Eduovisual
Renal & Urinary
Testicular cancer: presentation and management
— Most common solid malignancy in men aged 15–35; lifetime risk ~0.4% in US men
— Highest incidence in non-Hispanic White men; lower in Black and Asian populations
— >95% cure rate overall with modern multimodal therapy, even in metastatic disease — making early recognition and prompt referral the dominant Step 3 lever
— Bimodal distribution: peak in young adults (germ cell tumors) and a smaller peak after age 60 (lymphoma, spermatocytic tumors)
— Cryptorchidism (relative risk 4–6×); risk persists even after orchiopexy, and the contralateral descended testis is also at increased risk
— Prior testicular cancer (2–5% risk of contralateral primary)
— Family history (father or brother)
— Klinefelter syndrome → mediastinal germ cell tumors specifically
— Testicular microlithiasis on prior imaging, HIV infection, infertility/subfertility
— Intratubular germ cell neoplasia (GCNIS) on prior biopsy
— Painless unilateral testicular mass or swelling in a young man is testicular cancer until proven otherwise
— Dull scrotal ache, heaviness, or recent size change; ~10% present with acute pain mimicking epididymitis or torsion
— Gynecomastia (β-hCG–secreting tumor) or new-onset back pain (retroperitoneal nodal disease)
— Constitutional symptoms, cough/dyspnea (pulmonary mets), or supraclavicular adenopathy in advanced disease
— Incidental finding on scrotal ultrasound done for trauma or infertility workup
— Any solid intratesticular mass is malignant until proven otherwise — do NOT do a percutaneous biopsy (risk of scrotal seeding)
— Workup proceeds: history → exam → scrotal ultrasound → tumor markers → urology referral for radical inguinal orchiectomy
Board pearl: A young man with a painless testicular lump and a "negative" antibiotic trial for presumed epididymitis is the prototypical missed-diagnosis stem — image, don't retry antibiotics.
— Painless, firm, unilateral testicular nodule or diffuse enlargement noticed on self-exam, by a partner, or after minor trauma that drew attention to the area
— Sensation of heaviness or dull ache in the scrotum, groin, or lower abdomen
— Right testis slightly more often involved than left, mirroring cryptorchidism laterality
— Acute scrotal pain in ~10% from intratumoral hemorrhage or infarction — easily confused with epididymo-orchitis or torsion
— Recurrent or "treatment-resistant" epididymitis in a young man → image
— Gynecomastia from β-hCG or estrogen production (especially Leydig/Sertoli or choriocarcinoma elements)
— Infertility evaluation revealing an incidental testicular mass on ultrasound
— Hyperthyroidism-like symptoms from β-hCG cross-reactivity at TSH receptor in high-burden disease
— Low back pain from bulky retroperitoneal (para-aortic) lymphadenopathy
— Supraclavicular adenopathy (left Virchow node) via thoracic duct
— Cough, hemoptysis, dyspnea from pulmonary metastases — most common visceral site
— Abdominal mass, early satiety, leg edema from IVC compression
— Neurologic symptoms (rare) — brain mets typically from choriocarcinoma
— Onset, duration, change in size, prior trauma (often a red herring that brought patient in)
— Cryptorchidism history, age at orchiopexy if performed
— Prior testicular procedures, infertility evaluation, contralateral biopsies
— Family history of germ cell tumors
— Sexual/STI history (helps distinguish epididymitis), HIV status
— Fertility goals and prior children — critical before orchiectomy/chemo for sperm banking counseling
Step 3 management: Before any definitive therapy in a reproductive-age man, offer sperm banking — this is a tested counseling point and a malpractice landmine if omitted. Document the discussion.
— Examine standing and supine, with good lighting, warm hands, and a relaxed cremaster
— Palpate the normal testis first to establish baseline, then the affected side
— Identify the testis, epididymis (posterolateral), spermatic cord, and any masses; gently transilluminate
— Firm, non-tender, intratesticular mass that does not transilluminate and cannot be separated from the testis on palpation
— Loss of normal testicular contour; diffuse enlargement with increased firmness
— Reactive hydrocele in 10–20% — can obscure the underlying mass; image regardless
— Mass that persists or grows over weeks despite antibiotics for presumed epididymitis
— Varicocele: "bag of worms," left-sided, decompresses when supine, increases with Valsalva — new right-sided or non-decompressing varicocele warrants abdominal imaging for IVC or renal vein obstruction
— Hydrocele: cystic, transilluminates, surrounds testis
— Spermatocele/epididymal cyst: above and separate from testis
— Epididymitis: tender, posterolateral, often with pyuria, urethral symptoms, fever; Prehn sign relief with elevation
— Testicular torsion: acute severe pain, high-riding testis, absent cremasteric reflex — surgical emergency
— Supraclavicular and cervical lymph nodes (Virchow)
— Abdominal exam for bulky retroperitoneal mass, hepatomegaly, flank tenderness
— Gynecomastia (β-hCG effect) — palpate breasts in any young man with a testicular mass
— Lower extremity edema (IVC compression), respiratory exam for effusion/mets
Key distinction: Intratesticular = cancer until proven otherwise; extratesticular and cystic/transilluminating = usually benign. Ultrasound resolves uncertainty in minutes — never delay imaging while trialing antibiotics in a young man with a solid testicular lump.
