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Testicular Cancer Workup

  • Author: Kush Sachdeva, MD; Chief Editor: Jules E Harris, MD, FACP, FRCPC  more...
 
Updated: Jun 03, 2016
 

Approach Considerations

The workup of patients with suspected testicular cancer includes a complete history and physical examination. Lab tests and imaging studies include the following[14] :

  • Serum alpha-fetoprotein
  • Serum beta subunit of human chorionic gonadotropin (beta-hCG)
  • Lactate dehydrogenase (LDH)
  • Chemistry profile
  • Testicular ultrasound
  • High-resolution computed tomography (CT) scan of the abdomen and pelvis
  • Chest x-ray
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Imaging Studies

Testicular ultrasonography

Ultrasound can distinguish intrinsic from extrinsic testicular lesions and can identify masses within testes. A cystic or fluid-filled mass is unlikely to represent malignancy. Seminomas appear as well-defined hypoechoic lesions without cystic areas, while nonseminomatous germ cell tumors (NSGCTs) are typically nonhomogeneous hyperechoic lesions with calcifications, cystic areas, and indistinct margins. Ultrasound is not reliable in local tumor staging.

Other radiographic imaging

Once the diagnosis of testicular cancer is made, a high-resolution computed tomography (CT) scan of the abdomen and pelvis and a chest x-ray are ordered as part of the initial staging workup. Chest CT is recommended if the chest x-ray is abnormal, or if metastatic disease in the thorax is strongly suspected clinically.

Magnetic resonance imaging (MRI) of the abdomen and pelvis or scrotum usually adds little to the information obtained by CT scan and ultrasound. MRI of the brain and a bone scan are performed if brain and bone metastases are suspected.

Because of frequent false negative results positron emission tomography (PET) scans is of limited utility in the initial staging of patients with testicular cancers. However, PET scanning is gaining a significant adjunctive role in the evaluation of posttherapy residual masses. PET scans are negative in teratoma; therefore, PET scans could be used in some cases of nonseminoma.

Lymphangiograhy is currently rarely used to evaluate microscopic nodal involvement.

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Procedures

Radical inguinal orchiectomy and retroperitoneal lymph node dissection

Patients with a suggestive testicular mass, abnormal ultrasonographic findings, or both should undergo a radical inguinal orchiectomy. Radical inguinal orchiectomy is the definitive procedure to permit histologic evaluation of the primary tumor and to provide local tumor control. In patients with disseminated germ cell tumor, because of the incomplete penetration of the chemotherapeutic agent to the testes, orchiectomy must be performed sooner or later.

Intraoperative testicular and paratesticular frozen section assessments may be helpful in preserving patients' testicles. Results of a retrospective review of assessments performed on 45 testicular lesions and 20 paratesticular lesions show the procedure was successful in identifying benign lesions, therefore successfully avoiding orchiectomy. Frozen section assessment may be especially helpful in men with small, nonpalpable, incidentally found masses.[15]

Biopsy of a suggestive testicular lesion is not recommended.

Transscrotal orchiectomies are contraindicated, as they have been associated with local recurrence and spread to inguinal lymph nodes.

Retroperitoneal lymph node dissection (RPLND) is the gold standard and the only reliable method to identify nodal micrometastases and provide accurate pathologic staging of the retroperitoneal disease. Both the number and size of involved retroperitoneal lymph nodes have prognostic importance.

In patients with early-stage nonseminoma, RPLND should be considered following radiographic evaluation of the retroperitoneum and radical inguinal orchiectomy. The transabdominal approach is technically more difficult but poses a lower risk of small bowel obstruction and requires a shorter hospital stay.

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Histologic Findings

Cellular Classification

Approximately 95% of testicular tumors are germ cell tumors. These are divided into two types: pure seminoma (no nonseminomatous element present) and nonseminomatous germ cell tumors. Less than 50% of malignant testicular germ cell tumors are of a single cell type; roughly 50% of these are seminomas. Determining the cell type of these tumors is important for estimating the risk of metastasis and the response to chemotherapy.

The World Health Organization uses following histologic classification of malignant testicular germ cell tumors.

