| The Testicular Cancer Resource Center |
First examination and diagnosis
This is not a diagnostic test, but it is often how the process starts. A new lump, enlargement, firmness, heaviness or other persistent change in a testicle should be examined by a doctor. The TCRC has a separate Self Exam page with more detail.
A doctor will usually examine and gently feel both testicles and the scrotum. The exam may also include the abdomen, groin, lymph-node areas and breasts. A physical exam cannot tell exactly what a testicular mass is, but it helps determine whether a lump is in the testicle itself and whether anything else is suspicious.
Ultrasound uses sound waves, not radiation, to look inside the testicle. It is usually the first imaging test when a testicular mass is suspected. It is very good at showing whether a mass is inside the testicle and whether it is solid or fluid-filled. Ultrasound is also used to examine the other testicle.
The orchiectomy itself is treatment, not a test. But the removed testicle gives the pathologist the tissue needed to identify the tumor type and describe how far it extended in and around the testicle. That pathology report usually supplies the T part of the formal stage.
Blood tests
AFP, beta-hCG and LDH are often ordered together and are collectively called the traditional testicular-cancer tumor markers. They are very different tests, however, and a patient can have one elevated while the others are normal. Many testicular cancers do not elevate any of them.
AFP can be produced by several types of nonseminoma, especially yolk sac tumor and embryonal carcinoma. Pure seminoma does not produce AFP, so a convincing AFP elevation in a tumor called pure seminoma needs an explanation. Liver disease and a few other conditions can also raise AFP.
AFP should ideally be measured before orchiectomy and then followed afterward when it was elevated. Because AFP clears from the blood relatively slowly, its trend after surgery can be more informative than a single postoperative number.
beta-hCG can be elevated in nonseminoma and in some seminomas. It usually clears from the blood much faster than AFP after marker-producing cancer is removed, so serial measurements can be especially useful. Low-level hCG results sometimes have non-cancer explanations or laboratory interference, which is one reason trends and the overall clinical picture matter.
LDH is much less specific than AFP or beta-hCG. Many illnesses and ordinary tissue injury can raise it. In testicular cancer it can roughly reflect tumor burden and it remains part of the formal AJCC staging and IGCCCG prognosis systems, but by itself it is a weak test for deciding whether germ-cell cancer is present.
When LDH is used for staging or prognosis, the number is compared with that laboratory's own upper limit of normal. This is why you may see LDH written as something like "2.0 times the upper limit of normal."
These are not cancer-staging tests. Their value is that they can document how well the testicles are functioning hormonally before surgery or other treatment changes anything. Not every center routinely checks them in every patient, but a pre-treatment baseline can be useful later if symptoms of low testosterone develop.
The laboratory "normal range" for testosterone is broad. A later testosterone result can still fall inside that range while being substantially lower than that man's own pre-treatment level. A baseline gives the patient and doctor something personal to compare with. If testosterone is low or borderline later, LH and FSH can help show whether the problem is mainly in the testicle or in the hormonal signals controlling it.
Imaging
Computed tomography uses x-rays taken from many angles to create detailed cross-sectional pictures of the body. CT is especially useful for looking at the retroperitoneal lymph nodes in the abdomen, which are a common first place for testicular cancer to spread. Contrast dye is often used to make organs and blood vessels easier to see.
CT is fast and widely available, but repeated CT scans add radiation exposure. That matters in a cancer that often affects young men who may be followed for years.
Both are used to look for disease in the chest. A chest x-ray is quick, inexpensive and uses relatively little radiation. Chest CT is much more detailed and can detect smaller lung nodules and lymph nodes, but it also finds more incidental spots that are not cancer.
Exactly which chest test is used depends on the situation and the guideline or surveillance protocol being followed. Chest CT is commonly used during initial staging, while chest x-ray may be used in some surveillance and follow-up schedules to reduce radiation.
MRI uses a strong magnetic field and radio waves rather than x-rays. It can be used instead of CT for abdominal and retroperitoneal imaging, particularly when avoiding repeated radiation is important. MRI is used more often for testicular-cancer surveillance in parts of Europe than in the United States.
MRI interpretation is more dependent on experience than CT. If MRI is being used routinely to follow retroperitoneal lymph nodes, a radiologist who is familiar with this use is preferable.
PET is used frequently in many other cancers. A small amount of radioactive glucose-like tracer is injected into a vein, and the scanner looks for areas that take up unusually large amounts of it. Many cancers are metabolically active and can appear as "hot" areas on PET.
Germ-cell tumors are different. PET/PET-CT should not be used for routine initial staging or routine surveillance of testicular cancer. It can produce false-positive findings and it can miss teratoma.
One narrow exception is a residual seminoma mass larger than 3 cm after chemotherapy. When PET is used there, current European guidance recommends waiting at least two months after chemotherapy because inflammation can cause false-positive results. A negative PET can be reassuring; a positive PET is much less definitive and should not automatically trigger more treatment.
Brain imaging is not routinely needed. When it is needed, MRI is generally preferred. It is considered when there are neurological symptoms or other features that make brain metastases more likely, especially multiple lung metastases, very high beta-hCG, or poor-prognosis metastatic disease.
Emerging tests
miR-371a-3p is a promising blood-based marker for many germ-cell tumors and appears to be substantially more sensitive than the traditional markers in many settings. It is not yet part of the standard AJCC staging system and does not reliably identify teratoma. Its role is still evolving.
Sources and further reading