Working Diagnosis:
An elevated human chorionic gonadotropin and alpha-fetoprotein with associated ultrasound findings are consistent with testicular cancer

Treatment:
The athlete underwent a left radical orchiectomy. Pathology of the testicle found a mixed germ cell tumor, the majority of which was embryonal carcinoma. Pulmonary function tests were obtained prior to initiation of chemotherapy. He received one round of chemotherapy treatment consisting of Bleomycin, Etoposide, and Cisplatin. Follow up pulmonary function tests after the initial round of chemotherapy found a twenty percent decrease in lung function, therefore his further treatments were altered to only include Etoposide and Cisplatin. He ultimately received three rounds total of chemotherapy.

Outcome:
Follow up labs found hCG and AFP levels were undetectable and repeat CT of the abdomen and pelvis throughout the course of treatment demonstrated full resolution of lymphadenopathy. The athlete continued with supervised light conditioning and progressive strength training throughout his course of treatment and was able to return to playing competitively 6 months after his diagnosis.

Author's Comments:
Human chorionic gonadotropin is a glycoprotein hormone normally produced by the trophoblasts of the placenta. This hormone not only stimulates progesterone and estradiol in female ovaries but also testosterone production in male testicles by mimicking luteinizing hormone stimulation of Leydig cells. The increased testosterone production leads to enhanced muscle mass and strength. Exogenous hCG use can be used to prevent hypothalamic-pituitary-gonadal axis suppression associated with exogenous testosterone use. Serum levels of hCG can be tested to determine exogenous use in males. The hormone can be detected in urine up to 10 days after administration. A concentration greater than 5 IU/L is considered positive.

Testicular cancer is the most common malignancy in men aged 15 to 45. This form of cancer typically has a very high successful cure rate and a five-year survival rate above ninety-five percent. The standard treatment of this type of testicular cancer is typically three rounds of triple therapy treatment consisting of Bleomycin, Etoposide, and Cisplatin, though there have been cases where only Etoposide and Cisplatin are used in order to decrease the amount of side effects for patients. Special considerations in treatment have to be taken, especially in athletes, to preserve lung function capacity.

This case demonstrates how performance-enhancing drug screening may incidentally uncover a serious and otherwise asymptomatic underlying condition, which facilitated earlier diagnosis and intervention. This case also brings about the question of who is responsible for following up on abnormal labs when tested for WADA screening. By leaving the responsibility to young athletes there is the possibility that evaluation is delayed and metastasis can occur. Athletes may be afraid to bring up abnormal results for fear of disqualification from playing. Medical staff should have conversations with athletes to bring about awareness regarding not only testicular cancer but also reasons behind the routine WADA screenings and results.

Editor's Comments:
Exogenous hCG can be used as a doping agent to stimulate production of testosterone by the testes, leading to increased muscle mass and strength in male athletes. An elevated hCG level should prompt the clinician to look for pathologic causes of increased production, including testicular cancer, tumors in other areas of the body, or pituitary production.

References:
Gaddam SJ, Bicer F, Chesnut GT. Testicular Cancer. [Updated 2023 May 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563159/
Park JS, Kim J, Elghiaty A, Ham WS. Recent global trends in testicular cancer incidence and mortality. Medicine (Baltimore). 2018;97(37):e12390. doi:10.1097/MD.0000000000012390
Baird DC, Meyers GJ, Hu JS. Testicular Cancer: Diagnosis and Treatment. Am Fam Physician. 2018;97(4):261-268.
Smith ZL, Werntz RP, Eggener SE. Testicular Cancer: Epidemiology, Diagnosis, and Management. Med Clin North Am. 2018;102(2):251-264. doi:10.1016/j.mcna.2017.10.003
Lund H, Snilsberg AH, Paus E, Halvorsen TG, Hemmersbach P, Reubsaet L. Sports drug testing using immuno-MS: clinical study comprising administration of human chorionic gonadotropin to males. Anal Bioanal Chem. 2013;405(5):1569-1576. doi:10.1007/s00216-012-6566-6
Kuuranne T, Ahola L, Pussinen C, Leinonen A. Analysis of human chorionic gonadotropin (hCG): application of routine immunological methods for initial testing and confirmation analysis in doping control. Drug Test Anal. 2013;5(8):614-618. doi:10.1002/dta.1449
https://www.wada-ama.org/en/resources/scientific-research/development-standardized-methods-determinational-hcg-urine
https://www.wada-ama.org/sites/default/files/resources/files/wada_guidelines_hcg_lh_findings_v3_0_oct_2016_eng_clean.pdf
Vecchiato M, Baioccato V, Palermi S. Antidoping testing and testicle cancer diagnosis: An unexpected helper. J Sci Med Sport. 2024;27(12):834-836. doi:10.1016/j.jsams.2024.08.001

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