Patients with testicular cancer most frequently present with a painless testicular mass. The initial work-up includes a history and physical exam, cross-sectional imaging of the retroperitoneum, chest x-ray, and serum levels of AFP, hCG, and LDH.
Serum levels of AFP, hCG, and LDH should be obtained before orchiectomy and repeated weekly thereafter until marker levels normalize. Postorchiectomy tumor marker levels are used for risk stratification and are incorporated into the American Joint Committee on Cancer TNM Staging System for Testis Cancer. Men with nonseminomatous germ cell tumors (NSGCTs) with persistently elevated hCG or AFP following orchiectomy are presumed to have metastatic disease even without identifiable mass on imaging.
American Joint Committee on Testis Cancer S Stage parameters
| Stage | AFP (ug/I) | hCG (IU/I) | LDH |
| S0 | WNL | WNL | WNL |
| S1 | <1000 | <5000 | <1.5 × normal |
| S2 | 1000–10,000 | 5000–50,000 | 1.5–10 × normal |
| S3 | >10,000 | >50,000 | >10 × normal |
Abbreviations: AFP, alpha fetoprotein; hCG, human chorionic gonadotropin; LDH, lactate dehydrogenase; WNL, within normal limits.
The degree of AFP or hCG elevation is directly proportional to tumor burden, and higher serum levels of these tumor markers have been recognized as poor prognostic indicators. Therefore, the degree of marker elevation in patients with NSGCTs has been incorporated with staging criteria to stratify patients into good, intermediate, and poor risk groups according to the International Germ Cell Consensus Classification.
Prognostic-based staging system for metastatic germ cell cancer
| Group | Non-seminoma | Seminoma |
| Good-prognosis | All of the following criteria: • Testis/retroperitoneal primary • No non-pulmonary visceral metastases • AFP < 1,000 ng/mL • hCG < 5,000 IU/L (1,000 ng/mL) • LDH < 1.5 x ULN |
All of the following criteria: • Any primary site • No non-pulmonary visceral metastases • Normal AFP • Any hCG • Any LDH |
| Intermediate prognosis | All of the following criteria: • Testis/retroperitoneal primary • No non-pulmonary visceral metastases • AFP 1,000 – 10,000 ng/mL or • hCG 5,000 – 50,000 IU/L or • LDH 1.5 – 10 x ULN |
All of the following criteria: • Any primary site • Non-pulmonary visceral metastases • Normal AFP • Any hCG • Any LDH |
| Poor prognosis | Any of the following criteria: • Mediastinal primary • Non-pulmonary visceral metastases • AFP > 10,000 ng/mL or • hCG > 50,000 IU/L (10,000 ng/mL) or • LDH > 10 x ULN |
No patients classified as poor prognosis |
References:
- Adra N, Einhorn LH. Testicular cancer update. Clin Adv Hematol Oncol. 2017 May;15(5):386-396. [Medline]
- Milose JC, Filson CP, Weizer AZ, Hafez KS, Montgomery JS. Role of biochemical markers in testicular cancer: diagnosis, staging, and surveillance. Open Access J Urol. 2011 Dec 30;4:1-8. [Medline]
Created Dec 11, 2018.
