Synopsis
Treat a solid intratesticular mass as cancer until proved otherwise, measure markers before inguinal orchidectomy, avoid trans-scrotal biopsy and deliver risk-adapted surveillance, chemotherapy or retroperitoneal treatment with fertility and cure central.
- Painless intratesticular mass is a pivotal clue in Testicular germ-cell tumour: A firm unilateral lump, change in consistency or diffuse enlargement is the common presentation and needs urgent ultrasound.
- Immediate priority in unstable Testicular germ-cell tumour: Use immediate urological exploration for suspected torsion without delaying for tumour markers, and stabilise metastatic emergencies with the germ-cell centre because precipitous chemotherapy can cause tumour lysis or pulmonary haemorrhage in heavy choriocarcinoma burden.
- Scrotal ultrasound is used early to distinguish an intratesticular solid lesion from epididymal, cystic or inflammatory pathology. A solid vascular intratesticular mass is malignant until assessed; ultrasound of the contralateral testis documents baseline and additional lesions.
- AFP, hCG and LDH before orchidectomy refines the next decision because aFP elevation excludes pure seminoma regardless of initial label; normal markers do not exclude either seminoma or non-seminomatous cancer.
- Use markers and inguinal surgery: Take AFP, hCG and LDH before surgery, assess the contralateral testis and arrange urgent referral to the germ-cell pathway.
- Choose surveillance or adjuvant risk reduction: For seminoma, consider surveillance or risk-adapted carboplatin; avoid routine radiotherapy where modern pathways favour lower late toxicity.
- A major avoidable harm is infertility and hypogonadism; Baseline dysgenesis, orchidectomy, chemotherapy and retroperitoneal surgery can impair sperm, testosterone, sexual health and body image.
- A common diagnostic trap is epididymal cyst or spermatocele: A separate fluctuant extratesticular lesion is usually benign, but examination uncertainty warrants ultrasound.
Key red flags
A painless firm intratesticular lump or enlarged testis persists despite lack of constitutional symptoms.
Acute testicular pain and swelling could be torsion and requires immediate surgical assessment.
Gynaecomastia, infertility or testicular atrophy accompanies a suspicious lesion.
Back pain, cough, haemoptysis, neck nodes or weight loss suggests retroperitoneal or distant spread.
Very high hCG with lung metastases and haemoptysis raises concern for choriocarcinoma syndrome.
A patient with a solitary testis or future fertility wishes is about to undergo orchidectomy or gonadotoxic chemotherapy.
Cough, dyspnoea or haemoptysis suggests lung or mediastinal spread and can become critical with high-volume choriocarcinoma.
Investigation priorities
Distinguish an intratesticular solid lesion from epididymal, cystic or inflammatory pathology.
Management branches
Examination or ultrasound identifies a suspicious solid intratesticular lesion.
- Take AFP, hCG and LDH before surgery, assess the contralateral testis and arrange urgent referral to the germ-cell pathway.
- Offer sperm banking before orchidectomy when a solitary testis or fertility context makes this important and delay is safe.
- Perform radical inguinal orchidectomy without trans-scrotal biopsy, then obtain expert pathology including all germ-cell components and local stage.