Management of Testicular Tumors in Children

Initial Diagnostic Evaluation

Any solid testicular mass in a child must be managed as malignant until proven otherwise, requiring immediate scrotal ultrasound with Doppler and serum tumor markers 1, 2
Scrotal ultrasound with Doppler is the mandatory first-line imaging modality, with nearly 100% sensitivity for detecting intrascrotal masses and 98-100% accuracy for distinguishing intratesticular from extratesticular processes 3
Serum tumor markers (AFP, β-HCG, LDH) must be drawn and measured before any treatment, including orchiectomy 1, 2, 3
Pure seminoma does not secrete AFP; elevated AFP indicates non-seminomatous histology even if pathology suggests seminoma 4

Radical inguinal orchiectomy through an inguinal incision is the standard surgical approach for suspected malignant testicular tumors in children 1, 6, 2
Never use a scrotal approach for suspected malignancy, as scrotal violation is associated with higher local recurrence rates 6, 3
The tumor-bearing testis is resected with the spermatic cord at the level of the internal inguinal ring 6, 4

Adolescents/post-pubertal boys should follow adult protocols for tumor behavior and treatment, not pediatric protocols, as inferior outcomes occur when post-pubertal males <18 years are treated according to pediatric guidelines 5

Sperm banking must be discussed and offered before any therapeutic intervention in post-pubertal boys, particularly those without a normal contralateral testis or with known subfertility 1, 2, 3
Determination of total testosterone, LH, and FSH should be performed before operation 4
Semen analysis and sperm banking should be completed before operation or chemotherapy 4

Tumor markers must be repeated after orchiectomy until normalization, with adequate time allowed for marker half-lives (HCG: 24-36 hours; AFP: 5-7 days) 5, 4
Chest imaging is mandatory in all newly diagnosed germ cell tumors 5
Abdominopelvic imaging (CT or MRI) to evaluate retroperitoneal lymph nodes 4

Stage I seminoma (adolescents/post-pubertal): surveillance is the preferred approach after orchiectomy, as >80% are cured with surgery alone 5
Good-risk disease: BEP (bleomycin, etoposide, cisplatin) x3 cycles or EP (etoposide, cisplatin) x4 cycles 5
Intermediate or poor-risk disease: BEP x4 cycles 5

Management decisions must be made in a multidisciplinary setting involving experienced clinicians in pediatric urology, medical oncology, pathology, and radiology 5
Expert pathology review should be considered, as testicular cancers are heterogeneous with multiple histologic elements 5

Never perform scrotal biopsy or scrotal incision for suspected malignancy—only inguinal approach is appropriate 6, 3
Never delay obtaining tumor markers before orchiectomy, as this information is essential for staging 1, 2
Never treat post-pubertal adolescents with pediatric protocols—they require adult treatment algorithms 5
Never dismiss the need for fertility counseling in post-pubertal boys before any intervention 1, 2