— High-frequency (7.5–10 MHz) bilateral scrotal ultrasound with Doppler is the imaging modality of choice; sensitivity ~100% for intratesticular lesions
— Malignant features: hypoechoic, intratesticular, vascular mass; microcalcifications; heterogeneity
— Seminomas tend to be homogeneous, hypoechoic; nonseminomas more heterogeneous with cystic/hemorrhagic areas
— Always image the contralateral testis — 2–5% synchronous or metachronous primaries
— AFP (alpha-fetoprotein)
— Elevated in nonseminomatous germ cell tumors (NSGCT) — yolk sac, embryonal, mixed
— NEVER elevated in pure seminoma — if AFP is up, treat as NSGCT regardless of histology
— Half-life 5–7 days
— β-hCG (beta-human chorionic gonadotropin)
— Elevated in choriocarcinoma (markedly), embryonal, and ~15% of seminomas (mildly)
— Half-life 24–36 hours
— LDH
— Nonspecific marker of tumor bulk and turnover; correlates with stage and prognosis
— Used in IGCCCG risk stratification
— Confirm/refine pretreatment diagnosis and stage
— Establish baseline to assess response and detect relapse
— Persistent elevation after orchiectomy implies residual disease
— CBC, CMP (baseline renal/hepatic for chemo planning), urinalysis to help exclude UTI/epididymitis when presentation is ambiguous
Board pearl: A testicular mass with elevated AFP = nonseminoma, full stop — even if the pathology report says "seminoma," management follows NSGCT pathways. Conversely, pure seminoma can have mildly elevated β-hCG but never AFP.
CCS pearl: Order ultrasound and tumor markers (AFP, β-hCG, LDH) before urology consult to avoid clock-time penalties and to have results in hand.
— Radical inguinal orchiectomy is both diagnostic and therapeutic for the primary tumor
— Approached via inguinal incision with high spermatic cord ligation at the internal ring
— Trans-scrotal biopsy or orchiectomy is contraindicated — disrupts lymphatic drainage, risks scrotal/inguinal seeding, alters nodal staging, and changes radiation fields
— Pathology classifies as seminoma vs nonseminoma (NSGCT: embryonal, yolk sac, choriocarcinoma, teratoma, or mixed)
— CT abdomen and pelvis with contrast — primary site of metastasis (retroperitoneal nodes along renal vessels)
— CT chest (or CXR for very low-risk stage I seminoma per some guidelines; CT is standard)
— Brain MRI if choriocarcinoma, very high β-hCG, widespread visceral mets, or neurologic symptoms
— Bone scan only if symptoms or elevated alkaline phosphatase
— Repeat AFP, β-hCG, LDH and trend by half-life
— Failure to normalize along expected decay → residual or metastatic disease, even with normal imaging
— Stage I: confined to testis
— Stage II: retroperitoneal nodal involvement (IIA <2 cm, IIB 2–5 cm, IIC >5 cm)
— Stage III: supradiaphragmatic nodes or visceral mets
— S category (S0–S3) based on post-orchiectomy marker levels
— Good, intermediate, poor risk based on marker levels, primary site (testis vs mediastinal), and non-pulmonary visceral mets
— Mediastinal nonseminoma = automatic poor risk
Key distinction: Imaging stages the disease; markers prognosticate and guide therapy intensity. A patient with normal post-orchiectomy CT but persistently rising β-hCG has metastatic disease until proven otherwise — proceed to systemic therapy, not surveillance.
