61 TESTICULAR TUMOURS
# 62 TESTICULAR TUMOURS
Testicular cancer is the commonest solid malignancy in men aged 20–40 years and one of the great success stories of oncology — five-year survival now exceeds 95%. For MRCS Part A it is high-yield because it ties together embryology (descent and lymphatic drainage), surgical anatomy (the spermatic cord), pathology (germ cell vs non-germ cell), tumour markers, and several classic scrotal differentials (hydrocele, varicocele, torsion, epididymo-orchitis).
Relevant anatomy
The testis develops retroperitoneally near the kidney and is dragged caudally through the abdominal wall by the gubernaculum, picking up its three concentric coverings as it traverses the inguinal canal. This descent has two consequences examiners love:
- Lymphatic drainage follows the embryological origin, not the surface location. The testis drains to para-aortic nodes at L1/L2, NOT the inguinal nodes. Only the scrotal skin drains to inguinal nodes.
- The processus vaginalis is the peritoneal pouch that descends with the testis. Persistence of patency causes a communicating hydrocele or an indirect inguinal hernia.
Coverings of the spermatic cord (outside in)
➡ External spermatic fascia — from external oblique aponeurosis
➡ Cremasteric fascia (and muscle) — from internal oblique
➡ Internal spermatic fascia — from transversalis fascia
Contents of the spermatic cord — "3 arteries, 3 nerves, 3 other"
- Arteries: testicular (from aorta at L2), cremasteric (from inferior epigastric), artery to vas (from inferior vesical)
- Nerves: genital branch of genitofemoral (motor to cremaster), ilioinguinal (runs ON the cord, not in it — supplies anterior scrotum), sympathetic fibres
- Other: vas deferens, pampiniform plexus of veins, lymphatics
The left testicular vein drains into the left renal vein; the right drains directly into the IVC. This asymmetry explains why varicoceles are 90% left-sided.
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Classification of testicular tumours
95% are germ cell tumours (GCTs). The remainder are sex cord-stromal tumours, lymphoma, and metastases.
| Seminoma | Non-seminomatous GCT (NSGCT) | |
|---|---|---|
| Peak age | 30–45y | 20–30y |
| Subtypes | Classical, spermatocytic, anaplastic | Yolk sac, embryonal, teratoma, choriocarcinoma |
| AFP | Never raised | Raised (yolk sac, embryonal) |
| β-hCG | Raised in ~15% | Markedly raised in choriocarcinoma |
| Radiosensitivity | Highly sensitive | Less sensitive — chemo-led |
| Histology | Sheets of clear cells, fibrous septa with lymphocytic infiltrate | Variable; Schiller-Duval bodies in yolk sac |
| Prognosis | Excellent (>95%) | Good but stage-dependent |
👩⚕️ The single most testable rule: AFP is never raised in a pure seminoma. If AFP is up, it is NOT a pure seminoma even if the histology looks seminomatous — treat as NSGCT.
Tumour markers — what each tells you
- AFP (alpha-fetoprotein) — yolk sac and embryonal elements. Half-life ~5–7 days.
- β-hCG — choriocarcinoma (very high), also ~15% of seminomas (low-level). Half-life ~24–36 hours.
- LDH — non-specific marker of tumour bulk and turnover; prognostic, not diagnostic.
Non-germ cell tumours
- Leydig cell tumour — secretes testosterone (precocious puberty in boys, gynaecomastia in adults from peripheral aromatisation).
- Sertoli cell tumour — usually benign, may cause gynaecomastia.
- Testicular lymphoma — commonest testicular tumour in men >60y; often bilateral; usually diffuse large B-cell.
Risk factors
- Cryptorchidism — 5–10× risk; orchidopexy reduces but does not abolish risk. The contralateral (descended) testis is also at increased risk, implying a field defect.
- Previous testicular cancer (contralateral risk ~2%)
- Family history (brother or father)
- Klinefelter's syndrome (47,XXY) — predisposes to mediastinal germ cell tumours in particular
- Infertility / poor semen quality
Presentation and assessment
Classic story: painless, firm, irregular testicular lump in a young man, sometimes following minor trauma that drew attention to the area (trauma does not cause cancer — it just discovers it). Up to 10% present with metastatic symptoms (back pain from para-aortic nodes, supraclavicular lymphadenopathy, haemoptysis, gynaecomastia from β-hCG).
Examination clues:
- Does NOT trans-illuminate (contrast with hydrocele which does)
- Cannot get above it if extending into the cord
- Heavy, hard, irregular
Investigations
1. Scrotal ultrasound — first-line; >95% sensitive for intratesticular mass.
2. Tumour markers — AFP, β-hCG, LDH before orchidectomy (baseline for response).
3. CT thorax/abdomen/pelvis — staging once diagnosis confirmed.
4. Sperm banking — offered before orchidectomy or chemotherapy.
Management
Radical inguinal orchidectomy — testis and spermatic cord removed via an inguinal incision with high cord ligation at the internal ring.
👩⚕️ NEVER trans-scrotal biopsy or excision. This violates fascial planes, contaminates scrotal skin (which drains to inguinal nodes) and exposes the patient to an unnecessary lymphatic compartment for metastasis. It is a classic SBA trap.
