What is the recommended workup for testicular cancer?

Testicular Cancer Workup

Initial Diagnostic Evaluation

Any patient with a suspected testicular mass requires immediate scrotal ultrasound with high-frequency probe (>10 MHz) and color Doppler, followed by serum tumor markers before any surgical intervention. 1

Physical Examination

• Palpate both testes with both hands to identify unilateral testicular masses, the most common presentation 1
• Assess for scrotal pain (present in 27% of cases), back or flank pain (11%), or gynecomastia (1%) 1
• Examine for cryptorchidism, the strongest risk factor (relative risk 3.18 overall, 6.33 for ipsilateral testicular cancer) 1
• Document personal or family history of testicular cancer, infertility, or undescended testis 1, 2

Critical pitfall: Never misclassify a testicular mass as epididymitis—this is a common cause of delayed diagnosis in young men with testicular cancer 1, 3

Scrotal Ultrasound

• Use high-frequency probe (>10 MHz) with color Doppler as the mandatory first-line imaging 1, 3
• Ultrasound confirms intratesticular versus extratesticular location, evaluates contralateral testis for synchronous tumors, and identifies microcalcifications 1
• Any solid intratesticular mass must be managed as malignant until proven otherwise 3
• MRI has limited role and should only be used when ultrasound cannot distinguish intra- from extratesticular masses 1

Serum Tumor Markers (Pre-Orchiectomy)

Draw these markers BEFORE any treatment including orchiectomy—this is essential for diagnosis, staging, and prognosis: 1, 3

• α-fetoprotein (AFP) - half-life 5-7 days 1
• β-human chorionic gonadotropin (β-hCG) - half-life 1-3 days 1
• Lactate dehydrogenase (LDH) - important prognostic factor 1

Key interpretation: Pure seminoma does not secrete AFP; if AFP is elevated, manage as non-seminoma regardless of histology 1, 4. Normal markers do not exclude germ cell tumors, especially in seminoma where sensitivity is low 1.

Critical pitfall: Failing to obtain tumor markers before orchiectomy complicates staging and treatment planning 3

Staging Workup (After Orchiectomy Confirmed)

Imaging for Metastatic Disease

• CT chest, abdomen, and pelvis with contrast is the reference standard for staging 1
• Chest CT is mandatory for all newly diagnosed germ cell tumors 4
• Chest radiograph alone may be sufficient for pure seminoma stage I, but CT is preferred if chest X-ray or abdominal CT shows abnormalities 1
• Retroperitoneal lymph nodes >1 cm in short axis are highly suspicious for metastases, though up to 60% of metastatic nodes may be <1 cm 1

Brain and Bone Imaging (Selective)

• MRI brain without and with contrast only if symptomatic or high-risk features (β-hCG >5000 IU/L or extensive lung metastases) 1
• Bone scan only if alkaline phosphatase elevated or bone symptoms present 1

Post-Orchiectomy Tumor Markers

• Repeat markers minimum 7 days after orchiectomy to assess half-life kinetics 1
• Follow markers until normalization 1
• Persistent or rising markers after orchiectomy indicate metastatic disease 1

Fertility and Hormonal Assessment

Counsel about fertility risks and offer sperm banking BEFORE orchiectomy or any chemotherapy: 3, 4

• Determine total testosterone, LH, and FSH before operation 1, 4
• Semen analysis and sperm banking should be completed before any therapeutic intervention 1, 4
• This is particularly critical in patients without a normal contralateral testis or with known subfertility 4

Pathology Requirements

• Radical inguinal orchiectomy is both diagnostic and therapeutic 1
• Never perform scrotal biopsy or scrotal incision—only inguinal approach is appropriate to avoid tumor seeding and altered lymphatic drainage 1, 3, 4
• Pathology must specify: tumor location, size, pT category (UICC), histological type (WHO 2016 classification), vascular invasion, and presence of germ cell neoplasia in situ (GCNIS) 1
• Expert pathology review should be considered given the complexity and rarity of these tumors 1, 4

Laboratory Tests

• Complete blood count, creatinine, electrolytes, liver enzymes 1
• These baseline values guide chemotherapy dosing and monitor for treatment toxicity 1

Risk Stratification

• Use UICC/AJCC TNM staging combined with IGCCCG prognostic classification based on histology, marker levels, and metastatic sites 1
• This classification determines whether patients have good, intermediate, or poor prognosis disease, which guides treatment intensity 1

Common pitfall: Using aluminum-containing needles or IV sets with cisplatin causes precipitate formation and loss of potency 5