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OncologyStudy NoteHigh YieldLast updated 30 May 2026

Testicular Cancer

High-yield revision notes — full detail, one scroll.

Risk Factors

  • White race
  • HIV
  • Klinefelter (esp. mediastinal NSGCT)
  • Family history — brother 8–12× | father 2–4×
  • GCNIS/IGCN — ~50% develop GCT within 5 years
  • Personal history of testicular cancer: 12×
  • CHEK2 mutation: 4×
  • Infertility: 2×
  • Undescended testis (UDT) — 4–6× | reduced to 2–3× if orchidopexy pre-puberty

Not risk factors: microlithiasis, testicular atrophy, trauma

Most common genetic abnormality: extra copy of short arm chromosome 12 (i12p)

Tumor Classification

A. Germ Cell Tumors (~95%)

1. Seminoma (52–56%)

  • Age 20–30 (actually 4th–5th decade — older than NSGCT)
  • 15% have ↑ β-hCG
  • Chemo- and radiosensitive
  • Histology: clear cytoplasm ("fried egg")
  • Arises from GCNIS

2. NSGCT (44–48%)

SubtypeMarkersHistology / Key
Yolk sac↑ AFPSchiller-Duval bodies; infant; chemo-sensitive
Embryonal carcinoma↑ AFP ± β-hCGPapillary; aggressive; totipotent → can differentiate into other NSGCT subtypes
Choriocarcinoma↑ β-hCG (>10,000)Syncytiotrophoblasts; haematogenous spread → brain mets
TeratomaUsually negativeCystic germ layer elements; chemo-resistant; can transform to somatic malignancy

➡ Pure seminoma + ↑ AFP → treat as NSGCT

3- GCNIS

  • High risk of progression to invasive GCT
  • Management options (3): orchiectomy | low-dose RT (18–20 Gy) | surveillance
  • ➡ Preserve fertility → surveillance
  • ➡ ↓ cancer risk → orchiectomy or testicular RT
    • RT advantage: Leydig cells radioresistant (less hypogonadism — 40% need TRT)
    • RT disadvantage: scatter to contralateral testis impairs spermatogenesis

B. Sex Cord–Stromal Tumors (~90% benign)

  • Leydig cell — testosterone, gynecomastia; 10% bilateral; 40% need TRT post-op
  • Sertoli cell — testosterone, estrogen; assoc. Peutz–Jeghers
  • Gonadoblastoma — gonadal dysgenesis/intersex; bilateral orchiectomy (40% bilateral)

C. Non-Germ Cell

  • Spermatocytic tumor — elderly; benign; no GCNIS, no i(12p), no cryptorchidism link

D. Secondary

  • Lymphoma (most common testis tumor in men >50; 35% bilateral)
  • Leukemia (paediatric ALL relapse site)
  • Mets: prostate, lung, melanoma, colon, kidney

Special Notes

  • 5% of GCTs are extragonadal (midline)
    • Retroperitoneum
    • Mediastinum (common in Klinefelter; poor prognosis, chemo-resistant)
  • UDT patients: age 19–50 → orchiectomy | >50 → no surgery
  • Orchitis → re-evaluate 2–4 weeks after antibiotics

Metastatic Spread

  • Lymphatic (70–80%)
    • Right testis → interaortocaval nodes
    • Left testis → para-aortic nodes
  • Inguinal nodes only if:
    • Prior inguinal/scrotal surgery
    • Tunica vaginalis invasion
  • Exception: choriocarcinoma = haematogenous → lung, brain
  • Mets at diagnosis: 33% NSGCT | 15% seminoma

Tumor Markers & Half-Life

MarkerHalf-lifeProduced by
AFP7 daysYolk sac, EC, teratoma (NOT seminoma or chorio)
β-hCG36 hoursSeminoma (15%), EC, choriocarcinoma
LDH~1 dayNon-specific; used for S-stage
  • Repeat markers after 5 half-lives post-orchiectomy
  • False ↑ hCG → hypogonadism (LH cross-reactivity), cannabis use , alcoholism > Give Testosterone it will decrease if hypogonadism

Work-Up

  • History & physical exam
  • Scrotal ultrasound (both testes — 2% bilateral)
  • Tumor markers + LFTs + hormones
  • CT chest / abdomen / pelvis (CXR acceptable for CS I seminoma)
  • Brain imaging if:
    • Neurologic symptoms
    • β-hCG >5,000
    • AFP >10,000
    • Extensive lung mets
    • Non-pulmonary visceral mets
  • Contraindicated: testicular biopsy, trans-scrotal orchiectomy (scrotal violation ↑ local recurrence)

