Testicular cancer is uncommon overall but the most common solid malignancy in men roughly 15–40 — and it is among the most curable cancers in all of medicine, with cure rates above 95% for localized disease and above 70% even for widely metastatic…
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Didactics
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Testicular cancer
is uncommon overall but the most common solid malignancy in men
roughly 15–40 — and it is among the most curable cancers in all
of medicine, with cure rates above 95% for localized disease and
above 70% even for widely metastatic disease. That curability is
entirely dependent on managing it correctly from the first visit. The
cardinal rule: work up a suspicious testicular mass by the correct
pathway and NEVER perform a trans-scrotal biopsy.
11.1 Presentation and work-up
Classic
presentation: a painless testicular lump, firm swelling, or a
sensation of heaviness. A minority present with acute pain (from
hemorrhage into the tumor) and are misdiagnosed as epididymitis —
if “epididymitis” does not resolve on antibiotics, image it.
Risk
factors: cryptorchidism (even after orchiopexy, and the risk
applies to the contralateral testis too), a personal or family
history of testicular cancer, prior germ cell neoplasia in situ,
infertility, and Klinefelter syndrome.
First
test: scrotal ultrasound — a solid, hypoechoic, hypervascular
INTRAtesticular lesion is cancer until proven otherwise.
(Extratesticular lesions are almost always benign.)
Serum
tumor markers BEFORE orchiectomy: AFP, beta-hCG, and LDH. They
must be drawn pre-operatively — they aid diagnosis, they are
essential for staging and risk classification, and their
post-operative decline (by known half-lives) tells you whether
disease remains.
Staging:
CT of the chest, abdomen, and pelvis after diagnosis, to assess
the retroperitoneal nodes (the primary landing zone, following the
testicular lymphatics up to the renal hilum — which is exactly why
a scrotal incision is forbidden: it violates the lymphatic drainage
and puts the inguinal nodes at risk).
The cardinal rules
Do NOT biopsy the testis
trans-scrotally, and do NOT aspirate it. This risks tumor seeding
and alters the lymphatic drainage, converting a clean
retroperitoneal problem into a scrotal/inguinal one.
The correct diagnostic AND
therapeutic procedure is a RADICAL INGUINAL ORCHIECTOMY —
removal through a groin incision with high ligation of the
spermatic cord at the internal ring.
Draw tumor markers BEFORE
the orchiectomy. You cannot go back and get them.
OFFER SPERM BANKING BEFORE ANY TREATMENT — surgery,
chemotherapy, and radiation all impair fertility, and these are
young men. This conversation is not optional.
11.2 Tumor types, markers, and treatment
Type
Markers
Notes
Seminoma (~50%)
hCG may be MILDLY elevated; AFP is NEVER elevated
Exquisitely radiosensitive and chemosensitive; excellent cure
rates. Tends to present at an earlier stage and in slightly older
men
Non-seminomatous GCT (NSGCT)
AFP and/or hCG often elevated
Includes embryonal carcinoma, yolk sac tumor, choriocarcinoma,
and teratoma — usually a mixed tumor. More aggressive; presents
younger
The marker rule that matters most
An ELEVATED AFP means the
tumor has a non-seminomatous component — REGARDLESS of what the
pathology report says. If the pathology says “pure seminoma”
but the AFP is elevated, it is treated as an NSGCT. Do not let
this be missed.
Very high hCG can cause
gynecomastia and, rarely, hyperthyroidism (hCG cross-reacts with
the TSH receptor).
Teratoma is marker-negative, chemo-RESISTANT, and can
undergo malignant transformation — it must be resected, not
treated medically.
After
orchiectomy, management depends on histology, stage, and marker
trends: surveillance (the preferred option for many stage I
patients), chemotherapy (BEP — bleomycin, etoposide, cisplatin),
radiation (seminoma only), or retroperitoneal lymph node dissection
(RPLND). Even widely metastatic disease is frequently CURABLE with
cisplatin-based chemotherapy — this is a cancer where you do not
give up.
Post-chemotherapy
residual masses: in NSGCT, a residual mass > 1 cm is resected
(it may harbor teratoma or viable tumor). In seminoma, a residual
mass ≥ 3 cm is evaluated with FDG PET (≥ 6 weeks after chemo) to
decide whether it contains viable tumor (Chapter 21).
Survivorship — these men live for
decades
Monitor with tumor markers,
exams, and imaging on a defined schedule; most relapses occur
within the first 2 years.
Address long-term effects:
fertility, hypogonadism (a single remaining testis usually
maintains testosterone, but CHECK it if symptomatic — Chapter
22), and the late toxicities of chemotherapy (cardiovascular
disease, secondary malignancy, neuropathy, ototoxicity,
Raynaud's, and bleomycin pulmonary fibrosis).
Discuss a testicular prosthesis — it matters to many
young men and is easy to forget to offer.
Clinical Pathway
Click any node to expand
Testicular cancer is the most common solid malignancy in men roughly 15-40 and among the most curable cancers in medicine — but only if the first visit is handled correctly. The cardinal rule: work a suspicious testicular mass up by the correct pathway and NEVER perform a trans-scrotal biopsy.
From the presenting lump through markers, ultrasound, and radical inguinal orchiectomy — in the right order.
