What are the management options for a 35-year-old patient diagnosed with testicular cancer?

Management of Testicular Cancer in a 35-Year-Old Patient

Radical inguinal orchiectomy is the definitive initial management for testicular cancer, followed by staging and risk-stratified treatment based on histology and disease extent. 1

Diagnostic Approach

• Initial evaluation:

  • Scrotal ultrasound with Doppler to confirm testicular mass
  • Serum tumor markers before orchiectomy:
    • Alpha-fetoprotein (AFP)
    • Beta-human chorionic gonadotropin (β-HCG)
    • Lactate dehydrogenase (LDH) 2, 1

• Radical inguinal orchiectomy:

  • Performed through inguinal incision with high ligation of spermatic cord
  • Provides both diagnosis and initial treatment 2, 1
  • Should be timely scheduled but is not an emergency procedure 2

• Testis-sparing surgery considerations:

  • Only for highly selected cases with masses <2cm
  • Appropriate only for bilateral tumors or solitary testis 2, 1
  • Higher risk of local recurrence requiring close monitoring 2

Post-Orchiectomy Staging

• Imaging:

  • CT scan of abdomen and pelvis with IV contrast (or MRI if contraindicated)
  • Chest X-ray (initial chest imaging)
  • Chest CT for non-seminoma or if evidence of metastases 2, 1

• Tumor markers:

  • Repeat AFP, β-HCG, and LDH post-orchiectomy to establish nadir levels
  • Monitor at appropriate half-life intervals (AFP <7 days; β-HCG <3 days) 2

Treatment Based on Histology and Stage

For Seminoma:

1. Stage I (IA and IB):

   • Surveillance is preferred (category 1) 1
   • Alternatives:
     • Single-dose carboplatin (AUC 7) 2, 1
     • Radiation therapy (20 Gy/10 fractions) to paraaortic strip 2

2. Stage IIA-B:

   • Dogleg radiotherapy to 30-36 Gy/15-18 fractions 2
   • Alternative: Chemotherapy as for stage IIC 2

3. Stage IIC-III:

   • Chemotherapy based on IGCCCG risk classification:
     • Good risk: BEP × 3 cycles or EP × 4 cycles
     • Intermediate risk: BEP × 4 cycles 2, 1

For Non-seminoma:

1. Stage I:

   • Low-risk (no vascular invasion): Surveillance
   • High-risk (with vascular invasion): BEP × 2 cycles
   • Alternative: Nerve-sparing retroperitoneal lymph node dissection (RPLND) if chemotherapy not possible 1

2. Stage II-III:

   • Treatment based on IGCCCG risk classification:
     • Good risk: BEP × 3 cycles or EP × 4 cycles
     • Intermediate/poor risk: BEP × 4 cycles 1

Post-Chemotherapy Management

• Residual masses should be surgically resected when possible
• Surgery should be performed by experienced surgeons at high-volume centers 1
• PET scan may identify viable tissue in residual lesions ≥3 cm in advanced seminoma 2

Follow-Up Protocol

• Physical exam, tumor markers, and chest X-ray:
  • Every 2-3 months for first year
  • Every 3-4 months for second year
  • Every 6 months until 5 years 2, 1
• CT abdomen/pelvis at 3,6,9,12, and 24 months 1

Important Considerations

• Fertility preservation:

  • Discuss sperm banking before any therapeutic intervention 1, 3
  • Risk of infertility with both surgery and chemotherapy 3

• Chemotherapy toxicity monitoring:

  • Nephrotoxicity: Monitor renal function before each dose of cisplatin 4
  • Ototoxicity: Perform audiometric testing before and during cisplatin therapy 4
  • Myelosuppression: Monitor peripheral blood counts weekly 4

• Long-term follow-up:

  • Monitor for secondary malignancies
  • Assess cardiovascular risk
  • Evaluate for fertility issues 3, 5

Common Pitfalls to Avoid

• Delaying orchiectomy in patients with suspicious testicular masses
• Failing to obtain tumor markers before orchiectomy
• Not discussing sperm banking before treatment
• Overtreatment of stage I disease
• Managing patients outside of a multidisciplinary setting 1