The testicular mass: the cancer that you cure
A young man, a painless lump, and one of oncology's great success stories — even widely metastatic disease is often curable. But the cures depend on getting the first moves exactly right: the markers before the knife, the inguinal approach always, and the sperm bank before the chemo.
The one-liner
A solid intratesticular mass is cancer until proven otherwise. Draw tumor markers (AFP, β-hCG, LDH) BEFORE treatment, then radical INGUINAL orchiectomy — never trans-scrotal. Offer sperm banking before any therapy. A raised AFP means non-seminoma regardless of what the pathology says.
Testicular cancer is the disease that rewards getting the basics right and punishes improvisation. It strikes young men, it usually announces itself as a painless lump, and it is one of the most curable solid cancers in all of medicine — even when it has spread widely. That curability is precisely why the early, technical decisions matter so much: a wrong first incision or a forgotten tube of blood can compromise a cancer that was otherwise eminently beatable.
The frame
A firm, solid, intratesticular mass is testicular cancer until proven otherwise. Scrotal ultrasound is the imaging that confirms it sits within the testis (as opposed to an epididymal or extratesticular lesion, which is usually benign). The germ cell tumors split into seminoma and non-seminoma, and that distinction — refined by the markers — drives everything that follows.
Markers before the knife
Draw the serum tumor markers before any treatment, because they are diagnostic, prognostic, and the baseline you will track forever:
- AFP (alpha-fetoprotein)
- β-hCG
- LDH (tumor burden)
A raised AFP means non-seminoma — full stop. Pure seminoma does not make AFP, so an elevated level overrides a “seminoma” on the slide and the tumor is treated as a non-seminoma.
What everyone gets wrong
The two cardinal sins are biopsying through the scrotum and forgetting fertility. Never biopsy a testicular mass trans-scrotally — a trans-scrotal approach violates tissue planes and changes the lymphatic drainage from the para-aortic nodes to the inguinal nodes, seeding a new compartment with cancer. The definitive procedure is a radical inguinal orchiectomy, clamping the cord at the internal ring through a groin incision. And because treatment threatens fertility, offer sperm banking before any therapy — orchiectomy, chemo, or RPLND.
After the orchiectomy: stage, then tailor
Staging is a CT chest/abdomen/pelvis plus post-orchiectomy markers(a marker that doesn’t normalize signals residual disease). The lymphatic spread is predictable — to the retroperitoneal para-aortic nodes first — which is why those nodes feature in both imaging and surgery. Prognosis in metastatic disease is grouped by the IGCCCG classification into good, intermediate, and poor risk, based on marker levels and sites of spread.
The treatment, by type and stage
Seminoma is exquisitely radio- and chemo-sensitive:
- Stage I — surveillance is preferred (most are cured by orchiectomy alone); single-agent carboplatin is an alternative.
- Advanced — platinum-based chemotherapy.
Non-seminoma is more aggressive but still highly curable:
- Stage I — surveillance for most, with RPLND or chemo for higher-risk features (e.g. lymphovascular invasion).
- Advanced — BEP chemotherapy (bleomycin, etoposide, cisplatin), 3 or 4 cycles by IGCCCG risk.
A residual mass after chemotherapy in non-seminoma is taken out — post-chemo RPLND — because it may harbor teratoma (chemo-resistant) or viable cancer.
If you remember one thing
Get the first three moves right and the cancer usually loses: markers before treatment, a radical inguinal orchiectomy — never through the scrotum — and sperm banking before any therapy. Then let the AFP have the final word on whether you are treating a seminoma or a non-seminoma.