Workup/Staging

Question 1

What imaging modality is preferred for primary evaluation of a testicular mass?

Answer 1

Transscrotal US is preferred for primary evaluation of a testicular mass. Testicular tumors are typically hypoechoic.

Question 2

What is the preferred primary surgical Tx for a unilat testicular tumor?

Answer 2

Transinguinal orchiectomy is the preferred surgical Tx for unilat testicular tumor.

Question 3

What are the 3 tumor markers that should be drawn before orchiectomy for testicular tumor?

Answer 3

Before orchiectomy for a testicular tumor, levels of a-HCG, AFP, and LDH should be drawn.

Question 4

What are the half-lives of a-HCG and AFP?

Answer 4

The half-life for a-HCG is 22 hrs. The half-life for AFP is 5 days.

Question 5

How commonly are a-HCG and AFP elevated in testicular seminoma vs. NSGCT? What are unrelated etiologies for elevated a-HCG and AFP?

Answer 5

β-HCG is elevated in 15% of seminomas. AFP is NEVER elevated in seminoma. 1 or both markers will be elevated in 85% of NSGCTs. The use of marijuana can elevate β-HCG, and reagent cross-reaction with LH can cause falsely elevated results. Hepatocellular carcinoma, cirrhosis, and hepatitis can elevate AFP.

Question 6

What imaging studies, labs, and evaluation should be ordered following transinguinal orchiectomy for seminoma?

Answer 6

Following transinguinal orchiectomy for seminoma, chest imaging (CXR), CT abdomen/pelvis, AFP, β-HCG, and LDH should be ordered. If the CT is positive, bone scan should be added. Pts should also have fertility evaluation and consider sperm banking.

Question 7

Describe the AJCC 8th edition TNM and S staging for testicular tumors.

Answer 7

pT1: tumor limited to testis (including rete testis invasion) without LVSI

pT1a: tumor smaller than 3 cm

pT1b: tumor 3 cm or larger

pT2: limited to testis (including rete testis) with LVSI OR tumor invading hilar ST or epididymis or penetrating visceral mesothelial layer covering external surface of tunica albuginea with or without LVSI

pT3: involvement of spermatic cord irrespective of LVSI

pT4: scrotal invasion

N1: single or multiple regional nodes, all ≤2 cm in greatest dimension

N2: single or multiple regional nodes, any >2–5 cm in greatest dimension

N3: single or multiple regional nodes, any >5 cm in greatest dimension

M1a: nonretroperitoneal nodal or pulmonary Dz

M1b: nonpulmonary visceral mets

S0: normal LDH, β-HCG, and AFP

S1: LDH <1.5 times normal, β-HCG <5,000 mIU/mL, and AFP <1,000 ng/mL

S2: LDH 1.5–10 times normal, β-HCG 5,000–50,000, or AFP 1,000–10,000

S3: LDH >10 times normal, β-HCG >50,000, or AFP >10,000

Question 8

Summarize the AJCC 8th edition stage grouping for testicular tumors.

Answer 8

Stage I: no Dz beyond testis/scrotum (i.e., pT1–4N0M0S0–3)

Stage II: regional nodal involvement and S0–S1 tumor markers (IIA = N1, IIB = N2, IIC = N3)

Stage III: S0–S3 tumor markers with N1–3 Dz, or M1 Dz

Question 9

What is the stage group distribution for testicular seminoma at presentation?

Answer 9

Most testicular seminoma pts present with stage I Dz (70%–80%), 15%–20% have stage II Dz, and 5% have stage III Dz.

Question 10

In addition to AJCC staging, what is another common staging system for testicular seminoma?

Answer 10

In addition to AJCC staging, Royal Marsden staging is also used for testicular seminoma. This staging is largely similar to the AJCC stage grouping:

Stage I: confined to testis

Stage IIA: node <2 cm

Stage IIB: node 2–5 cm

Stage IIC: node 5–10 cm

Stage IID: node >10 cm

Stage III: nodes above/below diaphragm

Stage IV: extralymphatic mets