A 28-year-old man comes to the office for evaluation of a left testicular mass. The mass has been present for 2 months and has increased in size. He has had no pain in the affected testis or weight loss. He is otherwise healthy and has no other symptoms. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. The abdomen is soft and nontender with no palpable masses. A painless, hard nodule is noted in the left testicle. There is no inguinal lymphadenopathy. Scrotal ultrasound reveals a solid, hypoechoic 5-cm left testicular mass. What is the next best step in management of this patient?

Question

A 28-year-old man comes to the office for evaluation of a left testicular mass.  The mass has been present for 2 months and has increased in size.  He has had no pain in the affected testis or weight loss.  He is otherwise healthy and has no other symptoms.  The patient does not use tobacco, alcohol, or illicit drugs.  Vital signs are normal.  The abdomen is soft and nontender with no palpable masses.  A painless, hard nodule is noted in the left testicle.  There is no inguinal lymphadenopathy.  Scrotal ultrasound reveals a solid, hypoechoic 5-cm left testicular mass.  What is the next best step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d92c_03b0_bc81_dd5b165a3d97_MD0003_00 This patient's solid, hard, nontender testicular mass raises strong suspicion for testicular cancer, the most common solid-organ malignancy in men age 15-35. Most cases present with a unilateral testicular nodule that is generally painless but may be associated with a dull ache in the lower abdomen or perineum. Subsequent bimanual examination of the testes usually reveals a hard, ovoid mass within the tunica albuginea. Prompt diagnostic workup and treatment is required to provide the best chance for cure. This generally includes: Scrotal ultrasound, which usually reveals a solid, hypoechoic lesion (seminoma) or a lesion with cystic areas and calcifications (nonseminomatous germ cell tumor [NSGCT]). Serum tumor markers such as β-hCG, alpha-fetoprotein, and lactate dehydrogenase, which are often elevated (particularly with NSGCTs). Radical inguinal orchiectomy, which is performed to confirm the diagnosis histologically and provide definitive treatment. (Choice A) Disseminated prostate cancer is often treated with androgen deprivation therapy. Prostate cancer is often associated with a nodular prostate on examination and an elevated prostate-specific antigen level. Androgen deprivation is not used as primary therapy for testicular cancer. (Choice B) Epididymo-orchitis requires antibiotics and is generally associated with painful swelling of the posterior testes. This patient's solid, firm, nontender testicular mass should be considered testicular cancer until proven otherwise; delays in workup and treatment are associated with poor outcomes. (Choices C and E) Scrotal orchiectomy, transscrotal biopsy, and fine-needle aspiration are associated with worsened outcomes and increased chance of recurrence because incision through the scrotal wall promotes spread of the tumor through the local lymphatic system. Therefore, radical inguinal orchiectomy is preferred for diagnostic confirmation and treatment. Educational objective: A solid, firm, nontender testicular mass should be considered testicular cancer until proven otherwise. A diagnostic workup generally includes bilateral scrotal ultrasound, serum tumor markers, and radical inguinal orchiectomy.

A 28-Year-Old Man Comes to the Office for Evaluation of a Left