— Drives everything downstream — chemo regimens overlap but surveillance, radiation sensitivity, and surgery decisions differ
— Remember: AFP elevation = treat as NSGCT regardless of histology slide
— ~85% cured with orchiectomy alone; ~15% relapse risk if surveilled
— Options: active surveillance (preferred for compliant patients), single-agent carboplatin × 1–2 cycles, or adjuvant radiation to para-aortic nodes (less favored due to second-malignancy risk)
— Surveillance involves serial markers, CT abdomen/pelvis, and CXR over 5–10 years
— Risk-stratified by lymphovascular invasion (LVI) and embryonal predominance
— Low risk (no LVI): surveillance preferred
— High risk: surveillance, 1 cycle BEP, or retroperitoneal lymph node dissection (RPLND)
— Seminoma IIA/IIB: radiation or chemotherapy (BEP × 3 or EP × 4)
— Seminoma IIC and Stage III: chemotherapy per IGCCCG risk
— NSGCT IIA with normal markers: RPLND or chemo; IIB/IIC or marker-positive: chemotherapy first
— Good risk: BEP × 3 or EP × 4
— Intermediate risk: BEP × 4
— Poor risk: BEP × 4 (or VIP × 4 if bleomycin contraindicated)
— Seminoma: PET at ≥6 weeks — PET-positive >3 cm → resect or biopsy
— NSGCT: resect ALL residual masses >1 cm — may contain teratoma (chemo-resistant) or viable tumor
Step 3 management: When a stage I seminoma patient asks "Why not just zap it?" — counsel that surveillance avoids long-term cardiovascular and second-malignancy risks of radiation, with equivalent survival. Shared decision-making is the expected answer.
— Bleomycin 30 units IV weekly (days 1, 8, 15)
— Etoposide 100 mg/m² IV days 1–5
— Platinum (cisplatin) 20 mg/m² IV days 1–5
— Cycle repeated every 21 days
— BEP × 3 for good-risk metastatic disease; BEP × 4 for intermediate/poor risk
— Used when bleomycin is contraindicated (pre-existing pulmonary disease, smokers with poor reserve, older patients)
— EP × 4 substitutes for BEP × 3 in good-risk disease
— Alternative for poor-risk patients who cannot receive bleomycin
— More myelosuppressive than BEP; requires mesna for ifosfamide-induced hemorrhagic cystitis
— Reserved for adjuvant therapy in stage I seminoma (1–2 cycles) — not used for metastatic disease (inferior to cisplatin)
— Bleomycin: pulmonary fibrosis (dose-dependent, worsened by high FiO₂, age, renal dysfunction, smoking); obtain baseline DLCO; avoid high-flow oxygen perioperatively for life
— Cisplatin: nephrotoxicity (aggressive hydration, magnesium repletion), ototoxicity, peripheral neuropathy, severe nausea (use 5-HT3 + NK1 + dexamethasone)
— Etoposide: myelosuppression, secondary AML (11q23 translocations), alopecia
— Ifosfamide: hemorrhagic cystitis (mesna), encephalopathy (methylene blue)
— G-CSF for febrile neutropenia prevention in selected cycles
— Antiemetics per HEC guidelines; PPI; thromboprophylaxis if hospitalized
— Audiometry baseline if symptoms; pulmonary monitoring with bleomycin
Board pearl: A post-BEP patient undergoing RPLND who desaturates intraoperatively after liberal O₂ administration is the classic bleomycin pulmonary toxicity vignette — anesthesia must keep FiO₂ <30% and minimize IV fluids.
— Inguinal approach, high ligation of spermatic cord at internal inguinal ring
— Provides histology, removes primary tumor, and preserves correct lymphatic staging
— Offer testicular prosthesis at the same operation or later
— Sperm banking before surgery when feasible (and certainly before chemo/radiation)
— Never trans-scrotal — alters drainage to inguinal/pelvic nodes, mandates wider radiation fields if used adjuvantly, increases local recurrence
— Indications:
— Stage I NSGCT as alternative to surveillance/chemo, especially in teratoma-predominant tumors (teratoma is chemoresistant)
— Stage IIA NSGCT with normal markers
— Post-chemotherapy residual mass >1 cm in NSGCT — resect ALL residual masses
— Nerve-sparing RPLND preserves sympathetic chains (L1–L4) to maintain antegrade ejaculation; non–nerve-sparing causes retrograde ejaculation/anejaculation, but does not impair erection or libido
— Open or robotic approaches; high-volume centers strongly preferred
— Seminoma residual mass: PET-CT at ≥6 weeks; PET-positive masses >3 cm → biopsy or resect; PET-negative → surveillance
— NSGCT residual mass >1 cm: resect — pathology shows necrosis (~40%), teratoma (~40%), or viable tumor (~20%); viable tumor requires additional salvage chemotherapy
— First relapse: TIP (paclitaxel, ifosfamide, cisplatin) or VeIP
— Refractory disease: high-dose chemotherapy with autologous stem cell rescue
— Late relapses (>2 years) — often chemoresistant teratoma; surgical resection is mainstay
CCS pearl: For NSGCT with a 2 cm residual retroperitoneal mass after BEP and normalized markers, the next step on the case is surgical resection, not repeat imaging — residual teratoma will not respond to more chemo and can transform malignantly.
