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Reproductive · Clinical Topics
Testicular Cancer
Testicular cancer is the most common malignancy in men aged 15-35. The majority are Germ Cell Tumours (GCTs), classified into Seminomas and Non-Seminomatous Germ Cell Tumours (NSGCTs). It is highly treatable, even when metastatic, with orchidectomy and chemotherapy.
📌 Learning Objectives
- Describe the epidemiology and risk factors for testicular cancer.
- Differentiate between seminoma and non-seminomatous germ cell tumours (NSGCTs) based on clinical features, histology, and tumour markers.
- Outline the key clinical presentation and diagnostic approach for suspected testicular cancer.
- Explain the principles of management, including radical inguinal orchidectomy and adjuvant therapies.
- Identify the importance of tumour markers and imaging in diagnosis, staging, and monitoring of testicular cancer.
- Recognise common pitfalls and high-yield facts related to testicular cancer for MLA and OSCEs.
📋 Overview
Testicular cancer is a crucial topic for finals due to its prevalence in young men and excellent prognosis if managed correctly. While rare overall, it's the most common cancer in men aged 15-35 years in the UK. Approximately 95% are Germ Cell Tumours (GCTs), subdivided into Seminomas (typically 30-40s, more radiosensitive) and Non-Seminomatous Germ Cell Tumours (NSGCTs, typically 20-30s, more aggressive). Key risk factors include cryptorchidism (even if corrected), a personal history of contralateral testicular cancer, and family history. Early diagnosis is vital. Any firm, painless testicular lump must be considered malignant until proven otherwise. Management always begins with a radical inguinal orchidectomy; trans-scrotal biopsy is an absolute contraindication.
🔬 Basic Science
Testicular GCTs originate from 'germ cell neoplasia in situ' (GCNIS) within the seminiferous tubules. Seminomas are histologically uniform, resembling primordial germ cells, and are highly radiosensitive. NSGCTs are more heterogeneous and include subtypes like yolk sac tumour (produces AFP), choriocarcinoma (produces β-hCG), embryonal carcinoma, and teratoma. The specific tumour markers (AFP, β-hCG) are crucial for diagnosis and monitoring, as they correlate with specific histological components. Testicular lymphatic drainage follows the embryological descent of the testes, leading to the para-aortic lymph nodes at the level of L1/L2 (near the renal arteries). Haematogenous spread most commonly targets the lungs.
🏥 Clinical Relevance
Patients typically present with a painless, firm, or hard testicular lump, often discovered incidentally or after minor trauma. Be aware that ~10% may present with acute pain due due to intratumoural haemorrhage, mimicking testicular torsion – always consider malignancy. Advanced disease can manifest as a palpable abdominal mass (para-aortic nodes), supraclavicular lymphadenopathy, or pulmonary symptoms (e.g., dyspnoea, haemoptysis from lung metastases). Gynaecomastia can occur if the tumour secretes β-hCG, stimulating oestrogen production. Differentiating a testicular mass from a hydrocele (transilluminates, separate from testis), epididymal cyst/spermatocele (separate from testis, often soft/cystic), or epididymitis (painful, inflammatory) is a common OSCE scenario. Always refer any suspicious testicular mass urgently via the 2-week wait pathway.
🧪 Investigations
Examination: Palpate the scrotum. A firm, non-tender, non-transilluminable mass within the body of the testis is highly suspicious. Note if you can 'get above' the mass (suggests epididymal/paracord structure vs. intratesticular). Imaging: Urgent scrotal ultrasound (2WW referral). This will confirm an intratesticular lesion, typically hypoechoic. Bloods: Tumour markers – Alpha-fetoprotein (AFP) is elevated in NSGCTs (never pure seminoma). Beta-human chorionic gonadotropin (β-hCG) can be elevated in both seminomas and NSGCTs (especially choriocarcinoma). Lactate Dehydrogenase (LDH) is a non-specific marker of tumour burden. Staging: CT Chest/Abdomen/Pelvis is essential to identify metastatic disease, particularly para-aortic lymphadenopathy and lung metastases.
💊 Management
Acute Management: Any suspected testicular mass requires urgent referral (2WW). Definitive Surgical Management: Radical Inguinal Orchidectomy is the initial treatment for all suspected cases. This involves an incision in the groin, ligating the cord structures high up, and removing the entire testis. A testicular prosthesis can be offered. Further management depends on histology (seminoma vs. NSGCT) and stage (Royal Marsden staging).
- Seminoma (Stage I): Active surveillance, single dose Carboplatin, or radiotherapy (highly radiosensitive).
- NSGCT (Stage I): Active surveillance or chemotherapy.
- Metastatic Disease (both types): Combination chemotherapy, typically BEP regimen (Bleomycin, Etoposide, Cisplatin). Monitor for side effects: pulmonary fibrosis (Bleomycin), nephrotoxicity/ototoxicity (Cisplatin). Patients must be offered sperm banking prior to chemotherapy or orchidectomy due to potential fertility impairment.
- Seminoma (Stage I): Active surveillance, single dose Carboplatin, or radiotherapy (highly radiosensitive).
- NSGCT (Stage I): Active surveillance or chemotherapy.
- Metastatic Disease (both types): Combination chemotherapy, typically BEP regimen (Bleomycin, Etoposide, Cisplatin). Monitor for side effects: pulmonary fibrosis (Bleomycin), nephrotoxicity/ototoxicity (Cisplatin). Patients must be offered sperm banking prior to chemotherapy or orchidectomy due to potential fertility impairment.
