What are the investigations for testis cancer?

Investigations for Testicular Cancer

When testicular cancer is suspected, obtain scrotal ultrasound with Doppler and serum tumor markers (AFP, β-HCG, LDH) before any intervention, including orchiectomy. 1, 2

Mandatory Initial Investigations

Serum Tumor Markers (Pre-Orchiectomy)

• Alpha-fetoprotein (AFP): Essential for all suspected testicular malignancies 1, 3
• Beta-human chorionic gonadotropin (β-HCG): Required for diagnosis and staging 1, 3
• Lactate dehydrogenase (LDH): Important prognostic factor, particularly in advanced disease 3, 2

These markers must be drawn before orchiectomy as they support diagnosis, indicate histology, and provide baseline values for monitoring treatment response. 1, 2 Normal marker levels do not exclude testicular cancer, as they have limited sensitivity. 2

Imaging Studies

Primary Testicular Imaging:

• High-frequency scrotal ultrasound with Doppler (>10 MHz transducer): This is the mandatory first-line imaging to confirm intratesticular mass, assess size, detect multifocal disease, and evaluate the contralateral testis 1, 3, 2
• MRI should not be used for initial evaluation of testicular lesions 1

Staging Imaging (Post-Diagnosis):

• CT scan of chest, abdomen, and pelvis: Required for staging after diagnosis 3, 4
• Chest X-ray: Part of standard staging workup 3, 4
• Chest CT: Not mandatory for clinical stage I seminoma but required for non-seminoma 3

Laboratory Tests

• Complete blood count 4
• Renal function (urea, creatinine, electrolytes) 4
• Liver function tests 4

Optional Investigations

Additional Tumor Markers (Seminoma Only)

• Placental alkaline phosphatase (PLAP): Only reliable in non-smokers 3
• Neurone-specific enolase (NSE): May provide additional information for advanced seminoma 3

Fertility Assessment

• Total testosterone, LH, FSH, semen analysis: Should be considered before definitive treatment 3
• Sperm banking: Must be offered to all appropriate patients before orchiectomy, particularly those without a normal contralateral testis or with known subfertility 1

Advanced Disease Imaging

• Brain CT or MRI: Only indicated if β-HCG >10,000 IU/L or >10 lung metastases 4
• Bone scan: Only if alkaline phosphatase elevated or bone symptoms present 3, 4
• PET scan: Not for initial diagnosis; may identify viable tissue in residual masses ≥3 cm in advanced seminoma if performed ≥4 weeks post-chemotherapy 3

Post-Orchiectomy Investigations

Tumor Marker Kinetics

• Repeat serum markers 7 days post-surgery to assess half-life kinetics 5
• AFP half-life: <7 days 3
• β-HCG half-life: <3 days 3
• Delayed decline or rising levels indicate residual disease and affect staging 2

Risk Assessment

• Histopathologic evaluation for vascular (lymphatic or venous) invasion: Distinguishes low-risk (20% relapse) from high-risk (40-50% relapse) stage I disease 4

Clinical Assessment Components

History

• Risk factors: Cryptorchidism (RR 3.18), family history of testicular cancer, testicular atrophy (<12-16 ml volume), hypospadias, inguinal hernia, infertility 3, 2, 5, 6
• Presentation: Painless testicular mass (most common), scrotal pain (27%), back/flank pain (11%), gynecomastia (1%) 7

Physical Examination

• Both testes examination 2
• Abdominal examination 2
• Supraclavicular fossae palpation 2
• Chest examination for gynecomastia 2

Critical Pitfalls to Avoid

• Never delay obtaining tumor markers before orchiectomy: These baseline values are essential for staging and monitoring 1, 2, 5
• Never use scrotal approach for suspected malignancy: Inguinal orchiectomy is mandatory as scrotal violation increases local recurrence 2, 8, 5
• Do not rely on normal tumor markers to exclude cancer: Markers have low sensitivity and normal levels do not exclude disease 2
• Avoid emergency orchiectomy: Timely scheduling is appropriate; only life-threatening metastatic disease requires urgent chemotherapy before orchiectomy 3

Special Considerations

Testicular Microlithiasis

• Incidental microlithiasis (>5 small echogenic non-shadowing foci) without solid mass or risk factors does not require further evaluation 1
• Only pursue additional workup if other risk factors present (cryptorchidism, family history, personal history of GCT, or GCNIS) 1

Small or Indeterminate Masses

• For patients with normal tumor markers and indeterminate findings on ultrasound: repeat imaging in 6-8 weeks 1
• 50-80% of non-palpable or incidentally detected masses <2 cm are benign 1
• Consider testis-sparing surgery with intraoperative frozen section for small masses with normal contralateral testis 1, 2

Contralateral Testis Biopsy

• Consider in patients with testicular atrophy (<16 ml) to detect germ cell neoplasia in situ (GCNIS) 4
• Not routinely performed but may be indicated with cryptorchid testis or marked atrophy 8