What are the appropriate diagnostic steps and treatment options for a young male suspected of having testicular cancer?

Diagnostic Approach for Suspected Testicular Cancer

Any solid testicular mass must be managed as malignant until proven otherwise, requiring immediate scrotal ultrasound with Doppler and serum tumor markers (AFP, β-HCG, LDH) drawn BEFORE any intervention, including orchiectomy. 1

Initial Diagnostic Workup

Physical Examination

• Palpate for a painless testicular mass, scrotal heaviness, or any solid intratesticular abnormality 1, 2
• Examine the contralateral testis for size (<12 mL suggests atrophy and increased cancer risk) 3, 4
• Document any history of cryptorchidism, family history of testicular cancer, infertility, or prior testicular pathology 1, 2

Imaging

• Scrotal ultrasound with Doppler is mandatory as the first-line imaging study—any hypoechoic mass with vascular flow is highly suggestive of malignancy 1
• Do NOT use MRI for initial evaluation of testicular lesions 1
• If findings are indeterminate with normal tumor markers, repeat ultrasound in 6-8 weeks 1

Laboratory Studies

• Draw serum tumor markers (AFP, β-HCG, LDH) BEFORE orchiectomy—this is critical for staging and cannot be obtained accurately after surgery 1
• Note: Pure seminoma does NOT secrete AFP; elevated AFP indicates non-seminomatous histology regardless of pathology findings 5
• Obtain complete blood count, renal function (creatinine, BUN), and liver function tests for baseline assessment 1

Pre-Treatment Counseling (Before Orchiectomy)

Fertility Preservation

• Offer sperm banking to all reproductive-age men BEFORE any treatment—this is particularly critical in patients without a normal contralateral testis or with known subfertility 1, 5
• Counsel about risks of hypogonadism and infertility from both the disease and subsequent treatments 1

Surgical Planning

• Radical inguinal orchiectomy through an inguinal incision is the standard surgical approach—NEVER use a scrotal approach, as scrotal violation increases local recurrence rates 1, 5
• The tumor-bearing testis is resected with the spermatic cord at the level of the internal inguinal ring 5

Post-Orchiectomy Staging

Tumor Marker Follow-Up

• Repeat tumor markers after orchiectomy until normalization, allowing adequate time for marker half-lives (β-HCG: 24-36 hours; AFP: 5-7 days) 5, 2

Imaging for Metastatic Disease

• CT scan of chest and abdomen to evaluate for pulmonary and retroperitoneal lymph node metastases 1
• Brain MRI (or CT if unavailable) if β-HCG >10,000 IU/L or >10 lung metastases 1
• Bone scan in patients with metastatic disease 1

Contralateral Testis Evaluation

• Consider contralateral testis biopsy in patients with testicular atrophy (<12 mL volume), age <30 years, or history of cryptorchidism, as there is >34% risk of testicular intraepithelial neoplasia (TIN) 3, 4

Treatment Based on Stage and Histology

Stage I Disease (70-75% of patients at diagnosis)

• Surveillance is the preferred approach for most Stage I patients after orchiectomy, as >80% are cured with surgery alone 5, 2
• Surveillance protocol: Clinical review, chest X-ray, and tumor markers monthly for 1 year, every 2 months for year 2, every 4 months for year 3, then every 6 months to 5 years; CT scans at 3,6,9,12, and 24 months 1
• 5-year survival rate: 99% 2

Stage II Disease (20% of patients)

• Treatment depends on extent of retroperitoneal lymph node involvement and risk classification 2
• Options include surveillance, chemotherapy, or retroperitoneal lymph node dissection (RPLND) 2, 6
• 5-year survival rate: 92% 2

Stage III Disease (10% of patients)

• Good-risk disease: BEP (bleomycin, etoposide, cisplatin) × 3 cycles or EP (etoposide, cisplatin) × 4 cycles 5
• Intermediate or poor-risk disease: BEP × 4 cycles 5
• Cisplatin dosing for testicular cancer: 20 mg/m² IV daily for 5 days per cycle in combination regimens 7
• 5-year survival rate: 85% 2

Post-Chemotherapy Management

• Resect residual masses post-chemotherapy wherever possible by a specialist surgeon 1
• Follow-up: Clinical review, chest X-ray, and tumor markers every 2 months for 1 year, every 3 months for year 2, then every 6 months to 5 years, then annually; CT scans only as clinically indicated 1

Critical Pitfalls to Avoid

• Never perform scrotal biopsy or scrotal incision for suspected malignancy—only inguinal approach is appropriate to prevent altered lymphatic drainage and local recurrence 5, 4
• Never delay obtaining tumor markers before orchiectomy—this information is essential for accurate staging and cannot be reliably obtained afterward 1, 5
• Never dismiss fertility counseling—sperm banking must be discussed before any intervention in reproductive-age men 1, 5
• Never use aluminum-containing needles or IV sets with cisplatin, as aluminum reacts with cisplatin causing precipitate formation and loss of potency 7
• Never administer cisplatin by rapid IV injection—it must be given by slow IV infusion over 6-8 hours with adequate pre-hydration (1-2 liters over 8-12 hours) and post-hydration 7

Multidisciplinary Care

• Patients should be treated by an oncologist with experience in testicular cancer treatment 1
• Management decisions should involve experienced clinicians in urology, medical oncology, pathology, and radiology, particularly at high-volume centers 5, 2