Revision Resources – expand the sections below for high-yield notes, exam pearls, key facts and further reading.
MLA High-Yield Notes & Quick Revision ⌄
SBA Trap: The absolute contraindication of trans-scrotal biopsy for a suspected testicular tumour. This risks tumour seeding into the scrotal lymphatics, changing the drainage pattern from para-aortic to inguinal, which impacts staging and treatment. Always radical inguinal orchidectomy.
OSCE Pearl: When examining the scrotum, always ask if you can 'get above' the mass. If not, it's likely intratesticular. Remember the key differentials: hydrocele (transilluminates), epididymal cyst/spermatocele (separate from testis, often superior/posterior), epididymitis (painful, inflammatory signs).
Viva Question: What are the key tumour markers and what do they tell you? (AFP for NSGCT, β-hCG for both, LDH for bulk). What is the lymphatic drainage of the testes? (Para-aortic nodes, L1/L2 level).
Common Misconception: Testicular cancer is always painful. (No, usually painless).
Must-know association: Cryptorchidism and increased risk of testicular cancer. Even if corrected, the risk remains.
OSCE Pearl: When examining the scrotum, always ask if you can 'get above' the mass. If not, it's likely intratesticular. Remember the key differentials: hydrocele (transilluminates), epididymal cyst/spermatocele (separate from testis, often superior/posterior), epididymitis (painful, inflammatory signs).
Viva Question: What are the key tumour markers and what do they tell you? (AFP for NSGCT, β-hCG for both, LDH for bulk). What is the lymphatic drainage of the testes? (Para-aortic nodes, L1/L2 level).
Common Misconception: Testicular cancer is always painful. (No, usually painless).
Must-know association: Cryptorchidism and increased risk of testicular cancer. Even if corrected, the risk remains.
Scrotal lump (history and examination)
Abdominal pain/mass (metastatic disease)
Gynaecomastia (hormonal effects)
Weight loss/fatigue (systemic symptoms of malignancy)
Acute scrotum (differential diagnosis)
- Testicular cancer is the most common malignancy in men aged 15-35.
- The majority are Germ Cell Tumours (GCTs): Seminomas and NSGCTs.
- Risk factors include cryptorchidism and family history.
- Painless, firm testicular lump is the classic presentation.
- Urgent scrotal ultrasound is the first-line imaging.
- Key tumour markers: AFP (NSGCT), β-hCG (both), LDH (tumour burden).
Exam Pearls ⌄
⭐ High Yield
Most common cancer in men aged 15-35 in the UK.
95% are Germ Cell Tumours (GCTs): Seminomas (radiosensitive) and NSGCTs (more aggressive).
Classic presentation: Painless, firm, non-transilluminable lump within the testis.
Major risk factor: Cryptorchidism (undescended testis), even if surgically corrected.
Tumour markers (AFP, β-hCG, LDH) are essential for diagnosis, staging, and monitoring.
Definitive surgical management: Radical Inguinal Orchidectomy (NEVER trans-scrotal).
Lymphatic drainage: Para-aortic lymph nodes (L1/L2 level).
High cure rates, even with metastatic disease, often using BEP chemotherapy.
💡 Clinical Pearl
Testicular Torsion: Can mimic acute testicular cancer presentation if there's intratumoural haemorrhage. Torsion is typically acute, severe pain with absent cremasteric reflex.
Epididymitis: Inflammatory condition, usually painful, tender, and associated with urinary symptoms or STIs. Testis itself is usually normal.
Hydrocele: Fluid collection around the testis, transilluminates, and the testis can be palpated separately.
Epididymal Cyst/Spermatocele: Benign cystic lesions separate from the testis, often superior or posterior, usually soft and non-tender.
⚠️ Exam Tip — Common Mistakes
Performing a trans-scrotal biopsy for suspected testicular cancer.
Assuming all testicular lumps are benign or inflammatory.
Failing to refer suspicious testicular lumps urgently (2WW).
Not considering testicular cancer in a young man presenting with gynaecomastia or abdominal mass.
Confusing the lymphatic drainage of the testes with that of the scrotum.
Key Facts ⌄
Most common cancer in men aged 15-35 in the UK.
95% are Germ Cell Tumours (GCTs): Seminomas (radiosensitive) and NSGCTs (more aggressive).
Classic presentation: Painless, firm, non-transilluminable lump within the testis.
Major risk factor: Cryptorchidism (undescended testis), even if surgically corrected, increases risk 3-5x.
Tumour markers (AFP, β-hCG, LDH) are essential for diagnosis, staging, and monitoring.
First-line imaging: Scrotal ultrasound (urgent 2-week wait referral).
Definitive surgical management: Radical Inguinal Orchidectomy (NEVER trans-scrotal).
High cure rates, even with metastatic disease, often using BEP chemotherapy (Bleomycin, Etoposide, Cisplatin).
Lymphatic drainage: Para-aortic lymph nodes (L1/L2 level), NOT inguinal (unless scrotal invasion).
Related Topics ⌄
References ⌄
- NICE Guideline (NG12) - Suspected cancer
- European Association of Urology (EAU) Guidelines
- Kumar & Clark's Clinical Medicine
Further Resources
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