The initial evaluation of a possible testis cancer should involve:

• Scrotal ultrasound.
• Testicular tumor markers.
• Advanced imaging (optional).
• Orchiectomy.

Scrotal Ultrasound

Scrotal ultrasound often demonstrates an intratesticular, hypoechoic (dark) mass. Testis cancers are often vascular (or hypervascular), although the absence of blood flow does not rule out a testis cancer. Even in patients with suspicion of metastatic cancer, a scrotal ultrasound should be used to identify an active primary tumor or a “burned out” testicular mass, which is typically a small, impalpable scar or calcification. Radical orchiectomy should strongly be considered for any intratesticular mass and suspicion of testis cancer.

Testicular Tumor Markers

Testicular cancer is one of the few cancers associated with tumor markers. These markers are well established to help in the diagnosis, prognosis, treatment and monitoring of testis cancer. Tumor markers include alphafetoprotein (AFP), human chorionic gonadotropin (hCG) and lactate dehydrogenase (LDH).

Advanced Imaging

Additional imaging can be performed before or after the diagnosis of cancer is confirmed, based on the strength of suspicion for cancer. Imaging of the chest, abdomen and pelvis are typically required to evaluate for spread of testicular cancer — this process is called staging. CT, MRI and X-ray can be used for staging. PET scan or bone scan are not recommended for the routine evaluation of testicular cancer.

Orchiectomy

Biopsy (or removal of just a portion of the tumor) is not recommended for testis cancers, as this can spread the cancer and changes lymphatic drainage patterns. Therefore, surgical removal of the testicle is diagnostic (confirming the clinical suspicion provided by physical examination, ultrasound and tumor markers) and therapeutic in most cases.