Adjuvant treatment depends on histology and stage:
- Seminoma — radiotherapy to para-aortic nodes for early disease; BEP (bleomycin, etoposide, cisplatin) chemotherapy for advanced disease.
- NSGCT — BEP chemotherapy; retroperitoneal lymph node dissection for residual masses.
Differentials — the scrotal lump SBA
| Condition | Key features |
|---|---|
| Testicular tumour | Painless, hard, irregular; does NOT trans-illuminate; USS |
| Hydrocele | Fluid around testis; trans-illuminates; can get above it |
| Varicocele | "Bag of worms"; 90% left; disappears lying down |
| Epididymal cyst | Separate from testis, above and behind; trans-illuminates |
| Epididymo-orchitis | Painful, hot, tender; Prehn's sign positive |
| Torsion | Sudden severe pain, high-riding, absent cremasteric reflex |
Hydrocele
Fluid in the tunica vaginalis.
- Communicating (paediatric) — patent processus vaginalis; varies with crying/standing; usually resolves by 2y.
- Non-communicating (adult) — primary (idiopathic) or secondary to tumour/infection/trauma. Always image with USS in adults to exclude underlying tumour.
Varicocele
Dilated pampiniform plexus. 90% left-sided because the left testicular vein drains at right angles into the left renal vein and is compressed between the SMA and aorta ("nutcracker"). Associated with subfertility from raised scrotal temperature.
👩⚕️ A new right-sided varicocele in an adult, or any varicocele that does not decompress when lying flat, raises suspicion of a renal cell carcinoma obstructing the renal vein/IVC. Image the kidneys.
Epididymo-orchitis vs torsion
| Epididymo-orchitis | Testicular torsion | |
|---|---|---|
| Onset | Gradual (hours-days) | Sudden (minutes) |
| Age | Any | <20y (peak 12-18) |
| Cause | <35y: Chlamydia/Gonorrhoea; >35y: E. coli, UTI organisms | Bell-clapper deformity |
| Cremasteric reflex | Present | Absent |
| Prehn's sign | Pain relieved by elevation | Pain not relieved |
| Position | Normal lie | High-riding, horizontal |
| Management | Antibiotics | Surgical emergency — explore within 6 hours; bilateral orchidopexy |
👩⚕️ If torsion is even possible, explore — do NOT wait for USS. Time = testis. After 6 hours salvage rate falls steeply; after 24 hours it is essentially zero.
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Test yourself
Which are the most appropriate tumour markers to investigate testicular tumours?
- ((PSA and AFP::PSA is a prostate marker — not used for testicular tumours.))
- ((AFP, β-hCG and LDH::☑️ The core trio — AFP and β-hCG are specific; LDH is a bulk/prognostic marker.))
- ((β-hCG and PSA::Misses AFP; PSA is irrelevant.))
- ((CEA and CA125::CEA is colorectal; CA125 is ovarian.))
What is raised in the yolk sac variant of testicular tumour?
- ((AFP::☑️ Yolk sac tumours secrete AFP; Schiller-Duval bodies on histology.))
- ((β-hCG::Choriocarcinoma — syncytiotrophoblast origin.))
- ((LDH::Non-specific bulk marker; not characteristic of yolk sac.))
- ((PSA::Prostate marker — irrelevant.))
👩⚕️ AFP is never raised in pure seminoma — if it is, treat as NSGCT regardless of light microscopy.
A middle-aged man has a testicular mass. Histology shows tumour cells separated by fibrous septa with lymphocytes. Diagnosis?
- ((Classical seminoma::☑️ Sheets of uniform clear cells, fibrous septa with lymphocytic infiltrate.))
- ((Spermatocytic seminoma::Older men; lacks lymphocytic septa; better prognosis.))
- ((Embryonal carcinoma::Pleomorphic cells with necrosis and haemorrhage.))
- ((Teratoma::Tissues from multiple germ layers — no septal lymphocytes.))
A 15-year-old boy with an undescended testis presents with a testicular tumour. Diagnosis?
- ((Seminoma::☑️ Cryptorchidism is the strongest risk factor; seminoma is the commonest resulting malignancy.))
- ((Yolk sac tumour::Commonest in boys under 3 — not the cryptorchidism link in teens.))
- ((Teratoma::Weaker association with undescended testis.))
- ((Leydig cell tumour::Sex cord-stromal; not linked to cryptorchidism.))
A 20-year-old man was struck in the groin six weeks ago. He now has a painless, hard, irregular testicular swelling and supraclavicular lymphadenopathy. Diagnosis?
- ((Seminoma::☑️ Classic painless hard mass in a young man; supraclavicular nodes = advanced disease.))
- ((Epididymo-orchitis::Painful and tender, not hard and irregular.))
- ((Testicular torsion::Acute severe pain — not painless weeks later.))
- ((Haematocele::Post-traumatic blood collection; fluctuant, not hard.))
👩⚕️ Trauma does not cause testicular cancer — it draws attention to a lump that was already there.
