Oncology · Genitourinary Malignancies
The facts most likely to be tested
Testicular cancer presents as a painless, firm, fixed, non-transilluminating testicular mass in a young male.
The initial diagnostic step for a suspected testicular mass is a scrotal ultrasound to confirm the presence of an intratesticular lesion.
Radical inguinal orchiectomy is the gold standard for diagnosis and primary treatment, as transscrotal biopsy is contraindicated due to the risk of tumor seeding.
Non-seminomas are characterized by elevated alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (β-hCG), whereas pure seminomas only elevate β-hCG.
Cryptorchidism is the most significant risk factor for the development of testicular germ cell tumors.
Seminomas are highly radiosensitive and typically have a more indolent clinical course compared to non-seminomatous germ cell tumors.
Lymphatic spread to the retroperitoneal lymph nodes is the primary route of metastasis for testicular cancer.
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A 28-year-old male presents to the clinic complaining of a painless lump in his right testicle that he noticed three weeks ago. Physical examination reveals a firm, non-tender, fixed mass within the right testis that does not transilluminate. He has no history of trauma or recent infection. His past medical history is significant for cryptorchidism corrected at age 5.
What is the most appropriate next step in the management of this patient?
Scrotal ultrasound
The patient's presentation is classic for testicular cancer; the initial diagnostic step is always a scrotal ultrasound to confirm the mass before proceeding to surgical intervention.
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Etiology / Epidemiology
Most common solid malignancy in men 15-35 years old. Cryptorchidism is the most significant risk factor.
Clinical Manifestations
Painless, firm, fixed, non-tender testicular mass. Painless scrotal swelling is the classic presentation.
Diagnosis
Scrotal ultrasound is the initial imaging of choice. Radical inguinal orchiectomy is the diagnostic gold standard.
Treatment
Radical inguinal orchiectomy is the primary treatment. Avoid transscrotal biopsy due to risk of lymphatic spread.
Prognosis
Highly curable with >95% 5-year survival rate. Monitor AFP and beta-hCG for recurrence.
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Epidemiology & Etiology
Primarily affects young males aged 15-35. History of cryptorchidism increases risk 3-5 fold, even after orchiopexy. Caucasian race and Klinefelter syndrome are additional established risk factors.
Pertinent Anatomy
The testes are contained within the tunica vaginalis. Lymphatic drainage follows the spermatic cord to the retroperitoneal lymph nodes, which explains why metastasis often presents as back pain or abdominal masses.
Pathophysiology
Germ cell tumors account for 95% of cases, divided into seminomas (more indolent, radiosensitive) and non-seminomas (more aggressive, elevated markers). Malignant transformation occurs via genetic mutations, leading to rapid, painless cellular proliferation within the tunica albuginea.
Clinical Manifestations
Patients typically present with a painless, hard, fixed nodule. Acute pain is rare but can occur due to hemorrhage into the tumor. Look for gynecomastia in patients with high beta-hCG levels.
Diagnosis
Scrotal ultrasound is the first-line diagnostic tool to confirm a solid intratesticular mass. Radical inguinal orchiectomy is the definitive diagnostic procedure; transscrotal biopsy is strictly contraindicated due to altered lymphatic drainage.
Treatment
Radical inguinal orchiectomy is the standard of care for all patients. Seminomas are highly sensitive to radiation therapy, whereas non-seminomas require cisplatin-based chemotherapy. Avoid scrotal approach to prevent tumor seeding.
Prognosis
Overall prognosis is excellent with >95% survival. Serial monitoring of AFP and beta-hCG is mandatory to detect early relapse. Pulmonary metastasis is the most common site of distant spread.
Differential Diagnosis
Hydrocele: transilluminates on exam
Varicocele: 'bag of worms' sensation
Epididymitis: tender, associated with dysuria
Spermatocele: painless, cystic, superior to testis
Testicular torsion: acute, severe pain, absent cremasteric reflex