What tests should be repeated to monitor for potential testicular cancer recurrence in a patient with a history of orchiectomy and current urinary symptoms?

Surveillance Testing for Testicular Cancer Recurrence

Yes, tumor markers (AFP, β-HCG, and LDH) should be checked immediately, and the patient requires structured surveillance imaging with CT scans based on his post-orchiectomy treatment history.

Immediate Testing Required

Serum Tumor Markers

• Draw AFP, β-HCG, and LDH now to screen for biochemical recurrence, as these markers are elevated in approximately 90% of patients with recurrent non-seminomatous germ cell tumors 1, 2
• Tumor markers can detect recurrence before radiographic evidence appears, making them essential for early detection 3, 4
• Even if the patient's original tumor had normal markers, they should still be checked as marker patterns can differ at recurrence 3

Clinical Context

• This patient is one year post-orchiectomy, which places him in the highest risk period for recurrence (first 2 years account for the majority of relapses) 1
• His current urinary symptoms (dysuria, prostate calcifications) are likely unrelated to testicular cancer recurrence, but the timing necessitates cancer surveillance regardless 2

Surveillance Schedule Based on Treatment History

The surveillance protocol depends critically on whether this patient received adjuvant chemotherapy after orchiectomy:

If Patient Was on Surveillance Only (No Adjuvant Therapy)

• Tumor markers (AFP, β-HCG, LDH) every 2 months during year 2 post-orchiectomy 1
• CT chest, abdomen, and pelvis at 12 months and 24 months post-orchiectomy 1
• Chest X-ray every 2 months during year 2 1
• This intensive schedule reflects the 20-50% relapse rate in stage I non-seminomatous disease managed with surveillance 1

If Patient Received Adjuvant Chemotherapy

• Tumor markers every 3 months during year 2 1
• CT scans only as clinically indicated (not routine), as post-chemotherapy recurrence risk is substantially lower 1
• Chest X-ray every 3 months during year 2 1

Critical Action Points

What to Do Now

• Order AFP, β-HCG, and LDH stat before the patient leaves the office 2, 5
• Review the original pathology report to determine histology (seminoma vs. non-seminoma) and presence of vascular invasion, as this affects recurrence risk 1
• Verify what post-orchiectomy treatment he received (surveillance vs. chemotherapy vs. radiation) 1
• If markers are elevated or rising, obtain CT chest/abdomen/pelvis immediately and refer urgently to medical oncology 5

Contralateral Testis Evaluation

• Perform testicular ultrasound of the remaining left testicle to assess for new masses or testicular atrophy (<12 mL volume), as patients with prior testicular cancer have a 2-3% lifetime risk of contralateral disease 1
• Consider contralateral testis biopsy if the remaining testicle is atrophic (<12 mL), as this carries up to 34% risk of germ cell neoplasia in situ 1

Common Pitfalls to Avoid

• Never assume urinary symptoms exclude cancer recurrence – retroperitoneal lymph node metastases can present with back pain or urinary symptoms from mass effect 2
• Do not wait for symptoms to develop before checking markers, as the goal is to detect recurrence when disease burden is minimal and cure rates are highest 1
• Do not order CT scans without first checking tumor markers in asymptomatic patients, as markers guide the need for imaging 1, 5
• Never delay obtaining markers if there is any clinical suspicion of recurrence, as delayed diagnosis significantly impacts prognosis 5

If Markers Are Elevated

• Confirm true elevation by repeating markers to establish a rising trend (rule out false positives from cross-reactivity, particularly with β-HCG) 1, 5
• Obtain staging CT chest/abdomen/pelvis with IV contrast immediately 1, 5
• Classify according to International Germ Cell Cancer Collaborative Group (IGCCCG) risk stratification based on marker levels and imaging findings 1, 5
• Refer urgently to medical oncology for chemotherapy consideration, as elevated markers post-orchiectomy indicate systemic disease requiring treatment 5