1. Intratubular germ cell neoplasia, unclassified.

2. Malignant pure germ cell tumor (showing a single cell type):

A. Seminoma

B. Embryonal carcinoma

C. Teratoma

D. Choriocarcinoma

E. Yolk sac tumor

3. Malignant mixed germ cell tumor (showing more than one histologic pattern):

A. Embryonal carcinoma and teratoma with or without seminoma.

B. Embryonal carcinoma and yolk sac tumor with or without seminoma.

C. Embryonal carcinoma and seminoma.

D. Yolk sac tumor and teratoma with or without seminoma.

E. Choriocarcinoma and any other element.

4. Polyembryoma

Seminoma

In addition to pure seminomas, which constitute roughly 50% of pure germ cell tumors, a seminomatous component is present in 20% of mixed germ cell tumors. Serum tumor markers are usually at normal levels, but if syncytiotrophoblastic giant cells are present, beta-hCG may be elevated.

Spermatic seminomas are a variant of seminoma that differ in their clinical characteristics. They generally occur in older men (>60 years) and rarely metastasize without sarcomatous differentiation. They do not occur as part of mixed germ cell tumor and do not contain an isochromosome 12p.

Nonseminoma

Embryonal carcinomas constitute about 2% of all testicular germ cell tumors but are the histological type in 85% of mixed germ cell tumors. They have large pleomorphic cells with different architectural patterns.

Teratomas are part of the mixed germ cell tumor and are generally benign but have the potential for metastasis. They have elements from all three germ layers: ectoderm, endoderm, and mesoderm. In patients with residual disease after chemotherapy, teratoma is found in approximately 45% of resected specimens.

Choriocarcinomas are the least common type of nonseminoma but are very aggressive. Widespread hematological metastasis can occur very early in the disease course; the retroperitoneum may be spared. Choriocarcinomas are associated with increased levels of beta-hCG.

Yolk cell tumors, also called endodermal sinus tumor, are the most common testicular tumor in infants and young children. In adults, pure yolk cell tumors are rare, but yolk cell elements are found in approximately 40% of mixed germ cell tumors. Yolk cell tumors are associated with elevated alpha fetoprotein levels but they do not produce beta-hCG.

Mixed germ cell tumors (ie, those containing two or more germ cell types) constitute approximately one third of testicular cancer. Mixed germ cell tumor behave like nonseminomas. The average age at diagnosis is older than 30 years.

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Staging

Staging for testicular cancer follows the TNM (tumor, node, metastasis) system.

Tumor

The extent of primary tumor (pT) is classified after radical orchiectomy. Classifications are as follows:

  • pTX – Primary tumor cannot be assessed (if radical orchiectomy has not been performed, Tx is used)
  • pT0 – No evidence of primary tumor (eg, histologic scar in testis)
  • pTis – Intratubular germ cell neoplasia (carcinoma in situ)
  • pT1 – Tumor limited to the testis and epididymis without vascular/lymphatic invasion, or tumor invasion into the tunica albuginea but not the tunical vaginalis
  • pT2 – Tumor limited to the testis and epididymis with vascular/lymphatic invasion, or tumor extending through the tunica albuginea with involvement of the tunica vaginalis
  • pT3 – Tumor invades the spermatic cord with or without vascular/lymphatic invasion
  • pT4 – Tumor invades the scrotum with or without vascular/lymphatic invasion

Node

Regional lymph node involvement is used for clinical (N) or pathologic (pN) staging, as follows:

  • NX or pNX – Regional lymph nodes cannot be assessed
  • N0 or pN0 – No regional lymph node metastasis
  • N1 or pN1 – Metastases with a lymph node mass 2 cm or less in greatest dimension; or multiple lymph nodes, none more than 2 cm in greatest dimension
  • N2 or pN2 – Metastases with a lymph node mass more than 2 cm but not more than 5 cm in greatest dimension; or multiple lymph nodes, any one mass greater than 2 cm but not more than 5 cm in greatest dimension.
  • N3 or pN3 – Metastases with a lymph node mass more than 5 cm in greatest dimension

Metastasis

Distant metastasis (M) is classified as follows:

  • MX – Distant metastasis cannot be assessed
  • M0 – No distant metastasis
  • M1 – Distant metastasis
  • M1a – Nonregional nodal or pulmonary metastasis
  • M1b – Distant metastasis other than to nonregional lymph nodes and lungs

American Joint Committee on Cancer (AJCC) Stage Groupings

The AJCC stage groupings use both TNM staging and serum tumor marker levels. The designation SX indicates that markers were unavailable or not performed; S0 indicates normal levels. The table below defines other S categories.

Table 1. Serum Tumor Markers (Open Table in a new window)

       
Stage LDH HCG (mIU/mL) AFP (ng/mL)
       
S1 < 1.5 times normal < 5,000 < 1,000
S2 1.5-10 times normal 5,000-50,000 1,000-10,000
S3 >10 times normal >50,000 >10,000
LDH=lactate dehydrogenase; HCG=beta human chorionic gonadotropin; AFP=alpha fetoprotein.  