Select a box to open its teaching details.
Classic presentation
A painless testicular lump, firm swelling, or a sensation of heaviness
A minority present with acute pain from hemorrhage into the tumor — and are misdiagnosed as epididymitis
Pitfalls
If "epididymitis" does not resolve on antibiotics, image it. This is the classic missed testicular cancer.
Ch 11.1 — presentation
Risk factors
Cryptorchidism — even after orchiopexy, and the risk applies to the contralateral testis as well
Personal or family history of testicular cancer
Prior germ cell neoplasia in situ
Infertility
Klinefelter syndrome
Ch 11.1 — risk factors
What you are looking for
A solid, hypoechoic, hypervascular INTRAtesticular lesion is cancer until proven otherwise.
Extratesticular lesions are almost always benign
Ch 11.1 — first test
Time-critical
Order
AFP
beta-hCG
LDH
Why pre-operatively
They aid diagnosis
They are essential for staging and risk classification
Their post-operative decline by known half-lives tells you whether disease remains
Pitfalls
Markers drawn after the orchiectomy are not recoverable — the staging information is lost permanently.
Ch 11.1 — tumor markers
Time-critical
Never do
Do NOT biopsy the testis trans-scrotally
Do NOT aspirate it
Both risk tumor seeding and alter the lymphatic drainage
The anatomic reason
Testicular lymphatics drain up to the renal hilum — the retroperitoneum is the primary landing zone. A scrotal incision violates that drainage and puts the inguinal nodes at risk.
Ch 11.1 — the cardinal rules
What it is
Removal through a groin incision
High ligation of the spermatic cord at the internal ring
Ch 11.1 — the cardinal rules
Time-critical
Why
Surgery, chemotherapy, and radiation all impair fertility
These are young men — the window to bank closes once treatment starts
Ch 11.1 — the cardinal rules
What you are looking for
The retroperitoneum is the primary landing zone, following the testicular lymphatics up to the renal hilum.
Ch 11.1 — staging
Seminoma vs. NSGCT, the one marker rule that overrides pathology, and what happens after orchiectomy.
Select a box to open its teaching details.
The two families
Seminoma (~50% of cases)
Non-seminomatous germ cell tumor (NSGCT) — usually a mixed tumor
Ch 11.2 — tumor types
Which tumor family are you dealing with?
Markers
hCG may be MILDLY elevated
AFP is NEVER elevated in a true pure seminoma
Notes
Exquisitely radiosensitive and chemosensitive
Excellent cure rates
Tends to present at an earlier stage and in slightly older men
Ch 11.2 — tumor types
Markers
AFP and/or hCG often elevated
Components
Embryonal carcinoma
Yolk sac tumor
Choriocarcinoma
Teratoma
Ch 11.2 — tumor types
Time-critical
The rule that matters most
An ELEVATED AFP means the tumor has a non-seminomatous component, REGARDLESS of what the pathology report says.
If pathology says "pure seminoma" but the AFP is elevated, it is treated as an NSGCT
Pitfalls
Treating a marker-elevated "seminoma" as a seminoma undertreats a non-seminomatous tumor.
Ch 11.2 — the marker rule
Very high hCG
Can cause gynecomastia
Rarely hyperthyroidism — hCG cross-reacts with the TSH receptor
Teratoma
Marker-negative
Chemo-RESISTANT
Can undergo malignant transformation
It must be resected, not treated medically
Ch 11.2 — the marker rule
Options
Surveillance — the preferred option for many stage I patients
Chemotherapy — BEP (bleomycin, etoposide, cisplatin)
Radiation — seminoma only
Retroperitoneal lymph node dissection (RPLND)
Framing for the patient
Even widely metastatic disease is frequently CURABLE with cisplatin-based chemotherapy — this is a cancer where you do not give up. Cure rates exceed 95% for localized disease and 70% even for widely metastatic disease.
Ch 11.2 — treatment
Residual mass after chemotherapy — what next?
Rule
In NSGCT, a residual mass > 1 cm is resected
Ch 11.2 — post-chemotherapy residual masses
Rule
In seminoma, a residual mass ≥ 3 cm is evaluated with FDG PET
Perform the PET ≥ 6 weeks after chemo (Chapter 21)
The question the scan answers: does it contain viable tumor?
Ch 11.2 — post-chemotherapy residual masses
These men live for decades — the follow-up visit has its own agenda.
Select a box to open its teaching details.
Why this matters
Cure rates above 95% for localized disease and above 70% for widely metastatic disease mean the survivorship agenda is as important as the oncologic one.
Ch 11.2 — survivorship
Timing
Most relapses occur within the first 2 years
Ch 11.2 — survivorship
Address
Whether sperm was banked before treatment
Current fertility intentions
Ch 11.2 — survivorship
Rule
A single remaining testis usually maintains testosterone
But CHECK it if symptomatic (Chapter 22)
Ch 11.2 — survivorship
Late effects to look for
Cardiovascular disease
Secondary malignancy
Neuropathy
Ototoxicity
Raynaud's
Bleomycin pulmonary fibrosis
Ch 11.2 — survivorship
Pitfalls
This is the item most commonly left un-offered. Raise it rather than waiting for the patient to ask.