— After age 50–60, suspect testicular lymphoma (most common testicular malignancy in this age group) — often bilateral, with systemic B-symptoms
— Workup includes CT chest/abdomen/pelvis, LDH, peripheral smear, and consideration of bone marrow biopsy; treated as DLBCL with R-CHOP plus CNS prophylaxis (testis is a sanctuary site) and contralateral testicular radiation
— Spermatocytic tumor (older men, indolent, rarely metastasizes) — distinct from classic seminoma
— Cisplatin clearance is renal; dose adjustment required for CrCl <60
— Aggressive pre- and post-hydration (normal saline 1–2 L) with magnesium repletion and mannitol/forced diuresis to mitigate nephrotoxicity
— Monitor Mg, K, Cr each cycle; cumulative tubular dysfunction can be permanent
— If CrCl too low → consider carboplatin substitution (less curative for metastatic GCT — discuss tradeoffs) or dose-reduced cisplatin
— Bleomycin is renally cleared; impaired clearance markedly increases pulmonary toxicity risk
— Avoid bleomycin if CrCl <50; substitute EP × 4 or VIP × 4
— Etoposide and ifosfamide are hepatically metabolized; dose-reduce per bilirubin
— Monitor LFTs each cycle; check hepatitis B serologies before chemo (reactivation risk with steroids and cytotoxics)
— Survivors of cisplatin-based therapy have elevated long-term risk of hypertension, dyslipidemia, metabolic syndrome, and cardiovascular events — aggressive secondary risk-factor management is part of survivorship
Step 3 management: A 35-year-old smoker with stage I seminoma and FEV₁ 60%? Avoid bleomycin-containing regimens in any salvage setting and document baseline DLCO; if adjuvant therapy is chosen, single-agent carboplatin is reasonable instead of radiation or BEP.
— Offer sperm cryopreservation BEFORE orchiectomy whenever feasible, and absolutely before chemotherapy or radiation
— Many patients have pre-existing subfertility at diagnosis (oligospermia in 50%); single-testis function after orchiectomy is often adequate but unpredictable
— Chemotherapy causes temporary or permanent azoospermia; recovery may take 2–5 years and is incomplete
— RPLND risks retrograde ejaculation even with nerve-sparing technique
— Document fertility discussion in the chart — missed counseling is a frequent malpractice and exam stem
— Most common solid tumor in this age group; high cure rate but disproportionate long-term toxicity burden (cardiovascular, secondary malignancy, infertility, hypogonadism, neurocognitive)
— Coordinate with pediatric or AYA oncology when available
— Address psychosocial issues: body image after orchiectomy, prosthesis, sexual function, return to school/work
— Orchiopexy before age 1 reduces (but does not eliminate) cancer risk and improves examinability for future surveillance
— Post-pubertal undescended testes have higher cancer risk; some guidelines recommend orchiectomy rather than orchiopexy in adults
— Associated with mediastinal nonseminomatous germ cell tumors — anterior mediastinal mass + gynecomastia in a tall, hypogonadal young man
— Mediastinal NSGCT = automatic poor-risk IGCCCG category
— First-degree relatives have 4–8× increased risk; counsel testicular self-exam monthly
— Down syndrome — slightly increased risk
Board pearl: A young man with a mediastinal mass, elevated AFP/β-hCG, and a "normal scrotal exam" has a primary mediastinal germ cell tumor (often Klinefelter) — do not biopsy first; check markers, and treat as poor-risk NSGCT.