Fertility Considerations

  • At diagnosis: 50% oligospermic | 10% azoospermic
  • After chemo: all initially azoospermic → 50–80% recover in 2–5 years
  • ➡ Sperm bank before chemo/RT

Testis-Sparing Surgery (Selective)

  • Solitary testis
  • Synchronous bilateral tumors
  • Tumor <1 cm, <30% testicular volume, non-palpable, normal markers
  • 50–80% have concomitant GCNIS in ipsilateral testis

Pathologic Risk Factors for Relapse (CS IA/IB )

Seminoma (2)

  • Tumor size >4 cm
  • Rete testis invasion

NSGCT (2)

  • Embryonal predominance
  • LVI (most important)

TNM Staging (AJCC 8th)

T Stage

  • T1: testis only, no LVI
  • T2: LVI / epididymis / tunica vaginalis
  • T3: spermatic cord
  • T4: scrotum

N Stage

  • N1: <2 cm
  • N2: 2–5 cm
  • N3: >5 cm

M Stage

  • M1a: non-regional nodes or lung
  • M1b: non-lung visceral mets

S Stage

LDHAFPβ-hCG
S1<1.5×<1,000<5,000
S21.5–10×1,000–10,0005,000–50,000
S3>10×>10,000>50,000

Stage Grouping

Stage I (N0, M0)

  • IA: T1, S0
  • IB: T2–T4, S0
  • IS: Any T, S1–S3 (marker-positive post-orchiectomy)

Stage II (N+, M0, S0–1)

  • IIA: N1
  • IIB: N2
  • IIC: N3

Stage III (Any N, M1 and/or higher S)

  • IIIA: M1a, S0–S1
  • IIIB: N1–3 + M0–M1a + S2
  • IIIC: N1–3 + M0–M1a + S3, OR M1b any S

Risk Stratification (IGCCCG)

GroupNon-SeminomaSeminoma
GoodS0–S1No visceral mets
IntermediateS2Non-pulmonary visceral mets
PoorS3 OR mediastinal OR non-pulm visceralnone

Management

Pure Seminoma

  • Stage I (CS IA/IB Seminoma)
    • Surveillance → relapse ~15%
    • XRT → relapse ~3%
    • Chemo (carboplatin ×1) → relapse ~3%
  • Stage IIA → chemo or XRT (dog-leg 25–35 Gy)
  • Stage IIB → chemo
  • Stage IIC / III
    • Good risk → BEP ×3
    • Intermediate → BEP ×4

Residual Masses Post-Chemo (Seminoma)

  • 60–80% have radiologically detectable residuum
  • Histology: necrosis 80%, viable 20% (vs NSGCT: 40/15/45 necrosis/viable/teratoma)
  • ➡ <3 cm: observe
  • ➡ >3 cm: FDG-PET
    • Positive → post-chemo surgery
    • Negative → observe

Non-Seminoma

  • Stage I
    • Surveillance (compliant T1 only)
    • RPLND (unilateral) — preferred if teratoma in pathology
    • Chemo BEP ×2
  • Stage IIA/B — RPLND (bilateral) only if S0; otherwise chemo BEP ×3
  • Stage IS → BEP ×3
  • Stage IIC / III
    • Good risk → BEP ×3 or EP×4
    • Poor risk → BEP ×4
    • Substitute VIP×4 if compromised pulmonary function or extensive chest surgery expected

Post-RPLND (pre-chemo)

  • Assess nodal burden
  • Treat with chemo if pN2 or pN3

Residual Masses Post-Chemo (NSGCT)

  • Histology: fibrosis 40% | teratoma 45% | viable 15%
  • Markers elevated: salvage chemo
  • Markers normal:
    • >1 cm: ➡ resection (full bilateral template PC-RPLND if RP)
    • <1 cm: controversial
  • ➡ Multiple sites → RPLND first (highest probability of residual; predicts other sites)
  • PC-RPLND histology:
    • Necrosis/teratoma → surveillance
    • Viable disease → 2 cycles chemo (EP, TIP, VIP, or VeIP)
  • FDG-PET has NO role in NSGCT residual masses
  • Predictor of fibrosis-only RP = pure EC in primary

Special Scenarios

Growing Teratoma Syndrome

  • ↓ markers + ↑ mass during chemo
  • ➡ Complete chemo course, then resect

Brain Mets (choriocarcinoma)

  • High hCG → bleed risk on chemo (death 4–10% ICH)
  • ➡ BEP ×4 → resection ± RT

Bleomycin + RPLND

  • Risk of post-op respiratory distress
  • ➡ Low FiO₂ + conservative fluids