What is the management approach for a 35-year-old with testicular cancer?

Management of Testicular Cancer in a 35-Year-Old

The management of testicular cancer in a 35-year-old patient requires radical inguinal orchiectomy as the initial diagnostic and therapeutic approach, followed by staging and risk-stratified treatment based on histology, tumor markers, and imaging findings. 1

Initial Diagnostic Workup

Clinical Evaluation and Laboratory Tests

• Obtain serum tumor markers before any treatment, including orchiectomy:
  • Alpha-fetoprotein (AFP)
  • Beta-human chorionic gonadotropin (β-hCG)
  • Lactate dehydrogenase (LDH) 1
• Complete blood count, creatinine, electrolytes, and liver function tests 1

Imaging

• Scrotal ultrasound with Doppler to confirm testicular mass and evaluate contralateral testis 1, 2
• Chest radiograph as initial chest imaging 1
• CT scan of abdomen and pelvis with IV contrast (or MRI if contraindicated) 1
• CT chest for non-seminoma or if evidence of metastases on other studies 1

Pre-Treatment Considerations

• Discuss sperm banking before any therapeutic intervention (surgery, radiation, chemotherapy) 1
• Counsel about risks of hypogonadism and infertility 1

Primary Treatment

• Radical inguinal orchiectomy is the standard initial treatment for most testicular masses 1
  • Performed through an inguinal incision with high ligation of the spermatic cord 1
  • Provides both diagnostic and therapeutic benefit 3
  • In rare cases with life-threatening metastatic disease and elevated tumor markers, chemotherapy may be initiated before orchiectomy 1

Post-Orchiectomy Management Based on Histology

Pure Seminoma

1. Stage I (IA and IB):

   • Surveillance is strongly preferred (5-year disease-specific survival is 99%) 1
   • Alternatives include:
     • Single-agent carboplatin (1-2 cycles)
     • Radiotherapy to retroperitoneal lymph nodes 1

2. Stage II-III:

   • Treatment based on IGCCCG risk classification 1
   • Good risk: BEP (bleomycin, etoposide, cisplatin) x 3 cycles or EP (etoposide, cisplatin) x 4 cycles
   • Intermediate risk: BEP x 4 cycles 1

Non-Seminoma

1. Stage I:

   • Risk stratification based on presence of lymphovascular invasion:
     • Low risk (no invasion): Surveillance protocol
     • High risk (with invasion): Adjuvant chemotherapy (BEP x 2 cycles) 1

2. Stage II-III:

   • Treatment based on IGCCCG risk classification:
     • Good risk: BEP x 3 cycles
     • Intermediate/poor risk: BEP x 4 cycles 1
   • Post-chemotherapy surgery for residual masses >1 cm 4

Surveillance Protocol

Pure Seminoma Stage I

• Physical exam, tumor markers, and chest X-ray every 3-4 months for first 1-2 years
• CT abdomen/pelvis at 3,6,12,24, and 36 months 1

Non-Seminoma Stage I

• Physical exam, tumor markers, and chest X-ray monthly for first year, then every 2 months in second year
• CT abdomen at 3 and 12 months 1

Special Considerations

Testis-Sparing Surgery

• May be considered for small masses (<2 cm) with equivocal findings
• Only appropriate in select cases (bilateral tumors or solitary testis) 1

Management of Germ Cell Neoplasia In Situ (GCNIS)

• Options include testicular radiation (18-20 Gy) or orchiectomy 1

Prognosis

• Overall 5-year survival rate is 97% 5
• Stage-specific survival rates:
  • Stage I: 99%
  • Stage II: 92%
  • Stage III: 85% 3

Common Pitfalls to Avoid

1. Delaying orchiectomy in patients with suspicious testicular masses
2. Failing to obtain tumor markers before orchiectomy
3. Not discussing sperm banking before treatment
4. Overtreatment of stage I disease when surveillance is appropriate
5. Managing patients outside of a multidisciplinary setting with experienced clinicians 1

Remember that treatment decisions should balance oncologic control with minimizing long-term adverse effects, particularly in young patients with excellent survival prospects 3.