— Bulky retroperitoneal nodes: hydronephrosis, IVC compression with leg edema/DVT, back pain, ureteral obstruction requiring stent or nephrostomy
— Pulmonary metastases: massive hemoptysis (choriocarcinoma), respiratory failure
— Choriocarcinoma syndrome: hemorrhage from highly vascular metastases (brain, lung) with very high β-hCG — initiate chemo urgently despite bleeding risk
— Paraneoplastic: hyperthyroidism from β-hCG, gynecomastia
— Orchiectomy: hematoma, infection, hypogonadism if contralateral testis is impaired
— RPLND: chylous ascites (lymphatic injury), retrograde ejaculation, ileus, vascular injury, small bowel obstruction from adhesions
— Acute: febrile neutropenia, nausea, electrolyte disturbances (Mg, K wasting), tumor lysis (rare with bulky disease)
— Bleomycin pulmonary fibrosis: dry cough, dyspnea, restrictive pattern on PFTs, reticular infiltrates on CT; avoid high FiO₂ for life
— Cisplatin: peripheral sensory neuropathy (stocking-glove, may be permanent), high-frequency sensorineural hearing loss/tinnitus, Raynaud phenomenon, magnesium wasting, chronic kidney disease
— Etoposide: secondary acute myeloid leukemia with 11q23 MLL rearrangement, typically 2–3 years post-therapy
— Vascular: increased risk of MI, stroke, and venous thromboembolism during and after cisplatin
— Second malignancies (solid tumors and leukemia) — radiation contributes more than chemo
— Hypogonadism (low testosterone) in 10–20% — fatigue, low libido, osteoporosis, metabolic syndrome
— Cardiovascular disease — premature atherosclerosis, hypertension
— Infertility, sexual dysfunction, psychosocial distress, financial toxicity
Key distinction: Acute toxicities (cytopenias, nausea) are predictable and manageable; late effects (CV disease, second cancers, neuropathy, ototoxicity, hypogonadism) dominate survivorship and should be screened for indefinitely.
— Choriocarcinoma syndrome: hemorrhage from highly vascular mets (intracranial, pulmonary, GI) with markedly elevated β-hCG — admit, ICU monitoring, urgent chemotherapy despite bleeding concerns; mortality is highest from delay
— Massive hemoptysis or hypoxemic respiratory failure from bulky pulmonary mets
— Spinal cord compression from vertebral or epidural metastases → emergent MRI, dexamethasone, neurosurgery/radiation oncology consults
— Acute kidney injury from bilateral ureteral obstruction by bulky retroperitoneal nodes → urology for percutaneous nephrostomy or stents before chemo
— Tumor lysis syndrome with very bulky disease starting chemo — IV hydration, allopurinol or rasburicase
— Hemodynamic instability, respiratory failure, neutropenic sepsis with shock
— Severe electrolyte disturbances (hyponatremia, hypomagnesemia with arrhythmia)
— Post-RPLND complications: major vascular injury, chylous ascites with hemodynamic effect
— Urology: any solid intratesticular mass; suspected torsion; urinary obstruction
— Medical oncology: confirmed germ cell tumor for systemic therapy planning
— Radiation oncology: select stage I/II seminomas, palliation of brain or bone mets
— Reproductive endocrinology: sperm banking before treatment
— Cardiology: pre-chemo if cardiovascular history
— Pulmonology: PFTs/DLCO before bleomycin in smokers or older patients
— Palliative care: refractory disease, symptom burden, goals of care
— New severe back pain in a known patient (cord compression vs progression)
— Fever with neutropenia → ED, blood cultures, broad-spectrum antibiotics within 1 hour
— New neurologic deficits (brain mets, choriocarcinoma)
CCS pearl: In a CCS case of suspected febrile neutropenia post-BEP, order blood cultures × 2, urine culture, CXR, CBC and start cefepime (or pip-tazo) within the first clock hour — adding vancomycin if hemodynamic instability, line infection, or skin/soft tissue source.
— Acute, severe unilateral testicular pain, often with nausea/vomiting; high-riding testis with transverse lie; absent cremasteric reflex
— Surgical emergency; 6-hour window for testicular salvage
— Doppler ultrasound shows decreased/absent blood flow
— Key distinction: Torsion is acute and devastatingly painful; testicular cancer is typically painless and chronic — but the 10% of cancers presenting acutely can mimic each other on initial triage. Ultrasound differentiates.
— Subacute, posterolateral tenderness, dysuria, urethral discharge, fever; Prehn sign relief with elevation
— Causes: chlamydia/gonorrhea in <35; E. coli/enteric in older men or those practicing insertive anal sex
— Treat with ceftriaxone + doxycycline (younger) or fluoroquinolone (older); re-image at 4–6 weeks if not fully resolved to exclude underlying tumor
— Cystic, painless scrotal swelling that transilluminates, surrounds testis; reactive hydroceles can accompany tumors → image to confirm normal underlying testis
— "Bag of worms," left-sided typically (left spermatic vein drains into left renal vein at right angle), decompresses supine
— New right-sided varicocele or non-decompressing varicocele → suspect renal cell carcinoma or IVC obstruction; image abdomen
— Painless, cystic, above and separate from testis; transilluminates; benign
— Reducible mass extending from inguinal canal; bowel sounds on auscultation; may transilluminate variably; positive cough impulse
— Often the event that prompts discovery of an underlying tumor — image even after "obvious" trauma
Board pearl: Persistent or "recurrent" epididymitis in a young man despite appropriate antibiotics is testicular cancer until proven otherwise — repeat ultrasound, do not retry antibiotics.
