A 60-year-old man presents with a 3-month history of a painless solid mass in the right testis. Serum tumour markers are: beta-hCG 1,200 IU/L, AFP 0.8 ng/mL (normal), LDH mildly elevated. Scrotal ultrasound confirms a solid hypoechoic right testicular mass. CT chest, abdomen, and pelvis shows no lymphadenopathy or metastases. What is the most likely histological subtype?

• A Pure choriocarcinoma
• B Pure seminoma
• C Leydig cell tumour
• D Non-seminomatous germ cell tumour (NSGCT) — embryonal carcinoma or mixed ✓

Explanation

AFP is never elevated in pure seminoma — any AFP elevation indicates a non-seminomatous component. Beta-hCG is elevated here and can be elevated in both pure choriocarcinoma and NSGCTs, but pure choriocarcinoma is the rarest TGCT subtype, typically presents with very high hCG (often >100,000 IU/L), and virtually always has widespread haematogenous metastases at presentation. Normal AFP with elevated hCG and a localised testicular mass in a 60-year-old is most consistent with an NSGCT (commonly mixed germ cell tumour or embryonal carcinoma with syncytiotrophoblastic elements). Management is radical inguinal orchidectomy followed by staging-directed chemotherapy or surveillance. Leydig cell tumours are rare non-germ-cell tumours and do not produce hCG or AFP.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.