A patient with a non-seminomatous germ cell testicular tumour has normal CT of the chest, abdomen and pelvis. HCG and AFP persist at a high level after orchidectomy. What is the best strategy?
Answer A
The correct answer is A, as no lymph nodes are seen on CT. If the marker level for AFP or HCG increases after orchidectomy, the patient has residual disease. An US examination of the contralateral testicle must be performed. In case of NSGCT, if RPLND is performed, up to 87% of these patients have pathologically documented nodes in the retroperitoneum. The treatment of true Clinical Stage 1S NSGT patients is still controversial. They may be treated with chemotherapy and with follow-up as for Clinical Stage 1B patients (high risk, see below) after primary chemotherapy or by RPLND. In the UK and Europe standard practice is chemotherapy then RPLND if required. Primary RPLND is reserved for those with retroperitoneal (RP) mass, normal tumour markers and TD in the primary and it is felt that the RP nodes are only TD. TD may appear cystic on imaging.
In cases where a NSGCT has rising tumour markers after orchidectomy and a normal staging CT scan the next step should be?
Answer C
FDG-PET CT is the most commonly used PET scan in patients with testicular cancer. Its role is limited to patients with seminoma and a residual retroperitoneal mass greater than 3 cm.
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