— Most common testicular malignancy after age 60; often bilateral; aggressive DLBCL histology
— B-symptoms, elevated LDH, extranodal involvement; treat with R-CHOP + CNS prophylaxis (intrathecal methotrexate) + contralateral testicular radiation (sanctuary site)
— Key distinction: Older man with bilateral testicular masses + systemic symptoms = lymphoma until proven otherwise.
— Testis is a sanctuary site in ALL; recurrence in boys post-induction warrants testicular biopsy
— Rare; from prostate, lung, melanoma, GI primaries — usually elderly with known primary
— Leydig cell: hormonally active, gynecomastia, precocious puberty in boys; usually benign in adults but 10% malignant
— Sertoli cell: associated with Peutz-Jeghers, Carney complex
— Usually marker-negative; orchiectomy diagnostic and curative for localized disease
— Anterior mediastinal mass + elevated AFP/β-hCG; associated with Klinefelter and risk of hematologic malignancies (AML, MDS)
— Poor-risk IGCCCG; managed with BEP × 4, often surgical resection of residual mass
— Midline retroperitoneal mass with positive markers; consider "burned-out" testicular primary — image scrotum for scar/calcification even with normal exam
— Bilateral testicular masses in men with congenital adrenal hyperplasia; ACTH-driven, regress with steroid optimization — do not mistake for cancer; check 17-OHP
Key distinction: A retroperitoneal or mediastinal mass with elevated AFP/β-hCG in a young man = extragonadal germ cell tumor — biopsy is not required if markers are diagnostic; treat as germ cell malignancy after imaging the testes for occult primary.
— Cure rates >95% mean most patients live decades with treatment-related risks — Step 3 emphasizes this long arc
— Check morning total testosterone, LH, FSH at baseline and yearly
— Symptomatic hypogonadism (fatigue, low libido, ED, depression, low bone density) with confirmed low testosterone → testosterone replacement after counseling about fertility implications
— Bank sperm before initiating testosterone if fertility is desired
— DEXA in men with hypogonadism or those who received high-dose steroids/long courses
— Calcium 1000–1200 mg, vitamin D 800–1000 IU; bisphosphonates per T-score
— Aggressively manage blood pressure, LDL, glucose; cisplatin survivors have premature CVD
— Statin per ASCVD risk; treat hypertension to <130/80; smoking cessation; aerobic exercise
— Aspirin only by standard primary prevention criteria
— Age-appropriate USPSTF cancer screening (colon, lung in smokers, etc.)
— Awareness of secondary AML in first 5 years post-etoposide — investigate cytopenias promptly
— Contralateral testis self-exam monthly; 2–5% lifetime risk of second primary
— Address ED, ejaculatory dysfunction post-RPLND, body image, intimate relationships
— Screen for depression and anxiety at each visit; refer for survivorship counseling
— Influenza yearly; COVID per CDC; pneumococcal and zoster per age and immune status; HPV if eligible
Step 3 management: A 32-year-old testicular cancer survivor 3 years post-BEP presents with fatigue and low libido — order morning testosterone with LH/FSH, lipid panel, fasting glucose, and CBC (rule out treatment-related cytopenia/AML) before attributing symptoms to deconditioning.
— Surveillance intensity is highest in years 1–2 (peak relapse), tapering to years 5–10
— Schedule varies by histology (seminoma vs NSGCT), stage, and treatment received
— History, exam, markers every 3–6 months for years 1–2, every 6–12 months years 3–5, then annually to year 10
— CT abdomen/pelvis at 3, 6, 12, 18, 24, 36, 48, 60 months (varies by protocol)
— CXR at each visit or per protocol
— Average time to relapse: ~14 months; retroperitoneum is the dominant relapse site
— More intensive imaging in year 1 (markers monthly to every 2 months; CT at 3, 6, 12, 18, 24 months)
— Most relapses occur within 2 years; teratoma can relapse later
— Markers and exam every 2–3 months in year 1, less frequent thereafter
— Imaging based on residual disease and pathology
— Tumor markers (AFP, β-hCG, LDH) — most sensitive early-relapse signal in NSGCT
— Symptoms: back pain, cough, dyspnea, neurologic changes, supraclavicular nodes
— Contralateral testis exam
— Survivorship: BP, lipids, glucose, testosterone, mood, sexual function, fertility, peripheral neuropathy
— Cumulative radiation from repeated CT is a real concern in young survivors; low-dose CT protocols or selective MRI for abdominal surveillance are increasingly used
— Reinforce monthly testicular self-exam; smoking cessation; sunscreen (radiation patients); alcohol moderation
— Fertility plans, sperm bank status
— Mental health and return to work/school
Board pearl: Rising β-hCG or AFP after normalization is metastatic relapse — proceed to imaging and systemic therapy. Markers can rise before imaging detects disease; do not wait for a "visible" recurrence.
