What is the next step for a 23-year-old male with a testicular mass?

From the Guidelines

The next step for a 23-year-old male with a testicular mass is immediate referral to a urologist for urgent evaluation, typically within 1-2 weeks, where scrotal ultrasound with Doppler and serum tumor markers, including alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH), will be performed to determine the nature of the mass and guide further management 1.

Key Considerations

• A solid mass in the testis should be managed as a malignant neoplasm until proven otherwise, emphasizing the need for prompt evaluation 1.
• Scrotal ultrasound with Doppler is a crucial diagnostic tool for characterizing testicular masses, and it should be obtained in patients with a unilateral or bilateral scrotal mass suspicious for neoplasm 1.
• Serum tumor markers (STM) should be drawn and measured prior to any treatment, including orchiectomy, to help determine the presence of a malignant neoplasm 1.

Diagnostic Approach

• The diagnostic approach should include a complete physical examination, including lymph node assessment and a thorough medical history, in addition to the scrotal ultrasound and serum tumor markers 1.
• If testicular cancer is suspected, additional imaging such as a CT scan of the chest, abdomen, and pelvis may be ordered to assess for metastasis 1.

Importance of Prompt Evaluation

• Prompt evaluation is critical because testicular cancer, while highly treatable, is most common in young men aged 15-35, and early intervention significantly improves outcomes 1.
• The patient should be advised not to delay seeking care due to embarrassment, as testicular cancer has a high cure rate when caught early, with 5-year survival rates exceeding 95% for localized disease 1.

From the Research

Next Steps for Testicular Mass

The next steps for a 23-year-old male with a testicular mass include:

• A careful history and inguinoscrotal examination to evaluate the patient, as stated in the study 2
• Scrotal ultrasound to confirm the precise location of the mass and rule out the presence of an inguinal hernia, as mentioned in the studies 2 and 3
• Serum tumor markers, such as alpha-fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase, to aid in diagnosis and staging, as discussed in the studies 4, 5, and 6
• Prompt consultation with a urologist for further staging and intervention, as recommended in the study 2

Diagnostic Considerations

When evaluating a testicular mass, it is essential to consider the following:

• The differential diagnosis can be narrowed by characterizing masses as intra- or extratesticular using ultrasound, as discussed in the study 3
• Correlation with the patient's history is crucial, as non-neoplastic conditions may have a similar appearance to neoplasms, as mentioned in the study 3
• The role of lactate dehydrogenase in identifying relapse is limited, and its use in routine follow-up should be questioned, as suggested in the study 5

Tumor Markers

Tumor markers play a critical role in the diagnosis, staging, and follow-up of testicular germ cell tumors, as discussed in the studies 4, 5, and 6. However:

• The positive predictive value of these markers is limited, and they are often falsely elevated, as shown in the study 5
• Many patients do not have marker elevations despite a relapse, highlighting the importance of correlation with imaging and clinical findings, as discussed in the study 5