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OncologyStandardLast updated 29 May 2026

Testicular Cancer

Early toxicity:

  • Chemotherapy — cisplatin: fatigue, myelosuppression, infection, peripheral neuropathy, hearing loss, diminished renal function, and death; etoposide: myelosuppression.
  • Radiation — fatigue, nausea/vomiting, leukopenia, dyspepsia.

Late toxicity:

  • Hypogonadism — occurs in 10–20% after orchiectomy alone, 15–40% after radiation, and 20–25% after first-line chemotherapy. Measure AM testosterone and LH if symptomatic.
  • Infertility — most men can father children, but paternity rates are lower after radiation and/or chemotherapy.
  • Cardiovascular disease and secondary malignancy — both increased by subdiaphragmatic radiation or platinum-based chemotherapy; ensure primary-care follow-up for modifiable risk factors and appropriate cancer screening.

Chemotherapy-specific:

  • Bleomycin — pulmonary complications (including pulmonary fibrosis), Raynaud phenomenon, mild myelosuppression at high doses.
  • Cisplatin — nephrotoxicity, neurotoxicity, peripheral neuropathy, hearing loss.

Brain Metastases

Associated with choriocarcinoma — suspect in any patient with a very high serum hCG. Choriocarcinomas are highly vascular and tend to hemorrhage during chemotherapy, with death rates of 4–10% from intracranial hemorrhage.

  • At diagnosis: BEP×4, then resection of residual masses.
  • Brain relapse after first-line chemotherapy: second-line chemotherapy, then resection and/or radiotherapy.
  • Brain relapse after a complete response carries a worse prognosis than brain involvement present at diagnosis.

Primary Extra-gonadal GCT

95% of GCTs are gonadal and 5% extra-gonadal, arising in midline locations — in descending frequency: mediastinum, retroperitoneum, sacrococcygeal region, and pineal gland.

  • Primary mediastinal NSGCT (vs testicular/retroperitoneal NSGCT) more often has yolk sac components with elevated AFP, is associated with Klinefelter syndrome, is less chemosensitive, and carries a poor prognosis.
  • Primary mediastinal seminoma has a prognosis similar to testicular seminoma.
  • Primary retroperitoneal GCT behaves like, and carries the same prognosis as, testicular GCT.

Of patients with metastatic GCT and no testis mass, one-third each have: a true extra-gonadal primary, ITGCN in the testis, or sonographic evidence of a "burned-out" primary.

Diagnosis: consider GCT for any midline mass in a male <40. With elevated AFP and/or hCG, the diagnosis is established even if the testis is normal — no biopsy is needed before treatment; with normal markers, biopsy the midline mass to confirm first.

Inguinal orchiectomy is indicated in suspected extra-gonadal GCT when the metastatic pattern matches a right- or left-sided testicular primary, or there is a sonographic burned-out primary.

Small Impalpable Testicular Lesions

Small (<10 mm), impalpable intratesticular lesions without disseminated GCT or elevated markers are a diagnostic dilemma — most are benign (testicular cysts, small infarcts, small Leydig or Sertoli cell tumours), but 20–50% are small GCTs (usually seminoma), with malignancy risk rising with lesion size. Three options:

  • Inguinal orchiectomy.
  • Testis-sparing surgery — inguinal exploration and excision with frozen section to exclude GCT (intraoperative ultrasonography helps localize the lesion).
  • Close observation with serial ultrasound, exploring any growing lesion.

Self-Test

  1. Which subtypes comprise non-seminoma germ cell tumours? Embryonal carcinoma, choriocarcinoma, yolk sac tumour, and teratoma — alone or mixed. Any tumour containing these elements (even alongside seminoma) is classified as NSGCT.

  2. What percentage of patients have metastatic disease at diagnosis? ~33% of NSGCT and ~15% of pure seminoma.

  3. Which tumours secrete AFP and hCG, and what are their half-lives? AFP — yolk sac, EC, teratoma (half-life 5–7 days). hCG — seminoma (~15%), EC, choriocarcinoma (half-life 24–36 hours).

  4. What is the primary landing zone for a left vs right testicular tumour? Left → para-aortic nodes (then inter-aortocaval). Right → inter-aortocaval nodes (then paracaval/para-aortic).

  5. How is a post-chemotherapy retroperitoneal mass managed? Elevated markers → salvage chemotherapy. Normal markers: in NSGCT, resect a mass >1 cm by full bilateral template RPLND; in seminoma, use FDG-PET for masses >3 cm (positive → surgery) and observe masses <3 cm.