— Discuss infertility risk, hypogonadism, body image, testicular prosthesis option, sexual dysfunction, and surgical risks
— Document sperm banking discussion explicitly — omission is one of the most common malpractice/board exam pitfalls in oncology
— Address impact on intimate relationships and self-image in adolescent and young adult patients
— ASCO and AUA guidelines require offering sperm cryopreservation before gonadotoxic therapy
— Cost and insurance barriers are real; many states mandate fertility preservation coverage for iatrogenic infertility — know your local laws
— For minors, involve parents and (when developmentally appropriate) the adolescent in shared decision-making
— A 17-year-old with a testicular mass has confidentiality rights regarding sexual history and STI testing, but parental involvement is typically expected for surgical consent unless emancipated
— Balance disclosure of cancer diagnosis with developmental capacity; truthful, age-appropriate communication is the standard
— Post-discharge after orchiectomy or RPLND: ensure pathology results communicated, oncology referral scheduled, tumor markers redrawn, and follow-up imaging arranged before discharge
— Survivorship care plan should be transmitted to the primary care physician — a known handoff failure point that increases relapse detection delay
— Repeat antibiotic courses for "epididymitis" without re-imaging is a classic safety failure; document that ultrasound was performed and tumor markers checked when symptoms persist
— A young man with a testicular complaint must not be triaged by gestalt alone
— Cancer diagnoses are reportable to state cancer registries (not patient-identifiable to public)
— STI co-diagnoses on workup require partner notification per state law
— Even with high cure rates, ~5% of patients have refractory disease — early integration of palliative care improves quality and sometimes quantity of life
— Address advance directives, surrogate decision-making, and code status in young adults — uncomfortable but necessary
Step 3 management: A 19-year-old college student diagnosed with NSGCT requests that you not tell his parents — respect his autonomy as an adult, offer to help him communicate the diagnosis to his family, and proceed with treatment per his consent alone.
— AFP elevated → yolk sac, embryonal, mixed NSGCT; never pure seminoma
— β-hCG elevated → choriocarcinoma (very high), embryonal, ~15% seminomas (mild)
— LDH → bulk and turnover marker, prognostic
— Placental alkaline phosphatase (PLAP) → sometimes seminoma marker, not routinely used
— Seminoma: "fried-egg" cells, lymphocytic infiltrate, radiosensitive, chemosensitive, slow-growing
— Embryonal carcinoma: pleomorphic, glandular; predicts metastasis
— Yolk sac tumor: Schiller-Duval bodies; most common testis tumor in boys <4 years
— Choriocarcinoma: cytotrophoblasts + syncytiotrophoblasts; hematogenous spread; hemorrhagic mets
— Teratoma: multiple germ layers; chemo-resistant; must be resected; can undergo malignant transformation
— Spermatocytic tumor: older men, indolent, rarely metastasizes
— Cryptorchidism: 4–6× risk, including contralateral descended testis
— Klinefelter (47,XXY): mediastinal NSGCT
— Down syndrome: increased risk
— White > Hispanic > Asian > Black incidence
— Stage I seminoma: surveillance preferred
— Bulky retroperitoneal seminoma: BEP × 3 or EP × 4
— Any NSGCT with residual mass >1 cm post-chemo: resect
— Mediastinal NSGCT: automatic poor-risk
— AFP elevated even with "seminoma" pathology: treat as NSGCT
— Bleomycin = Breath (pulmonary fibrosis) — avoid high FiO₂
— Cisplatin = Cochlea, Creatinine, Cramping nerves (ototoxicity, nephrotoxicity, neuropathy)
— Etoposide = Eleven-eleven (11q23 secondary AML)
— Ifosfamide = Irritated bladder (hemorrhagic cystitis — give mesna)
— Cardiovascular disease, secondary malignancy, hypogonadism — screen at every visit
Board pearl: A young man with elevated β-hCG, gynecomastia, and a small testicular mass with widespread pulmonary "cannonball" hemorrhagic metastases = choriocarcinoma; start BEP urgently and image the brain.
