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testicular neoplasms AND orchiectomy

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EAU guidelines testicular cancer diagnostic evaluation radical inguinal orchiectomy scrotal biopsy

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This page explains the diagnosis and initial surgical management of a suspected testicular tumour, usually a germ-cell tumour.

1. Initial work-up

A. Scrotal ultrasound

  • First-line test for a testicular mass.
  • It distinguishes an intratesticular solid lesion from extratesticular or cystic conditions.
  • A solid intratesticular lesion is treated as malignant until proved otherwise.

B. Serum tumour markers

Draw before surgery:
  • AFP: alpha-fetoprotein
  • β-hCG: beta-human chorionic gonadotropin
  • LDH: lactate dehydrogenase
They help with diagnosis, risk assessment, staging, and later follow-up. However, normal markers do not exclude cancer, especially seminoma. Markers should also be rechecked after orchidectomy to assess their expected decline. The EAU diagnostic guideline recommends markers both before and after orchidectomy.

2. Do not do trans-scrotal FNAC or biopsy

The highlighted note is very important:
Trans-scrotal biopsy/FNAC should not be done for a suspicious testicular mass.
Why?
  • It can cause tumour spillage or scrotal seeding.
  • It may alter normal lymphatic drainage.
  • It raises the risk of local recurrence and can make subsequent treatment more extensive, sometimes requiring scrotal skin excision.
Therefore, the diagnostic and therapeutic procedure is usually radical inguinal orchidectomy, not a scrotal biopsy. Robbins, Cotran & Kumar Pathologic Basis of Disease states that biopsy can cause tumour spillage and that a solid testicular mass is generally managed by radical orchidectomy.

3. Chevassu manoeuvre / inguinal exploration

This is the operative sequence shown:
  1. High inguinal incision
    • The surgeon approaches through the groin, not through the scrotum.
  2. Clamp the spermatic cord early
    • Done before manipulating the testis, to limit possible tumour-cell dissemination.
  3. Deliver the testis into the operative field
  4. Examine the testis and, in selected cases, perform frozen section
    • Frozen section is a rapid intraoperative pathology examination.
    • It is mainly useful when a benign lesion is plausible or preserving testicular tissue is important, such as a solitary testis or bilateral lesions.
  5. If malignant or malignancy cannot be excluded: high radical inguinal orchidectomy
    • The testis and spermatic cord are removed, with division of the cord at or near the internal inguinal ring.
  6. If clearly benign on frozen section: replace/preserve the testis
    • This is selected testis-sparing surgery, not the usual approach for a typical suspicious solid mass.
This is consistent with Smith and Tanagho’s General Urology, p. 394: inguinal exploration, cord control, and delivery of the testis are the standard approach; scrotal surgery and open testicular biopsy should be avoided.

4. Histopathology and staging

The removed testis is sent for histopathology, which determines:
  • Tumour type: seminoma, non-seminomatous germ-cell tumour, mixed tumour, etc.
  • Local invasion and the pathological T stage (pT)
  • Presence of lymphovascular invasion and other risk features
The note pTX means:
TermMeaning
pTPathological assessment of the primary tumour
pTXPrimary tumour cannot be assessed pathologically
Usually, after orchidectomy, the tumour can be assigned a pathological T category.

5. Imaging for staging

After confirmation or strong suspicion, staging evaluates retroperitoneal lymph nodes and distant metastases.
The page says “PET-CT,” but this needs correction:
  • Contrast CT of chest, abdomen, and pelvis is the usual standard staging study.
  • PET-CT is not routinely used for initial staging of all testicular cancers.
  • PET-CT has a more limited role, particularly in assessing a residual mass after chemotherapy in selected seminoma cases.
The EAU guideline specifies orchidectomy with pathology for confirmation and local pathological staging, and recommends cross-sectional imaging for staging.

6. Notes at the top: hormone effects of special tumours

  • Leydig-cell tumour
    • Can produce androgens or estrogens.
    • May cause precocious puberty/virilisation in children or gynecomastia in adults.
  • Sertoli-cell tumour
    • May be associated with estrogenic effects and gynecomastia.
  • Choriocarcinoma
    • A non-seminomatous germ-cell tumour that may produce very high β-hCG.
    • It is aggressive and spreads early through the bloodstream, often to lungs, brain, or liver.
    • The “average survival 6 months” written in the margin is not a general modern prognostic rule. Prognosis now depends on metastatic site, marker levels, risk classification, and response to cisplatin-based therapy.

Core exam takeaway

Painless solid intratesticular mass → ultrasound + AFP/β-hCG/LDH → no trans-scrotal FNAC/biopsy → radical inguinal orchidectomy → histopathology + CT-based staging.
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