What is the recommended staging workup for a 21-year-old male patient with testicular cancer?

Staging Workup for Testicular Cancer in a 21-Year-Old Male

For a 21-year-old male with newly diagnosed testicular cancer, you must obtain CT abdomen/pelvis with IV contrast, chest imaging (chest X-ray for seminoma, CT chest for non-seminoma), and serum tumor markers (AFP, β-hCG, and LDH) measured before and after orchiectomy to establish proper TNM staging. 1

Essential Staging Components

Serum Tumor Markers (Mandatory)

• Obtain AFP, β-hCG, and LDH before orchiectomy to establish baseline values for staging and risk stratification 1, 2
• Repeat markers at appropriate half-life intervals post-orchiectomy (hCG: 24-36 hours; AFP: 5-7 days) to determine nadir levels, which are critical for IGCCCG risk stratification 1
• If markers remain elevated post-orchiectomy, monitor to establish nadir before initiating treatment, as these values determine chemotherapy regimen and number of cycles 1
• For borderline elevations (within 3x upper limit of normal), confirm a rising trend before making management decisions to avoid false positives 1

Abdominal/Pelvic Imaging (Mandatory)

• CT abdomen and pelvis with IV contrast is the reference standard for assessing retroperitoneal lymphadenopathy 1
• MRI is acceptable only if CT is contraindicated 1
• Lymph nodes >1 cm in short axis are highly suspicious for metastatic disease, particularly in testicular cancer "landing zones" (para-aortic, paracaval, interaortocaval regions) 1
• CT accuracy for detecting metastatic retroperitoneal nodes ranges from 73-97%, with sensitivity 65-96% and specificity 81-100% 1

Critical caveat: Up to 60% of metastatic lymph nodes may be <1 cm, so some experts suggest using 0.7-0.8 cm cutoff at the expense of reduced specificity 1

Chest Imaging (Mandatory)

The approach differs by histology:

For seminoma:

• Chest X-ray is preferred over CT to minimize radiation exposure in this young population 1
• Upgrade to CT chest only if: elevated/rising post-orchiectomy markers, evidence of metastases on abdominal/pelvic imaging, or abnormal chest X-ray 1

For non-seminoma:

• CT chest is preferred over chest X-ray, particularly for patients who may receive adjuvant therapy 1
• Non-seminomas are more clinically aggressive and warrant more comprehensive chest evaluation 1

What NOT to Order

• Do not obtain PET scan for initial staging of testicular cancer 1
• Do not obtain bone scan unless there are specific clinical symptoms suggesting bone metastases, as bone metastases from testicular cancer are uncommon 1

Staging Classification

Assign TNM-s category (the "s" denotes serum tumor markers) to guide all management decisions 1

The staging system follows:

• Stage I (70-75% of cases): Disease localized to testicle 3
• Stage II (20% of cases): Metastatic only to retroperitoneal lymph nodes 3
• Stage III (10% of cases): Widely metastatic disease 3

Risk Stratification for Metastatic Disease

If metastatic disease is present (Stage IIC or III), use IGCCCG risk stratification based on nadir serum tumor markers, staging imaging, and histology to determine chemotherapy regimen 1

IGCCCG classification determines:

• Good risk
• Intermediate risk
• Poor risk

This directly impacts treatment intensity and prognosis 1

Special Considerations for This 21-Year-Old Patient

Age-Specific Factors

• Any post-pubertal male should be treated according to adult treatment guidelines 1
• Testicular cancer is the most common solid malignancy in males aged 15-40 years 3
• Mean age at diagnosis is 33 years, so this patient fits the typical demographic 3

Fertility Preservation

• Discuss sperm cryopreservation before any therapeutic intervention in this reproductive-age male 4
• This is particularly important as treatment may include chemotherapy or radiation that can impair fertility 4

Lymphatic Drainage Patterns

• Left testicular tumors metastasize to left para-aortic nodes below the left renal vein and interaortocaval group 1
• Right testicular tumors metastasize to paracaval, precaval, and interaortocaval groups 1
• Crossover can occur, but contralateral metastasis without ipsilateral involvement is unusual 1
• Prior scrotal or inguinal surgery alters drainage patterns, making external iliac and inguinal nodes regional 1

Common Pitfalls to Avoid

• Do not delay marker assessment: Adequate time must elapse post-orchiectomy for markers to normalize before making treatment decisions 1
• Do not use scrotal approach for orchiectomy: Always use radical inguinal orchiectomy to avoid altering lymphatic drainage 2
• Do not over-interpret small retroperitoneal nodes: Remember that accuracy declines in limited disease (stage N1/N2), and inflammatory nodes cannot be differentiated from metastatic nodes on CT alone 1
• Do not assume normal-sized nodes exclude metastases: CT cannot detect metastatic disease in normal-sized lymph nodes 1