AKT · Renal & urology/Scrotum & male GU

Testicular cancer

Germ-cell tumour (seminoma or non-seminomatous) — commonest solid cancer in young men

Overview

The commonest solid malignancy in young men (20–40), almost always a germ-cell tumour — seminoma or non-seminomatous germ-cell tumour (NSGCT). It presents as a painless, hard testicular lump. Tumour markers (AFP, β-hCG, LDH) aid diagnosis and monitoring. It is highly curable, even when metastatic. Cryptorchidism (undescended testis) is a key risk factor.

Recognise

Painless, hard, craggy testicular lump/swelling that does not transilluminate; sometimes a dull ache or a reactive hydrocoele
Young man (20–40); risk factors — cryptorchidism (undescended testis), previous testicular cancer, family history, infertility
Markers: AFP raised in NSGCT (NOT in pure seminoma), β-hCG in both, LDH (tumour bulk); lymphatic spread to para-aortic nodes (not inguinal)

Red flags

Any solid intratesticular mass → urgent urology referral (don't aspirate/biopsy through the scrotum)
Metastatic symptoms (back pain from para-aortic nodes, chest symptoms) → staging

Differentials & how to tell them apart

Hydrocoeletransilluminates, can't get above it if communicating; cystic not solid

Epididymal cyst / epididymo-orchitisseparate from/posterior to the testis (cyst) or painful with infection

Varicocoele'bag of worms', often left, decompresses lying down

Investigations

Scrotal ultrasound (solid intratesticular mass — the key test); tumour markers AFP/β-hCG/LDH (before and after orchidectomy); staging CT chest/abdomen/pelvis; diagnosis is confirmed at radical inguinal orchidectomy (NOT trans-scrotal biopsy).

Management

Radical inguinal orchidectomy (sperm bank first) + stage/type-guided surveillance/chemo/radiotherapy

1A solid intratesticular mass on ultrasound → urgent urology; send AFP/β-hCG/LDH and stage with CT. Confirm at radical INGUINAL orchidectomy (offer sperm banking first).Gate: Never biopsy/aspirate trans-scrotally (seeding) — the inguinal approach is mandatory; AFP is NOT raised in pure seminoma (its elevation means NSGCT).
2Stage- and type-guided management: surveillance or adjuvant therapy; seminoma is very radiosensitive; chemotherapy (BEP) for NSGCT/metastatic disease — highly curable even when advanced.

Radical INGUINAL orchidectomy — diagnostic and therapeutic; via the groin (never trans-scrotal — seeding risk); offer sperm banking first

Surveillance / adjuvant therapy by stage and type — seminoma is very radiosensitive; chemotherapy (e.g. BEP) for higher-stage/NSGCT

Chemotherapy for metastatic disease — highly curable even when metastatic (platinum-based)

Sperm banking + prosthesis discussion — fertility preservation before treatment

Key points

Painless hard testicular lump in a young man = germ-cell cancer → scrotal USS + AFP/β-hCG/LDH, radical INGUINAL orchidectomy (never trans-scrotal). AFP raised = NSGCT (not pure seminoma); β-hCG in both. Spreads to PARA-AORTIC nodes. Cryptorchidism is the key risk factor. Highly curable.

Monitor & prognosis

Tumour markers, staging surveillance; fertility; long-term treatment effects.

Excellent — among the most curable cancers, even when metastatic.

Source: NICE NG12; BAUS; cross-ref child_health (cryptorchidism)