What is the next step in managing a 20-year-old male with abdominal pain, ultrasonography (USG) showing necrotic para-aortic nodes and a hard mass on the right testis, with testicular tumor markers and renal function tests pending, and a planned computed tomography (CT) abdomen and pelvis with contrast?

Management of Suspected Testicular Cancer with Retroperitoneal Lymphadenopathy

You should proceed with chest imaging (CT chest with IV contrast) immediately, ensure radical inguinal orchiectomy is scheduled urgently, and await tumor marker results before finalizing the treatment plan, as these will determine risk stratification and guide subsequent therapy.

Immediate Next Steps

Complete Staging Workup

• Chest imaging is mandatory and missing from your current plan. CT chest with IV contrast is required for complete staging of testicular cancer, as pulmonary metastases are common and influence prognosis and treatment decisions 1.

• The planned CT abdomen and pelvis with contrast is appropriate and should proceed once renal function is confirmed adequate 1.

• Do not delay orchiectomy while awaiting imaging. Radical inguinal orchiectomy should be performed within 4 weeks of CT scan and within 7-10 days of repeat serum marker testing to ensure accurate presurgical staging 1.

Critical Laboratory Monitoring

• Tumor markers (AFP, β-HCG, LDH) must be obtained both pre- and post-orchiectomy and followed until normalization or lack of further decrease 1. The half-life for β-HCG is 1-3 days and 5-7 days for AFP 1.

• At least one of these three markers is elevated in 91% of patients with advanced nonseminomatous germ cell tumors 2. These markers are indispensable for diagnosis, staging, risk assessment, and monitoring response to therapy 3, 4.

• If markers remain elevated or rise post-orchiectomy despite no visible metastases on imaging, this indicates stage IS disease requiring systemic chemotherapy 1.

Additional Baseline Studies

• Obtain complete blood count, comprehensive metabolic panel (including liver function tests), and coagulation profile if not already done 1.

• Measure serum testosterone, sex hormone-binding globulin, luteinizing hormone, and follicle-stimulating hormone to assess baseline endocrine function 1.

Risk Stratification Based on Imaging and Markers

If Metastatic Disease is Confirmed

The presence of necrotic para-aortic nodes indicates at minimum stage II disease. Risk classification using the International Germ Cell Cancer Collaborative Group (IGCCCG) criteria is essential and depends on:

• Primary tumor site (testicular vs. retroperitoneal)
• Presence of non-pulmonary visceral metastases
• Marker levels: AFP, β-HCG, and LDH values 1

For nonseminoma with metastatic disease:

• Good prognosis: AFP <1000 ng/mL, β-HCG <5000 IU/L, LDH <1.5× upper limit of normal, no non-pulmonary visceral metastases (5-year survival 96%) 1
• Intermediate/poor prognosis groups have different marker thresholds and require more aggressive therapy 1

Brain Imaging Considerations

• MRI of the brain is advisable in nonseminoma patients with high β-HCG values or multiple lung metastases belonging to the poor-prognostic group 1.

• This should be considered if chest CT shows multiple pulmonary metastases or if β-HCG is markedly elevated.

Fertility Preservation

Sperm banking must be discussed immediately before any therapeutic intervention (surgery, radiation, or chemotherapy) that may compromise fertility 1, 5. This can be performed either before or after orchiectomy, but certainly before any adjuvant therapy 1.

Surgical Planning

• Radical inguinal orchiectomy (not scrotal approach) is the standard procedure 5. A scrotal approach is associated with higher local recurrence rates 5.

• The procedure should use an inguinal incision with early high ligation of the spermatic cord 1, 5.

• Pathology must include assessment of vascular invasion, tumor size, rete testis invasion, and percentage of embryonal carcinoma, as these influence risk stratification 1.

Common Pitfalls to Avoid

• Do not skip chest imaging. This is a critical component of staging that directly impacts treatment decisions and prognosis 1.

• Do not delay orchiectomy waiting for "complete" workup. The surgery itself provides definitive histology needed for treatment planning 1, 5.

• Do not order PET scan routinely. There is no evidence to support routine use of FDG-PET in staging of germ cell tumors 1.

• Do not perform scrotal ultrasound for restaging after orchiectomy unless there is concern for contralateral tumor 1, 6.

• Ensure adequate hydration protocols are in place if platinum-based chemotherapy is anticipated, as cisplatin requires pretreatment hydration with 1-2 liters of fluid for 8-12 hours prior to dosing 7.

Post-Orchiectomy Management Path

Treatment after orchiectomy depends entirely on:

1. Final histology (seminoma vs. nonseminoma vs. mixed)
2. Pathologic stage
3. Post-orchiectomy marker levels and kinetics
4. IGCCCG risk classification if metastatic 1

Given the necrotic para-aortic nodes, this patient will likely require either chemotherapy or retroperitoneal lymph node dissection depending on final pathology and marker behavior 1.