What is the management approach for a 19-year-old male with testicular swelling, elevated HCG (human chorionic gonadotropin), and LDH (lactate dehydrogenase), with pending AFP (alpha-fetoprotein) and CT (computed tomography) scan results?

Management of Suspected Testicular Germ Cell Tumor with Elevated HCG

This 19-year-old requires urgent radical inguinal orchiectomy after completing the diagnostic workup, which includes obtaining the pending AFP and CT scan results before surgery unless life-threatening metastatic disease is present. 1

Immediate Diagnostic Completion

Complete Tumor Marker Panel

• Obtain the pending AFP result immediately as this is mandatory for diagnosis, staging, and distinguishing seminoma from non-seminoma 1
• The elevated HCG (1255 IU/L) with LDH (317) already suggests germ cell tumor, but AFP is essential because:
  • Elevated AFP absolutely excludes pure seminoma and indicates non-seminomatous histology regardless of pathology findings 1, 2
  • Pure seminoma can have elevated HCG (up to 20% of cases) but never elevated AFP 3, 2
  • HCG levels up to 200 IU/L are compatible with pure seminoma, but this patient's level of 1255 IU/L suggests either non-seminoma or seminoma with syncytiotrophoblastic giant cells 2

Complete Staging Imaging

• Proceed with the pending CT chest, abdomen, and pelvis with contrast as this is mandatory for all patients before treatment 1
• The ultrasound showing "parasitic nodes" (likely retroperitoneal lymphadenopathy) requires CT confirmation and measurement 1
• Chest imaging is mandatory to evaluate for pulmonary metastases 1, 4

Surgical Management Algorithm

Timing of Orchiectomy

• Perform radical inguinal orchiectomy promptly but NOT as an emergency unless life-threatening metastatic disease is present 1
• If the patient has life-threatening metastatic disease with unequivocally elevated markers (which this case may represent given HCG >1000), chemotherapy can be started immediately and orchiectomy postponed until after chemotherapy completion 1
• However, based on the information provided, proceed with orchiectomy first unless clinical deterioration occurs 1

Surgical Technique

• Use only the inguinal approach - never scrotal approach 1
• Resect the tumor-bearing testicle along with the spermatic cord at the level of the internal inguinal ring 1
• The scrotal approach is absolutely contraindicated as it increases local recurrence risk 1, 5, 6

Pre-Treatment Considerations

Fertility Preservation

• Offer sperm cryopreservation before orchiectomy as this is the most cost-effective fertility preservation strategy 1, 6
• This is particularly critical given the patient's young age (19 years) and potential need for chemotherapy 1, 6, 4
• Semen analysis should be performed if time permits 1

Marker Kinetics Post-Orchiectomy

• Remeasure all tumor markers (AFP, HCG, LDH) after orchiectomy and follow until normalization to determine half-life kinetics 1
• Expected half-lives: AFP <7 days, HCG <3 days 1
• Failure to normalize or plateau indicates metastatic disease requiring systemic therapy 1, 7

Risk Stratification Based on Current Data

Preliminary IGCCCG Classification

Based on the elevated HCG (1255 IU/L) and normal-range LDH (317), this patient likely falls into:

• Good-risk non-seminoma if AFP is 1000-10,000 ng/mL and no non-pulmonary visceral metastases 1
• Intermediate-risk non-seminoma if AFP >1000 ng/mL or HCG 5000-50,000 IU/L 1
• The HCG of 1255 IU/L is below the intermediate-risk threshold of 5000 IU/L, suggesting good-risk disease if other criteria are met 1

Post-Orchiectomy Management

Histology-Dependent Treatment

• If pure seminoma (unlikely given HCG level): surveillance, radiotherapy, or single-agent carboplatin depending on stage 1
• If non-seminoma with retroperitoneal nodes: chemotherapy (BEP or EP regimen) based on final IGCCCG risk classification 1
• Management decisions should only be made by highly experienced clinicians in testicular cancer 1

Critical Pitfalls to Avoid

• Never delay obtaining AFP before making treatment decisions - elevated AFP changes the entire management algorithm 1, 3, 2
• Never use scrotal incision or biopsy for suspected testicular malignancy 1, 5, 6
• Never dismiss the need for fertility counseling before any intervention in this 19-year-old 1, 6, 4
• Never interpret elevated HCG alone as excluding seminoma - up to 20% of pure seminomas have mildly elevated HCG 3, 2
• Never start treatment without complete staging imaging unless life-threatening disease requires immediate chemotherapy 1