From the Guidelines
The next step for a 23-year-old with ultrasound findings suspicious for testicular cancer is prompt referral to a urologist for further evaluation, typically within 1-2 weeks, as recommended by the European Association of Urology guidelines 1. The urologist will likely order serum tumor markers including alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH), which should be obtained before any surgical intervention, as suggested by the American Urological Association guideline 1. Some key points to consider in the management of testicular cancer include:
- A chest, abdomen, and pelvis CT scan with contrast will also be necessary to evaluate for metastatic disease, as outlined in the ACR Appropriateness Criteria for staging and surveillance of testicular cancer 1.
- The definitive management typically involves a radical inguinal orchiectomy (surgical removal of the affected testicle through an inguinal incision), which serves both diagnostic and therapeutic purposes, as recommended by the European Association of Urology guidelines 1.
- The patient should be counseled about sperm banking before orchiectomy if fertility is a concern, as subsequent treatments like chemotherapy or radiation may affect fertility, as suggested by the American Urological Association guideline 1.
- Prompt action is essential as testicular cancer is highly treatable when caught early, with cure rates exceeding 95% for localized disease, as reported in the Journal of the American College of Radiology 1.
- The patient should be reassured that even with a single testicle, normal hormone production and sexual function can be maintained. It's worth noting that testis-sparing surgery may be considered in certain cases, such as small or indeterminate testicular masses, negative tumor markers, and a normal contralateral testis, as outlined in the European Association of Urology guidelines 1. However, this approach should be individualized and discussed with the patient, taking into account the potential risks and benefits.
From the Research
Next Steps for Suspicious Testicular Cancer
Given the ultrasound findings suspicious for testicular cancer in a 23-year-old, the next steps are crucial for early diagnosis and treatment. The following points outline the recommended approach:
- History and Physical Examination: A thorough medical history and physical examination are essential to identify any risk factors or symptoms associated with testicular cancer, such as a painless testicular mass 2.
- Scrotal Ultrasound: The patient has already undergone an ultrasound, which is a critical diagnostic tool for visualizing the testicles and identifying any abnormalities 2.
- Laboratory Assessment: Blood tests to evaluate serum tumor markers, including alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (β-hCG), and lactate dehydrogenase (LDH), are necessary for diagnosis and staging 2, 3.
- Referral to a Urologist: Prompt referral to a urologist is recommended for further evaluation and management, as early diagnosis and treatment are vital for optimizing outcomes 2.
- Radical Inguinal Orchiectomy: If testicular cancer is confirmed, a radical inguinal orchiectomy may be performed as the initial treatment, followed by staging to determine the extent of the disease 2.
- Treatment Options: Treatment may involve surveillance, surgery (retroperitoneal lymph node dissection), chemotherapy, and/or radiation, depending on the histology, clinical staging, and risk classification of the tumor 2.
- Multidisciplinary Care: Optimal treatment often requires a multidisciplinary team approach at a high-volume, experienced medical center to balance oncologic control with survivorship concerns and minimize long-term adverse effects of treatment 2.
Importance of Serum Tumor Markers
Serum tumor markers play a critical role in the diagnosis, staging, and follow-up of testicular germ cell tumors. Elevated levels of AFP, β-hCG, and LDH can indicate the presence of a tumor, and their measurement after orchiectomy has implications for patient prognosis 3. However, false-positive elevations can occur, and correlation with imaging and clinical findings is essential to avoid over-treatment 4.