AJCC stage groupings are as follows[16] :

  • Stage 0 - pTis, N0, M0, S0
  • Stage I - pT1–4, N0, M0, SX
  • Stage IA - pT1, N0, M0, S0
  • Stage IB - pT2–4; N0, M0, S0
  • Stage IS - Any pT/Tx, N0, M0, S1–3
  • Stage II - Any pT/Tx, N1–3, M0, SX
  • Stage IIA - Any pT/Tx, N1, M0, S0–1
  • Stage IIB - Any pT/Tx, N2, M0, S0–1
  • Stage IIC - Any pT/Tx, N3, M0, S0–1
  • Stage III - Any pT/Tx, any N, M1, SX
  • Stage IIIA - Any pT/Tx, any N, M1a, S0–1
  • Stage IIIB - Any pT/Tx, N1–3, M0, S2; or any pT/Tx, any N, M1a, S2
  • Stage IIIC - Any pT/Tx, N1–3, M0, S3; any pT/Tx, any N, M1a, S3; or any pT/Tx, any N, M1b, any S

Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois.

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Risk Classification

Risk classification for both nonseminomas and seminomas is determined on the basis of tumor and metastasis characteristics and serum tumor marker levels. Nonseminomas are classified as good, intermediate, or poor risk. Seminomas are classified as good or intermediate risk; no patients with seminomas are considered to have a poor prognosis.

Good-risk nonseminoma

Nonseminomas are classified as good risk when all of the following are present:

  • Testicular or retroperitoneal primary tumor
  • No nonpulmonary visceral metastases
  • Good markers

Good markers are defined as all of the following:

  • Alpha-fetoprotein (AFP) < 1,000 ng/mL
  • Human chorionic gonadotropin (hCG) < 5,000 IU/mL (1,000 ng/mL)
  • Lactate dehydrogenase (LDH) < 1.5 times the upper limit of normal

Intermediate-risk nonseminoma

Nonseminomas are classified as intermediate risk when all of the following are present:

  • Testicular or retroperitoneal primary tumor
  • No nonpulmonary visceral metastases
  • Any intermediate markers

Intermediate markers are defined as follows:

  • AFP 1,000 to 10,000 ng/mL
  • hCG 5,000 IU/L to 50,000 IU/L
  • LDH 1.5 to 10 times the upper limit of normal

Poor-risk nonseminoma

Nonseminomas are classified as poor risk when any of the following are present:

  • Mediastinal primary
  • Nonpulmonary visceral metastases
  • Any poor markers[#Section_111]

Poor markers are as follows:

  • AFP > 10,000 ng/mL
  • hCG > 50,000 IU/mL (10,000 ng/mL), or
  • LDH > 10 times the upper limit of normal

Good-risk seminoma

Seminomas are classified as good risk when all of the following are present:

  • Any primary site
  • No nonpulmonary visceral metastases
  • Normal AFP, any hCG, any LDH[#Section_96]

Intermediate-risk seminoma

Seminomas are classified as intermediate risk when all of the following are present:

  • Any primary site
  • Nonpulmonary visceral metastases
  • Normal AFP, any hCG, any LDH[#Section_106]
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Lab Studies

Blood should be obtained for a chemistry profile including lactate dehydrogenase (LDH), complete blood count, and serum tumor markers including alpha fetoprotein (AFP), and the beta subunit of human chorionic gonadotropin (beta-hCG).

Serum levels of AFP and/or beta-hCG are elevated in approximately 80% to 85% of patients with nonseminomatous germ cell tumors (NSGCTs), even when nonmetastatic. Patients with pure seminoma may have elevated levels of beta-hCG but do not have elevated AFP levels. If AFP is elevated in patients with pure seminoma then the presence of an NSGCT component should be considered.

Elevation of serum beta-hCG and AFP levels, alone or in combination, is not sufficiently sensitive or specific to establish the diagnosis of testicular cancer in the absence of histologic confirmation, although markedly elevated levels are rarely found in normal individuals. However, AFP, beta-hCG, and LDH levels are vital in the evaluation and management of patients with testicular cancers. They are used for determining diagnosis, staging, and prognosis and for following response to therapy. Obtaining levels of AFP, beta-HCG, and LDH in patients in whom testicular cancer are suspected is mandatory prior to treatment, as is monitoring of these levels during and after treatment.