— 24-year-old man with painless right testicular nodule, no trauma, "treated for epididymitis without improvement"
— Best next step: scrotal ultrasound + tumor markers (AFP, β-hCG, LDH) → radical inguinal orchiectomy
— Wrong answers: another antibiotic course, trans-scrotal biopsy, FNA
— Pathology reports pure seminoma; AFP is 250 ng/mL
— Treat as NSGCT, not seminoma — the marker overrides the slide
— 28-year-old with NSGCT, completed BEP × 3, markers normalized, but 2.5 cm residual retroperitoneal mass on CT
— Best next step: surgical resection (RPLND) — likely teratoma or necrosis; treat to prevent transformation
— Post-BEP patient undergoing RPLND, FiO₂ raised to 80% for desaturation, develops worsening hypoxia and bilateral infiltrates
— Diagnosis: bleomycin pulmonary toxicity exacerbated by hyperoxia — keep FiO₂ <30%, minimize fluids
— 68-year-old with bilateral testicular swelling, weight loss, elevated LDH
— Diagnosis: primary testicular lymphoma — biopsy/orchiectomy, R-CHOP + CNS prophylaxis + contralateral testicular radiation
— Young man with gynecomastia, hemoptysis, β-hCG 500,000; "cannonball" lung mets
— Diagnosis: choriocarcinoma, poor-risk; start BEP × 4 urgently, MRI brain
— Tall hypogonadal man with anterior mediastinal mass, elevated AFP/β-hCG
— Diagnosis: mediastinal NSGCT (poor-risk); chemo first, surgical resection of residual
— 25-year-old before orchiectomy and BEP — best counseling: offer sperm banking before any therapy
— 33-year-old 4 years post-BEP with fatigue, low libido — order morning testosterone, LH/FSH, lipids, CBC
— Rising β-hCG on routine labs with normal imaging → metastatic relapse, initiate systemic therapy after restaging
Key distinction: Most testicular cancer stems test next step in workup (ultrasound, markers, no trans-scrotal biopsy), histology-vs-marker discordance (AFP overrules seminoma), and survivorship/toxicity (bleomycin/O₂, fertility, hypogonadism).
— A painless intratesticular mass in a young man is germ cell cancer until proven otherwise; workup is scrotal ultrasound plus AFP/β-hCG/LDH, definitive therapy begins with radical inguinal orchiectomy, and treatment is then driven by seminoma-vs-nonseminoma histology, marker behavior, and stage — with cure rates exceeding 95%, the dominant Step 3 task is preventing iatrogenic harm and managing long-term survivorship.
— Diagnosis: painless solid intratesticular mass → ultrasound + markers (AFP, β-hCG, LDH) → radical inguinal orchiectomy (never trans-scrotal, never percutaneous biopsy)
— Marker rules: AFP elevated = NSGCT regardless of slide; β-hCG very high = choriocarcinoma; markers before AND after orchiectomy, trend by half-life
— Management framework:
— Stage I seminoma → surveillance preferred; alternative: single-agent carboplatin
— Stage I NSGCT → surveillance or 1 cycle BEP or RPLND, stratified by LVI
— Metastatic → BEP × 3 (good risk) or BEP × 4 (intermediate/poor); EP/VIP if bleomycin contraindicated
— Residual mass post-chemo: resect all NSGCT masses >1 cm; PET-guided for seminoma
— Don't miss: sperm banking before therapy; avoid high FiO₂ in bleomycin-exposed patients; image the contralateral testis; reassess persistent "epididymitis" in young men
— Survivorship: cardiovascular disease, secondary AML (etoposide, 11q23), hypogonadism, neuropathy, ototoxicity, infertility, second primaries — screen indefinitely, manage risk factors aggressively
— High-yield associations: cryptorchidism → testicular cancer (and contralateral risk); Klinefelter → mediastinal NSGCT (poor risk); older man, bilateral testicular masses → lymphoma; new right-sided varicocele → retroperitoneal/IVC pathology
Board pearl: Testicular cancer is the model curable solid malignancy — boards reward the candidate who orders the right test first (ultrasound, not antibiotics), respects marker–histology discordance (AFP trumps the slide), preserves fertility, and follows survivors for decades of treatment-related risk rather than focusing only on the cure.