If a person is suspected to have testicular cancer due to the presence of signs and symptoms, testicular cancer investigations are required to confirm the diagnosis of the disease.
Further, these investigations can help in determining the stage of the disease to other body parts, which in turn help in choosing an appropriate treatment option.
Following are some commonly used diagnostic tools for testicular cancer:
Methods for Testicular Cancer Investigations:
1. Ultrasound: Ultrasound of the scrotum is generally the first test performed when testicular cancer is suspected. In this technique, sound waves at very high frequency are used to produce images of the internal body structures.
Using a special instrument, sound waves are directed towards the target body parts to be examined, which are reflected off the internal body parts and collected by a special probe to produce a real-time image of the tissues reflecting varying degrees of sound on a computer screen. This helps the doctor to examine both the testes along with the nearby structures for any abnormal areas.
This test can distinguish testicular cancer from non-cancerous conditions such as testicular torsion, hydrocele, varicocele, spermatocele, and epididymitis.
2. Blood tests for tumor markers: Tumor markers are generally proteins or other substances produced by normal cells and cancer cells as well. However, in case of cancer, the level of these markers rises in blood, urine, or other body fluids, which can be detected by certain laboratory tests.
Human chorionic gonadotropin (HCG), alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH) are common tumor markers for testicular cancer. Assessment of levels of these markers is very useful in testicular cancer as the blood level of these markers convey useful information concerning diagnosis, staging, prognosis (course of a medical condition), disease progression/recurrence, and response to treatment.
- HCG: HCG is a glycoprotein consisting of 2 subunits – alpha and beta. HCG level in blood is generally measured with the help of beta-subunit. An elevated level of HCG is usually associated with embryonal carcinoma, choriocarcinoma, and seminoma. Extremely high level of HCG is generally detected in choriocarcinoma. However, an increase in the level of HCG can also be seen in other cancer types such as prostate, bladder, ureteral, renal cancer, etc.
- AFP: An elevated level of AFP is usually associated with embryonal carcinoma and yolk sac tumors. Seminomas and choriocarcinoma do not increase the level of AFP. However, increased level of AFP may also be found in patients with hepatocellular carcinoma, liver cirrhosis, hepatitis, etc.
- LDH: LDH is an enzyme which helps in energy production and normally found in almost all body tissues. An elevated level of LDH is generally associated with the tissue damage. In patients with testicular cancer, it is usually related to tumor burden, disease prognosis, and indicates the response to treatment.
3. Inguinal orchiectomy: If the abnormal area(s) are observed during the ultrasound examination, the doctor may recommend high inguinal orchiectomy (surgical resection of the affected testicle). Orchiectomy is considered most important for pathological diagnosis and as a curative procedure for testicular cancer. The entire tumor along with the affected testicle and spermatic cord (containing part of the vas deferens), and associated blood and lymph vessels (that can provide passage for cancer spread) are removed during the procedure. The collected sample is then tested in a laboratory to find out the type and extent of disease.
4. Imaging Tests: These tests are generally employed after the establishment of the pathological diagnosis. They help to diagnose the extent of locoregional invasion and spread of disease to the distant organs. Alternatively, these tests are employed after treatment to evaluate the treatment efficacy and to detect any signs of disease progression/recurrence.
- Computed tomography (CT) scan: In this technique, detailed cross-sectional images of body organs are generated using x-rays, with or without a contrast medium. It can help diagnose the spread of disease to nearby/distant lymph nodes and other organs, and may also be used to guide a biopsy needle into the affected area.
- Positron emission tomography (PET) scan: This technique uses a radioactive substance (fluorodeoxyglucose [FDG], etc) that is given via intravenous injection prior to the procedure. Cancer cells absorb larger amounts of the radioactive substance than normal cells. The areas of higher radioactivity indicate cancerous tissue on the PET scan. Thus, this technique can diagnose unsuspected spread of disease to distant body parts. It is usually combined with CT scan (PET/CT). The indications of PET are very limited in testicular germ cell tumor, mainly in recurrent NSGCT.
- Magnetic resonance imaging (MRI) scan: This technique provides detailed images of tissues inside the body using radio waves, a strong magnetic field, and gadolinium contrast. It can accurately diagnose the extent of invasion and spread of disease to nearby/distant body parts.
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Watch the video below to understand the INVESTIGATIONS required for diagnosis and staging of testicular cancer.
CancerBro, if anyone comes with a testicular mass is it always testicular cancer only?
No, not necessarily, conditions other than testicular cancer may also be present similarly. For this, we have to further investigate the patient.
The next step is testicular ultrasound. It helps us to differentiate whether the mass is intra-testicular or extra-testicular, that is, whether it is inside or outside the testis.
Then we have to see whether it is solid or cystic.
A solid, intratesticular mass goes in the favor of testicular cancer.
The next step is to do blood tests, to check for tumor markers.
Before discussing the tumor markers in detail, we will first discuss the subtypes of testicular cancer.
Testicular tumors may be broadly divided into seminomas and non-seminomas.
The non-seminomatous germ cell tumors may be further divided into embryonal carcinoma, endodermal sinus or yolk sac tumor, choriocarcinoma or teratoma.
Now, let’s discuss the tumor markers for testicular germ cell tumors according to the subtypes.
First we will discus about seminoma. In seminoma, LDH is the most commonly elevated tumor marker, and beta-HCG may be elevated in some cases.
Next comes choriocarcinoma, in which beta HCG is significantly elevated, and LDH maybe elevated in some cases.
In endodermal sinus or yolk sac tumors, AFP is significantly elevated and LDH maybe elevated in some cases.
And in embryonal carcinoma all the three, that is, AFP, beta HCG and LDH maybe elevated.
So after doing testicular ultrasound and tumor markers, the next step is systemic imaging. This helps us to diagnose the spread of the disease to other part of the body.
For systemic imaging, we require the CT scan of abdomen, pelvis and thorax.
Very rarely, we may require MRI brain or bone scan to look for the spread of the disease to brain or bones.
So after doing testicular ultrasound, tumor markers and system imaging, we are very close to diagnosis, but to be 100% sure, we require a tissue histropathology.
So for that, we do high inguinal orchiectomy, in which the involved testis is removed.
The procedure is both diagnostic as well as therapeutic because it provides tissue for histopathological diagnosis, as well as it removes the involved testis.
A pathology report after high inguinal orchiectomy confirms the diagnosis of germ cell tumor. It also tells us whether it is a seminoma or non-seminoma or whether it is a mixed germ cell tumor, having components of both.
It also tells about the sub-type of non-seminoma, that is, whether it is embryonal carcinoma, endodermal sinus or yolk sac tumor, choriocarcinoma or teratoma.
CancerBro, as you previously told, even the tumor markers can help to differentiate the various sub-types of germ cell tumors.
The tumor markers may not br elevated in all the cases, and even if they are elevated they are highly overlapping in different sub-types, so 100% diagnosis is rarely possible with just the tumor markers.
Therefor, for the confirmation of the diagnosis of testicular germ cell tumor, we require both, that is histopathology and tumor markers.
Rarely, it is possible that histopathology shows seminoma, but AFP is elevated, such cases are related as non-seminoma.
So, always remember that elevation of AFP strictly goes in the favor of non-seminoma even if the hispathological diagnosis is suggestive of a seminoma.
Once the diagnosis of the testicular germ cell tumor is confirmed, the next step is staging and risk stratification of the disease.