Testicular Cancer
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Direct answer
A painless, firm, non-transilluminating testicular mass in a man of 15 to 35 is a germ cell tumour until excluded — ultrasound first, then inguinal radical orchidectomy with early cord clamping, never a trans-scrotal biopsy, because scrotal violation seeds tumour along a different lymphatic drainage. Markers drawn before surgery — AFP, beta-hCG and LDH — stage the disease alongside CT of chest, abdomen and pelvis: AFP is never raised in pure seminoma, so a raised AFP makes the disease non-seminomatous regardless of histology. Stage I seminoma is managed with surveillance as the preferred option, stage I non-seminoma with surveillance for low risk or surgery or single-cycle chemotherapy for high risk; metastatic disease receives BEP — three cycles for good prognosis, four for intermediate or poor.
What you must remember
- Markers with meaning: AFP from yolk sac elements (half-life about five days), beta-hCG from choriocarcinoma and syncytiotrophoblastic seminoma (half-life two to three days), LDH reflecting tumour burden; post-operative decline should follow the half-life, and a plateau means metastatic disease.
- The AFP rule: a raised AFP in a histological "seminoma" is treated as NSGCT — a one-line exam stem that never ages.
- Stage I seminoma options: surveillance (preferred in compliant patients), single-dose carboplatin AUC 7, or radiotherapy (historical, rarely chosen now).
- Stage I NSGCT risk split: no vascular invasion with marker normalisation — surveillance; vascular invasion — retroperitoneal lymph node dissection or one cycle of BEP.
- Chemotherapy: BEP — bleomycin, etoposide, cisplatin; good prognosis three cycles (or EP for four), intermediate and poor four; bleomycin threatens the lungs, so pulmonary function and smoking status matter before cycle one.
- Residual masses after chemotherapy: NSGCT residuals above 1 cm need surgical excision, because they harbour teratoma or viable cancer that chemotherapy cannot kill; seminoma residuals are observed unless growing, with PET at about eight weeks guiding the 3 cm-plus residue.
- Fertility: sperm banking before chemotherapy — counselling is a documented standard, not a courtesy.
From groin incision to post-chemotherapy masses
A 27-year-old notices a painless hard swelling for six weeks; ultrasound shows an intratesticular hypervascular mass. Markers: AFP 240 IU/mL, beta-hCG normal, LDH raised. Through an inguinal incision the cord is clamped, the testis delivered in a swab, and radical orchidectomy completed; histology: mixed germ cell tumour with embryonal carcinoma, vascular invasion present. That AFP already declared the disease non-seminomatous before the pathologist did. Staging CT shows retroperitoneal nodes of 4 cm and two lung nodules — good-prognosis metastatic NSGCT by IGCCCG criteria. Sperm is banked; three cycles of BEP follow, with bleomycin lung fibrosis explained and pulmonary function watched. Markers fall along the half-life curve, and a post-chemotherapy CT leaves a 2.5 cm retroperitoneal residue: excise it — the specimen may be necrosis, teratoma or viable tumour, and only resection of teratoma prevents the late, chemotherapy-resistant relapse. Had the histology been pure seminoma with a 2 cm residue, the same CT would be watched, with PET at eight weeks deciding intervention.
Where the exam sets its traps
The incision is the first trap: any option containing "trans-scrotal biopsy" is wrong, and the follow-up viva asks what scrotal violation costs — altered lymphatic fields, local recurrence, additional scrotal resection. The second is marker logic: "AFP raised, biopsy reports seminoma — next step?" — treat as NSGCT. The third is the residual mass: post-BEP 3 cm residual in NSGCT means surgery, not more chemotherapy; the same size residue in seminoma means observation with PET. The fourth is the emergency presentation: choriocarcinoma metastases bleed, and the haemoptysis or intracranial bleed stem expects chemotherapy started urgently rather than biopsy first. And the counselling mark: a 25-year-old about to start BEP is asked about fertility — the candidate who forgets sperm banking loses a mark that takes five seconds to earn.
Frequently asked questions
Why is orchidectomy inguinal rather than trans-scrotal?
The testis drains to para-aortic nodes; scrotal skin drains to inguinal nodes, so a scrotal incision violates compartments and risks local recurrence and inguinal spread. Inguinal radical orchidectomy with early cord clamping also limits tumour spill.
What does a raised AFP in an apparent seminoma signify?
Pure seminoma never raises AFP, so the tumour harbours non-seminomatous elements and is managed as NSGCT — marker-based staging, chemotherapy decisions and residual-mass surgery included.
How is stage I seminoma managed after orchidectomy?
Surveillance is preferred for compliant patients; single-dose carboplatin AUC 7 and, historically, para-aortic radiotherapy are alternatives. All approaches preserve near-normal cancer-specific survival.
How many BEP cycles, and by what rule?
Three cycles for good-prognosis metastatic disease (or four of EP), four for intermediate- and poor-prognosis disease per IGCCCG. Good prognosis requires a testis primary, no non-pulmonary visceral metastases, and markers below AFP 1000, hCG 5000 and LDH 1.5 times the upper limit.
Why excise a residual mass after chemotherapy for NSGCT?
Residual tissue over 1 cm may be necrosis, teratoma or viable malignancy, and neither teratoma nor resistant tumour responds to further chemotherapy. Surgical excision prevents late relapse and clarifies prognosis.