What is the recommended diagnostic work‑up and treatment approach for a male patient diagnosed with both a testicular germ‑cell tumor and prostate cancer?

Management of Concurrent Testicular Germ Cell Tumor and Prostate Cancer

When a patient presents with both testicular germ cell tumor and prostate cancer, treat each malignancy independently according to standard protocols, prioritizing the testicular cancer first due to its aggressive nature and excellent curability, while staging and risk-stratifying the prostate cancer to determine if it requires immediate intervention or can be managed with active surveillance. 1

Diagnostic Work-Up

For the Testicular Germ Cell Tumor

Immediate diagnostic steps:

• Perform radical inguinal orchiectomy as the definitive diagnostic and therapeutic procedure—this is mandatory and should not be delayed 1
• Obtain serum tumor markers (AFP, β-HCG, LDH) both pre- and post-orchiectomy to establish baseline values and monitor half-life kinetics (AFP <7 days; β-HCG <3 days) 1
• Complete staging with CT scan of chest, abdomen, and pelvis 1
• Obtain chest X-ray 1
• Consider contralateral testis biopsy, especially if testicular atrophy is present (<16 ml volume), as this may reveal testicular intraepithelial neoplasia (TIN) 1

Critical pitfall: If AFP is elevated, the tumor cannot be pure seminoma—this automatically indicates non-seminomatous components even if imaging suggests otherwise 2. Never assume pure seminoma with elevated AFP.

Additional imaging based on disease burden:

• Brain MRI (or CT) if β-HCG >10,000 IU/L or >10 lung metastases 1
• Bone scan only if alkaline phosphatase is elevated or symptoms present 1

For the Prostate Cancer

The prostate cancer work-up should proceed in parallel but not delay testicular cancer treatment. Standard prostate cancer staging and risk stratification should be completed to determine whether immediate treatment is necessary or if active surveillance is appropriate.

Treatment Approach

Testicular Germ Cell Tumor Takes Priority

Stage I disease (70-75% of cases at diagnosis):

• For seminoma: Options include surveillance, single-agent carboplatin chemotherapy, or radiotherapy to para-aortic lymph nodes (26 Gy) 3, 4
• For non-seminoma without vascular invasion: Surveillance is preferred 5, 4
• For non-seminoma with vascular invasion: One cycle of BEP (bleomycin, etoposide, cisplatin) chemotherapy 5

Stage II/III disease:

• BEP chemotherapy remains the standard of care 6, 7, 5
• Good-risk disease: 3 cycles of BEP 5, 4
• Intermediate/poor-risk disease: 4 cycles of BEP 5, 4
• Alternative regimens (EP or VIP) may be used to avoid bleomycin in selected patients 6, 5

The patient must be treated by an oncologist with specific experience in testicular cancer management 1

Sequencing Considerations

If both cancers require active treatment:

1. Complete testicular cancer treatment first, as it has excellent cure rates (99% for stage I, 92% for stage II, 85% for stage III) and is time-sensitive 7
2. Assess prostate cancer risk stratification—many prostate cancers, particularly low-risk disease, can be safely managed with active surveillance
3. If prostate cancer requires immediate treatment, coordinate timing with the testicular cancer treatment team to minimize overlapping toxicities

Important exception: In life-threatening metastatic testicular cancer with unequivocally elevated AFP or HCG, chemotherapy must be initiated immediately without delay—orchiectomy can be postponed until after chemotherapy completion 1

Fertility and Quality of Life Considerations

• Discuss sperm banking before any treatment, as both orchiectomy and chemotherapy affect fertility 1, 3
• Consider testosterone monitoring (total testosterone, LH, FSH) as bilateral testicular pathology or treatment may impact hormonal function 1
• Long-term survivorship concerns include cardiovascular disease risk, secondary malignancies, hypogonadism, and psychosocial effects 7

Follow-Up Strategy

For testicular cancer post-treatment:

• Surveillance patients: Monthly clinical review, chest X-ray, and tumor markers for year 1; every 2 months for year 2; every 4 months for year 3; every 6 months to year 5. CT scans at 3,6,9,12, and 24 months 1
• Post-chemotherapy patients: Every 2 months for year 1; every 3 months for year 2; every 6 months to year 5; then annually. CT scans only as clinically indicated 1

For prostate cancer: Follow standard prostate cancer surveillance protocols based on treatment modality and risk stratification.

Critical Pitfalls to Avoid

• Never delay testicular cancer diagnosis or treatment to complete prostate cancer work-up 1
• Do not perform trans-scrotal biopsy or surgery—always use inguinal approach for testicular masses 1
• Ensure tumor markers are obtained before orchiectomy and repeated post-operatively to establish proper kinetics 1
• Do not reduce chemotherapy doses or delay cycles for testicular cancer—this compromises cure rates 6
• Remember that residual masses after chemotherapy for non-seminoma require surgical resection by a specialist surgeon 1