In a 68-year-old man with a newly discovered testicular abnormality who is concerned about cancer, what is the appropriate evaluation and management?

Immediate Evaluation with Scrotal Ultrasound and Serum Tumor Markers

This 68-year-old man requires urgent scrotal ultrasound with Doppler and serum tumor marker testing (AFP, hCG, LDH) before any other intervention, as any solid testicular mass must be managed as malignant until proven otherwise. 1

Initial Diagnostic Workup

The evaluation must proceed systematically:

• Scrotal ultrasound with Doppler is the mandatory first imaging study (Strong Recommendation, Grade B evidence) 1

  • Any hypoechoic mass with vascular flow is highly suggestive of malignancy
  • Do NOT use MRI as initial evaluation 1

• Serum tumor markers must be drawn BEFORE any treatment, including orchiectomy 1:

  • Alpha-fetoprotein (AFP)
  • Human chorionic gonadotropin (hCG)
  • Lactate dehydrogenase (LDH)

Age-Specific Considerations

While testicular cancer is most common in younger men (ages 20-34), this patient's age of 68 years changes the differential diagnosis significantly 2, 3:

• Primary lymphoma becomes the most frequent testicular tumor after age 60 (>30% of cases) 2
• Germ cell tumors (mainly seminomas) represent <20% of cases in this age group 2
• Sex cord stromal tumors, sarcomas, and metastases each represent approximately 10% 2
• Spermatocytic tumors and testicular lymphomas show increasing incidence with age 3

Management Algorithm Based on Ultrasound Findings

If Solid Mass Identified:

1. Radical inguinal orchiectomy is both diagnostic and therapeutic 1, 4

   • Must be performed through inguinal approach, NOT scrotal 4
   • Provides definitive histologic diagnosis
   • Resect testis with spermatic cord at internal inguinal ring level

2. Pre-orchiectomy counseling (before surgery if time permits):

   • Discuss hypogonadism risk 1
   • Sperm banking consideration (though less relevant at age 68, discuss if patient has fertility concerns) 1

If Indeterminate Findings with Normal Markers:

• Repeat imaging in 6-8 weeks 1
• Note: 50-80% of non-palpable masses <2 cm are benign 1

Critical Pitfalls to Avoid

Do NOT:

• Perform scrotal biopsy or scrotal surgery (violates proper oncologic principles) 4
• Delay orchiectomy if solid mass confirmed on ultrasound 1
• Use MRI as first-line imaging 1
• Assume benign disease based on age alone—while germ cell tumors are less common at 68, lymphoma and other malignancies are more prevalent 2

Do NOT reassure without imaging: Even if physical exam seems benign, ultrasound confirmation is mandatory for any testicular abnormality 1, 5

Post-Diagnosis Staging (If Cancer Confirmed)

After orchiectomy and histologic diagnosis:

• Chest radiograph (CT if abnormal or if retroperitoneal adenopathy present) 6, 7
• Abdominopelvic CT scan 7
• Repeat tumor markers until normalization 6, 4

Prognosis Context

Reassure the patient that testicular cancers have excellent cure rates (>90% overall, approaching 100% for stage I disease), even in older patients when appropriately managed 4, 8, 9. However, the specific histology at age 68 will significantly influence treatment approach and prognosis, making prompt diagnosis essential.