Local Examination Findings of Testicular Cancer
A painless solid testicular mass is pathognomonic for testicular tumor and warrants immediate urologic evaluation with scrotal ultrasound and serum tumor markers. 1
Clinical Presentation
The most common presentation of testicular cancer includes:
- Painless testicular mass or swelling - This is the classic finding, though patients may also present with testicular discomfort initially mistaken for epididymitis or orchitis 1
- Testicular enlargement - May be detected by the patient or incidentally on imaging 1
- Firm, non-tender intratesticular mass on palpation 1
Physical Examination Components
A complete examination must include 1:
- Bilateral testicular palpation - Assess size, consistency, and presence of masses in both testes
- Abdominal examination - Evaluate for retroperitoneal lymphadenopathy
- Supraclavicular fossa palpation - Check for nodal metastases
- Chest examination - Identify gynaecomastia, which may indicate β-HCG elevation 1
Immediate Diagnostic Workup
Imaging
High-frequency testicular ultrasound (>10 MHz) is mandatory to confirm the presence of a testicular mass and determine if it is intra- or extratesticular 1. Ultrasound can detect:
- Mass location (intratesticular vs extratesticular)
- Lesion size and characteristics
- Multifocal disease
- Contralateral testicular abnormalities 1
Important caveat: MRI should not be used as the initial evaluation tool for suspected testicular neoplasm 1. Scrotal ultrasound with Doppler is the first-line imaging modality 1.
Serum Tumor Markers
Obtain serum tumor markers BEFORE any treatment, including orchiectomy 1. Required markers include:
These markers are critical for diagnosis, staging, prognosis assignment, and treatment monitoring 1. Normal marker levels do not exclude disease - they have low sensitivity 1.
Key consideration: Elevated AFP indicates nonseminoma even with seminoma histology, and patients must be managed as nonseminoma 1. Hypogonadism and marijuana use may cause benign β-HCG elevations 1.
Laboratory Tests
If an intratesticular mass is identified, obtain 1:
- Complete blood count
- Creatinine and electrolytes
- Liver function tests
Pre-Treatment Counseling
Fertility Preservation
Sperm banking must be discussed before any therapeutic intervention 1. This is particularly critical for:
- Patients of reproductive age 1
- Those without a normal contralateral testis 1
- Patients with known subfertility 1
Sperm banking may be performed before or after orchiectomy, but must occur before subsequent therapy (radiation or chemotherapy) 1.
Counseling Topics
Patients should be counseled about 1:
- Risk of hypogonadism
- Risk of infertility
- Treatment options and their implications
Definitive Diagnosis and Initial Treatment
Radical Inguinal Orchiectomy
Inguinal orchiectomy with division of the spermatic cord at the internal inguinal ring is the standard initial intervention 1. Critical technical points:
- Use inguinal approach only - A scrotal approach is associated with higher local recurrence rates and must be avoided 1
- Perform timely but not emergent surgery 1
- Resect the tumor-bearing testicle along with the spermatic cord at the level of the internal inguinal ring 1
Exception: In patients with life-threatening metastatic disease and unequivocally elevated AFP or β-HCG, chemotherapy should be initiated immediately without waiting for orchiectomy 1.
Testis-Sparing Surgery (Highly Selective)
Testis-sparing surgery may be considered only in highly selected patients 1:
Indications:
- Single testicle with normal preoperative endocrine function 1
- Single tumor <2 cm located at lower pole 1
- Excellent patient compliance 1
- Small or indeterminate masses with negative tumor markers and normal contralateral testis 1
Requirements if performed:
- At least two additional testicular biopsies from remaining testicle to exclude germ cell neoplasia in situ (GCNIS) 1
- Intraoperative frozen section analysis 1
Contralateral Testicular Biopsy
Not routinely indicated 1, but consider in high-risk patients 1:
Contralateral biopsy is not indicated in patients >40 years without risk factors 1.
Post-Orchiectomy Management
Tumor Marker Reassessment
Repeat serum tumor markers after orchiectomy considering half-life kinetics 1:
Delayed declines or rising levels provide critical staging and prognostic information 1.
Staging Imaging
For confirmed germ cell tumors 1:
- Abdominopelvic CT scan - Assess retroperitoneal nodes 1
- Chest radiograph - Initial chest evaluation 1
- Chest CT - Indicated if abdominopelvic CT shows retroperitoneal adenopathy or chest X-ray is abnormal 1
Brain MRI or bone scan only if metastases to these organs are suspected 1.
Histologic Classification and Further Management
Management is dictated by 1:
- Histology: Pure seminoma vs. nonseminoma (includes mixed tumors)
- Stage: Based on TNM classification
- Risk classification: Per International Germ Cell Cancer Collaborative Group criteria
Critical distinction: When both seminoma and nonseminoma elements are present, manage as nonseminoma 1. Pure seminoma diagnosis requires pure seminoma histology AND normal AFP 1.
Common Pitfalls to Avoid
- Delaying evaluation of persistent testicular symptoms - Delay in diagnosis correlates with higher stage at presentation 1, 2
- Using scrotal approach for suspected tumors - Associated with higher local recurrence 1, 2
- Failing to obtain tumor markers before orchiectomy - These are essential for staging and prognosis 1
- Not discussing fertility preservation - Must occur before any treatment that may compromise fertility 1
- Misinterpreting elevated β-HCG - Can be elevated in hypogonadism and marijuana use 1
- Diagnosing seminoma with elevated AFP - This indicates nonseminoma regardless of histology 1