A 28-year-old man presents with a painless right testicular lump. Ultrasound confirms a 1.5 cm intratesticular heterogeneous mass. Tumour markers: AFP 850 ng/mL (elevated), beta-hCG 12 IU/L (mildly elevated), LDH normal. After right orchidectomy, histology shows 90% embryonal carcinoma, 10% teratoma — no yolk sac elements. Three weeks post-orchidectomy, AFP remains elevated at 500 ng/mL. Staging CT shows no retroperitoneal lymphadenopathy. What is the most appropriate next step?

• A Active surveillance as CT shows no nodal disease
• B Persistently elevated AFP post-orchidectomy indicates metastatic disease; BEP chemotherapy should be initiated ✓
• C Retroperitoneal lymph node dissection (RPLND) is the preferred treatment
• D Repeat CT in 6 weeks to allow AFP to normalise before deciding on management

Explanation

AFP has a half-life of approximately 5–7 days. Three weeks post-orchidectomy, AFP should have halved at least 3–4 times from 850 ng/mL to approximately 50–100 ng/mL if it were from the primary tumour alone. AFP of 500 ng/mL at 3 weeks represents a marker plateau or inadequate decline, which under IGCCCG and EAU guidelines constitutes marker-positive disease (stage IS — elevated markers post-orchidectomy with no radiological metastases), classified as the S1-3 marker category. Stage IS requires chemotherapy (3 cycles BEP for good-risk S1/S2), not surveillance or RPLND. RPLND is not appropriate for marker-positive disease.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.