A patient being investigated for testicular cancer has normal AFP and β-hCG. Most likely diagnosis?
- ((Yolk sac::AFP raised in ~95% of yolk sac tumours.))
- ((Choriocarcinoma::β-hCG markedly raised in essentially all cases.))
- ((Embryonal::AFP raised in ~70%, β-hCG in 40–60%.))
- ((Teratoma::Mixed adult teratomas usually have raised markers.))
- ((Seminoma::☑️ ~70% of seminomas have normal AFP and β-hCG.))
A 58-year-old man presents with a painless testicular swelling and a family history of testicular cancer. What is the tumour marker for testicular teratoma?
- ((AFP::☑️ Adult teratomas are usually mixed with yolk sac elements — AFP rises.))
- ((CEA::Colorectal and some gastric cancers.))
- ((CA125::Ovarian cancer marker.))
- ((ALP::Bone and hepatobiliary disorders.))
- ((S100::Melanoma and neural crest tumours.))
Where do testicular tumours primarily metastasise via lymphatics?
- ((Superficial inguinal nodes::Drain the scrotal skin, not the testis.))
- ((Deep inguinal nodes::Drain the glans and lower limb.))
- ((Para-aortic nodes at L1/L2::☑️ Testis descended from the posterior abdominal wall — lymphatics follow embryological origin.))
- ((Internal iliac nodes::Drain pelvic viscera, not testis.))
👩⚕️ Classic trap: scrotal skin drains to inguinal nodes; the testis drains to para-aortic. This is why trans-scrotal orchidectomy is forbidden.
What is the correct surgical approach for a suspected testicular tumour?
- ((Trans-scrotal excisional biopsy::Forbidden — violates fascial planes and seeds inguinal nodes.))
- ((Trans-scrotal needle biopsy::Same problem — contaminates a new lymphatic compartment.))
- ((Radical inguinal orchidectomy::☑️ Inguinal incision with high cord ligation at the internal ring.))
- ((Partial orchidectomy via scrotum::Inadequate clearance and wrong route.))
A 30-year-old man has a new left-sided "bag of worms" scrotal swelling that decompresses on lying flat. What is the diagnosis?
- ((Varicocele::☑️ Dilated pampiniform plexus; 90% left because the left testicular vein drains into the left renal vein.))
- ((Hydrocele::Trans-illuminates and does not decompress on lying flat.))
- ((Indirect inguinal hernia::Reducible but presents as a cord/groin swelling, not "bag of worms".))
- ((Epididymal cyst::Discrete cyst above and behind the testis.))
👩⚕️ A new right-sided varicocele in an adult mandates renal imaging — think renal cell carcinoma obstructing the right testicular vein at the IVC.
A 16-year-old presents with sudden severe testicular pain. The testis is high-riding and the cremasteric reflex is absent. Best next step?
- ((Scrotal ultrasound::Useful but must not delay surgery if torsion is clinically suspected.))
- ((IV antibiotics and admit::Treats epididymo-orchitis — wrong diagnosis here.))
- ((Immediate scrotal exploration::☑️ Surgical emergency — explore within 6 hours; bilateral orchidopexy.))
- ((Analgesia and reassess in 6 hours::Salvage rate collapses after 6 hours.))
A 40-year-old man with a unilateral painless scrotal swelling that trans-illuminates. Best initial investigation?
- ((Scrotal ultrasound::☑️ Always image an adult hydrocele — exclude an underlying testicular tumour.))
- ((Aspiration::Therapeutic only — never before excluding malignancy.))
- ((CT abdomen/pelvis::Reserved for staging confirmed cancer.))
- ((Tumour markers alone::Markers can be normal in seminoma — imaging is mandatory.))
Revision summary
- 95% of testicular tumours are germ cell — seminoma (commonest adult, 30–45y) vs NSGCT (younger, 20–30y; yolk sac, embryonal, teratoma, choriocarcinoma).
- Tumour markers: AFP (yolk sac, embryonal — never seminoma), β-hCG (choriocarcinoma, ~15% seminomas), LDH (bulk).
- Lymphatic drainage: testis → para-aortic L1/L2 (embryological); scrotal skin → inguinal.
- Spermatic cord coverings: external spermatic, cremasteric, internal spermatic. Contents: 3 arteries, 3 nerves, vas + pampiniform + lymphatics.
- Risk factors: cryptorchidism (5–10×), FHx, previous contralateral tumour, Klinefelter's.
- Investigation: USS first-line, markers before orchidectomy, CT TAP staging, sperm banking first.
- Treatment: radical inguinal orchidectomy — NEVER trans-scrotal. Seminoma radiosensitive; NSGCT chemo (BEP).
- Varicocele: 90% left; new right-sided → think renal cell carcinoma.
- Hydrocele: trans-illuminates; image adults to exclude tumour.
- Torsion vs EO: torsion = sudden, high-riding, absent cremasteric reflex, Prehn negative → explore within 6 hours. EO = gradual, Prehn positive; <35y STI organisms, >35y E. coli.
- Testicular lymphoma: commonest testicular tumour in men >60y; often bilateral.