Testicular Cancer: Evaluation
INITIAL EVALUATION (1)
Note:
Retrospective review of avascular hypoechoic lesions showed 23 of 63 lesions were malignant with 40 benign. (14) A retrospective study of small testicular masses who underwent partial orchiectomy after testicle biopsy vs. radical orch if frozen was positive found 14% malignant. (15)
- Physical exam
- Testicular ultrasound of both testicles
- Tumor markers (beta-HCG, AFP, LDH)
- CT chest, abdomen and pelvis with contrast
- Lymph Nodes >1.5cm are abnormal (2) Smaller LN may still have disease. Using 10mm as cutoff has shown sensitivity of 37% and specificity of 100% (3) . Using 8mm as the threshold gave sensitivity and specificity of about 70%. (4)
- Lymph nodes normally have fat in them
- 20-30% of patients with clinical stage II disease diagnosed by radiographic images have normal LN on final pathology (5,6)
- >50% with LN mets also have lung mets and ~10% have isolated lung mets. (7) <5% of pure seminoma have lung mets. (8)
- Bone scan if bone symptoms
- PET scan 6-8 weeks post chemo, only if pure seminoma post chemotherapy imaging shows mass >3cm
- MRI brain if symptoms or IGCCCG poor risk disease (12) and pure choriocarcinoma have higher risk of brain mets (13)
Note:
- US + Physical exam has sensitivity approaching 100%
- If equivocal lesions, especially less than 1cm with normal tumor markers, repeat ultrasound at 6 weeks as most <1cm will be benign with other lesions such as hematoma, epidermal cyst, infarct and infection that can look similar on US.
- PET scan should not routinely be used in initial evaluation and has limited value after chemotherapy due to extensive FDG uptake due to inflamation, the inability to detect small lesions and the fact that mature teratoma cannot be distinguished from necrosis. (1) The SEMPET trial shows there is a role for detection of residual disease in pure seminoma with sensitivity of 82%, specificity of 90%, NPV 95% and PPV 69% when performed 6 weeks after therapy (9,10) and recent meta-analysis covering 375 PET or PET/CTs from 9 studies showed sensitivity of 78%, specificity of 86%, PPV of 58% and NPV of 94%. (11)
Retrospective review of avascular hypoechoic lesions showed 23 of 63 lesions were malignant with 40 benign. (14) A retrospective study of small testicular masses who underwent partial orchiectomy after testicle biopsy vs. radical orch if frozen was positive found 14% malignant. (15)
- Daneshmand, Siamak, and Dorff, Tanya. "Lesson 3: Update on Medical and Surgical Management of Advanced Testis Cancer. AUA Update Series." (2018).
- Chalian, Hamid, et al. "Radiologic assessment of response to therapy: comparison of RECIST versions 1.1 and 1.0." Radiographics 31.7 (2011): 2093-2105.
- Hilton, S., et al. "CT detection of retroperitoneal lymph node metastases in patients with clinical stage I testicular nonseminomatous germ cell cancer: assessment of size and distribution criteria." AJR. American journal of roentgenology169.2 (1997): 521-525.
- Hudolin, Tvrtko, et al. "Correlation between retroperitoneal lymph node size and presence of metastases in nonseminomatous germ cell tumors." International journal of surgical pathology 20.1 (2012): 15-18.
- Donohue, John P., et al. "The role of retroperitoneal lymphadenectomy in clinical stage B testis cancer: the Indiana University experience (1965 to 1989)." The Journal of urology153.1 (1995): 85-89.
- Stephenson, Andrew J., et al. "Retroperitoneal lymph node dissection for nonseminomatous germ cell testicular cancer: impact of patient selection factors on outcome." Journal of clinical oncology 23.12 (2005): 2781-2788.
- Cagini, L., et al. "Thoracic metastasectomy for germ cell tumours: long term survival and prognostic factors." Annals of oncology 9.11 (1998): 1185-1191.
- White, P. M., et al. "Imaging of the thorax in the management of germ cell testicular tumours." Clinical radiology 54.4 (1999): 207-211.
- Bachner, M., et al. "2-18fluoro-deoxy-D-glucose positron emission tomography (FDG-PET) for postchemotherapy seminoma residual lesions: a retrospective validation of the SEMPET trial." Annals of oncology 23.1 (2011): 59-64.
- De Santis, Maria, et al. "2-18fluoro-deoxy-D-glucose positron emission tomography is a reliable predictor for viable tumor in postchemotherapy seminoma: an update of the prospective multicentric SEMPET trial." Journal of Clinical Oncology 22.6 (2004): 1034-1039.
- Treglia, Giorgio, et al. "Diagnostic performance of fluorine-18-fluorodeoxyglucose positron emission tomography in the postchemotherapy management of patients with seminoma: systematic review and meta-analysis." BioMed research international 2014 (2014).
- Wilkinson, Peter M., and G. Read. "International Germ Cell Consensus Classification: a prognostic factor-based staging system for metastatic germ cell cancers. International Germ Cell Cancer Collaborative Group." Journal of Clinical Oncology (1997).
- Kollmannsberger, C., et al. "First-line high-dose chemotherapy±radiation therapy in patients with metastatic germ-cell cancer and brain metastases." Annals of oncology11.5 (2000): 553-559.
- Ma, Weining, et al. "Causes of Avascular Hypoechoic Testicular Lesions Detected at Scrotal Ultrasound: Can They Be Considered Benign?." American Journal of Roentgenology209.1 (2017): 110-115.
- Gentile, Giorgio, et al. "Testis sparing surgery of small testicular masses: retrospective analysis of a multicenter cohort." The Journal of Urology 203.4 (2020): 760-766.