A 31-year-old man comes to the physician because of right testicular swelling for the past one week. He recalls trauma to the perineum and testes when he fell from a bike one month ago. He is otherwise healthy and has no other complaints. His past medical history is unremarkable. He admits to several unprotected sexual encounters in the past. He smokes marijuana occasionally but does not smoke tobacco. He denies any intravenous drug use.
On physical examination, a non-tender right testicular mass is palpated. Scrotal ultrasound shows a well-defined 2 x 1.5 cm hypoechoic lesion without cystic components in the right testis. His HIV test is negative. Serum alpha-fetoprotein and β-hCG levels are normal. CT scan of the abdomen and pelvis do not reveal any lymphadenopathy.
Which of the following is the best next step in managing this patient?

Question

A 31-year-old man comes to the physician because of right testicular swelling for the past one week.  He recalls trauma to the perineum and testes when he fell from a bike one month ago.  He is otherwise healthy and has no other complaints.  His past medical history is unremarkable.  He admits to several unprotected sexual encounters in the past.  He smokes marijuana occasionally but does not smoke tobacco.  He denies any intravenous drug use.
On physical examination, a non-tender right testicular mass is palpated.  Scrotal ultrasound shows a well-defined 2 x 1.5 cm hypoechoic lesion without cystic components in the right testis.  His HIV test is negative.  Serum alpha-fetoprotein and β-hCG levels are normal.  CT scan of the abdomen and pelvis do not reveal any lymphadenopathy.
Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

11ec193a_986e_fa74_853d_33ea10bbcdbc_MD0002_00 This patient's presentation is concerning for testicular cancer. The majority (95%) of testicular cancers are germ cell tumors (GCT), which are further divided into seminomas and non-seminomatous tumors. Testicular malignancies classically present as painless scrotal swelling. Patients with suspected testicular cancer on physical examination should undergo testicular ultrasound to differentiate cystic from hypoechoic (more likely malignant) lesions. In addition, ultrasound can also rule out hydrocele or epididymitis. After the ultrasound, a staging work-up should be performed. A CT scan of the abdomen and pelvis is required in all patients since testicular cancer initially spreads to the regional retroperitoneal lymph nodes. In addition, a chest x-ray and tumor markers should also be obtained. Non-seminomas typically have elevated AFP and/or β-hCG. Pure seminomas may have elevated β-hCG, but AFP is usually not elevated. Thus, these tumor markers either alone or in combination are insufficient to establish a diagnosis of testicular cancer. Definitive diagnosis and histology is confirmed by inguinal orchiectomy. Biopsy procedures (e.g., fine needle aspiration, incisional biopsy) are contraindicated due to the risk of local seeding and poorer outcomes (Choices A and B). Histologic distinction is important, since the treatment differs for seminomas (usually chemotherapy and/or radiation therapy) and non-seminomas (usually chemotherapy). (Choice D) An expedited work-up is important as the majority (90%) of GCTs can be cured. (Choice E) Antibiotics would treat epididymitis, which usually presents as acute testicular pain with exquisite tenderness on examination. Educational objective: Testicular cancers are usually hypoechoic on ultrasound. Pure seminomas do not cause alpha-fetoprotein elevation. Testicular cancer spreads into the retroperitoneum and imaging of the abdomen is an important part of staging. Testicular biopsy is contraindicated. Radical orchiectomy is required for confirming the diagnosis, histologic classification, and local tumor control, even in patients with metastasis. __________ References: Part I: testicular cancer-management of early disease (http://www.ncbi.nlm.nih.gov/pubmed/14662429) The role of imaging in staging and monitoring testicular cancer. (http://www.ncbi.nlm.nih.gov/pubmed/22464993)

A 31-Year-Old Man Comes to the Physician Because of Right