "AFP-producing seminoma" means non-seminomatous elements are hiding), beta-hCG belongs to choriocarcinoma, and gynaecomastia in a young man earns a testicular examination first. The oncology one-liner is the residual mass after BEP — excise it, because chemoresistant teratoma lurks there — and the statistic worth quoting is that testicular cancer is the most curable solid malignancy, with five-year survival above 95% overall.
Frequently asked questions
Why is transscrotal biopsy of a testicular tumour forbidden?
Scrotal skin drains to inguinal nodes while the testis drains to para-aortic nodes; the transscrotal route seeds the scrotum and corrupts both lymphatic spread and staging.
Which markers belong to which tumour?
AFP marks yolk sac and embryonal carcinoma; beta-hCG marks choriocarcinoma (and some seminomas); LDH reflects tumour bulk — and AFP never rises in pure seminoma.
What are the options for stage I seminoma after orchidectomy?
Surveillance, a single cycle of carboplatin, or para-aortic radiotherapy — each with excellent survival.
What is BEP and when is it given?
Bleomycin, etoposide and cisplatin — the chemotherapy backbone for metastatic non-seminomatous disease and high-risk stage I, given three to four cycles.
Why bank sperm before treatment?
Cisplatin-based chemotherapy and retroperitoneal surgery both threaten fertility, and testicular cancer already impairs the contralateral testis in many patients.