Nearly all tumours of the testis are malignant. In Africa, most of them are rhabdomyosarcomas under the age of 16; seminomas are very rare. Elsewhere, most are seminomas or teratomas or a combination of both, and are usually seen between the ages of 20 and 45. The patient complains of: (1) A large painless (usually) testicular swelling. (2) An abdominal mass. (3) Gynaecomastia and breast tenderness (rare), in which case gonadotrophin production by the tumour may result in a positive pregnancy test.
If he is diagnosed and treated early he has an 80% chance of cure by orchidectomy alone. Seminomas are sensitive to radiotherapy, but not to chemotherapy, whereas teratomas are amenable to chemotherapy (75% complete cure), although this needs cisplatin and expert management.
TUMOURS OF THE TESTIS DIAGNOSIS. The patient's testis is large, harder than his normal one, smooth, heavy, and not tender. It loses its normal sensation early. When he stands it usually hangs lower than his normal one, unlike testes with inflammation or torsion, which are usually pulled higher. He has a normal vas, a normal cord until late, occasionally a hydrocele (10%), and a normal prostate and seminal vesicles. Early, his epididymis is normal, later it is flattened or hidden in the tumour. Feel for deposits above his umbilicus on the same side, in his liver, and above his clavicles. X-ray his lungs.
THE DIFFERENTIAL DIAGNOSIS includes epididymo-orchitis (very common, 23.22a), a hydrocele (23.23), a haematocele following trauma, torsion of his testis (23.24), an epidermal cyst, a tuberculoma, and a gumma (rare). In sub-Saharan Africa a seminoma is rarer than all these.
MANAGEMENT. Operate soon. While he is anaesthetized palpate his abdomen for para-aortic masses. Open his inguinal canal through an inguinoscrotal incision, as in Fig. 23-33. Clamp his cord with a soft clamp to avoid damaging its vessels. Draw up his testis and examine it. If it looks malignant, divide and tie his cord at the level of his internal inguinal ring. Remove his cord and testis, from above downwards, by separating them from their attachments. Close the wound. If he has a seminoma refer him for radiotherapy to his upper abdominal para- aortic nodes as soon as possible, even in the absence of demonstrable secondaries. If he has a teratoma, observe him carefully, and refer him if secondaries appear.
CAUTION ! (1) If he presents with symptoms which might be due to secondaries, don't fail to examine his testes. A small primary is easily missed. (2) Don't remove his testis through his scrotum. (3) Don't try to biopsy the lesion.
TUMOURS OF THE FEMALE GENITAL ORGANS [s8]OTHER THAN THE BREAST (21.3)