Serum alpha-fetoprotein features are as follows:

  • Secretion is restricted to nonseminoma
  • Reference adult concentration is < 10 ng/mL
  • Serum half-life is 4-5 days
  • Concentrations above 10,000 ng/ml are seen exclusively in germ cell tumor and hepatocellular carcinoma
  • levels may be elevated in patients with hepatic dysfunction, hepatitis, cirrhosis, and drug or alcohol abuse

B-hCG features are as follows:

  • Increased levels of beta-HCG can be found in either seminoma or nonseminoma
  • Serum half-life is 18-36 hours
  • Patients with high levels of beta-HCG may experience nipple tenderness or gynecomastia
  • Serum beta-hCG concentrations above 10,000 mIU/mL are seen exclusively in germ cell tumor
  • Elevated levels may also be seen in patients with trophoblastic differentiation of a lung or gastric primary cancer or with hypogonadism
  • False-positive elevations may result from marijuana use

LDH features are as follows:

  • LDH has independent prognostic significance: increased levels reflect tumor burden, growth rate, and cellular proliferation
  • levels are elevated in 30% to 80% of patients with pure seminoma and 60% of patients with nonseminomatous tumors
  • LDH is not a sensitive or specific indicator of disease recurrence and therefore is not a useful serum marker for posttreatment surveillance
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Contributor Information and Disclosures
Author

Kush Sachdeva, MD Southern Oncology and Hematology Associates, South Jersey Healthcare, Fox Chase Cancer Center Partner

Disclosure: Nothing to disclose.

Coauthor(s)

Brendan Curti, MD Director, Genitourinary Oncology Research, Robert W Franz Cancer Research Center, Earle A Chiles Research Institute, Providence Cancer Center

Brendan Curti, MD is a member of the following medical societies: American College of Physicians, American Society of Clinical Oncology, Oregon Medical Association, Society for Immunotherapy of Cancer

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Prometheus Pharmaceuticals<br/>Received research grant from: Prometheus Pharmaceuticals.

Issam Makhoul, MD Associate Professor, Department of Medicine, Division of Hematology/Oncology, University of Arkansas for Medical Sciences

Issam Makhoul, MD is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology

Disclosure: Nothing to disclose.

Mansoor Javeed, MD, FACP Clinical Assistant Professor of Medicine, University of California, Davis, School of Medicine; Consultant, Sierra Hematology-Oncology Medical Center

Mansoor Javeed, MD, FACP is a member of the following medical societies: American College of Physicians, Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Bagi RP Jana, MD Associate Professor of Medicine (Genitourinary Oncology), Division of Hematology and Oncology, University of Texas Medical Branch

Bagi RP Jana, MD is a member of the following medical societies: American Cancer Society, American Medical Association, SWOG, American Society of Clinical Oncology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jules E Harris, MD, FACP, FRCPC Clinical Professor of Medicine, Section of Hematology/Oncology, University of Arizona College of Medicine, Arizona Cancer Center

Jules E Harris, MD, FACP, FRCPC is a member of the following medical societies: American Association for the Advancement of Science, American Society of Hematology, Central Society for Clinical and Translational Research, American Society of Clinical Oncology

Disclosure: Nothing to disclose.

Additional Contributors

Philip Schulman, MD Chief, Medical Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center

Philip Schulman, MD is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Society of Hematology, Medical Society of the State of New York

Disclosure: Nothing to disclose.

Acknowledgements

The author and editors wish to thank Salah Almokadem, MD,  Assistant Professor of Medicine, Department of Medicine, Penn State Milton S Hershey Medical Center; and Charles J Ryan, MD, Assistant Clinical Professor, Department of Medicine, Division of Hematology and Oncology, University of California at San Francisco, for their contributions to previous versions of this article.

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Table. Incidence of Testicular Cancer by Race
Incidence of Testicular Cancer by Race
Race/Ethnicity Annual rate per 100,000 men
All Races 5.7
White 6.7
Black 1.5
Asian/Pacific Islander 2.1
American Indian/Alaska Native 4.9
Hispanic 5.0
Table 1. Serum Tumor Markers
       
Stage LDH HCG (mIU/mL) AFP (ng/mL)
       
S1 < 1.5 times normal < 5,000 < 1,000
S2 1.5-10 times normal 5,000-50,000 1,000-10,000
S3 >10 times normal >50,000 >10,000
LDH=lactate dehydrogenase; HCG=beta human chorionic gonadotropin; AFP=alpha fetoprotein.  
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