Evaluation

Testicular Cancer: Evaluation

INITIAL EVALUATION (1)

Physical exam
Testicular ultrasound of both testicles
Tumor markers (beta-HCG, AFP, LDH)
CT chest, abdomen and pelvis with contrast
1. 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)
2. Lymph nodes normally have fat in them
3. 20-30% of patients with clinical stage II disease diagnosed by radiographic images have normal LN on final pathology (5,6)
4. >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)