What is the best next step for a 23-year-old male with a suspicious mass and ultrasound findings indicative of testicular cancer, showing a hypoechoic mass?

From the Guidelines

The best next step for a 23-year-old male with a suspicious testicular mass and hypoechoic findings on ultrasound is immediate referral to a urologist for surgical exploration and radical inguinal orchiectomy (removal of the affected testicle). This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of prompt treatment for suspected testicular cancer 1.

Key Considerations

• Prior to surgery, the patient should have baseline tumor markers drawn, including alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH), as recommended by the American Urological Association guideline 1.
• A CT scan of the chest, abdomen, and pelvis should also be performed to evaluate for metastatic disease, as suggested by various studies and guidelines 1.
• The surgical approach is critical, with an inguinal approach and early control of the spermatic cord necessary to prevent tumor spillage and potential spread 1.
• Testicular-sparing surgery is generally not recommended for suspected malignancy, given the high cure rates associated with radical orchiectomy when caught early 1.

Rationale

The urgency of this approach is justified by the fact that testicular cancer is highly treatable when caught early, with cure rates exceeding 95% even with metastatic disease 1. The hypoechoic appearance on ultrasound is highly suspicious for malignancy in this age group, as testicular cancer is the most common solid malignancy in young men aged 15-35 1. Delaying diagnosis and treatment could allow for disease progression and potentially compromise outcomes.

Additional Recommendations

• Sperm banking should be discussed with the patient before undergoing any therapeutic intervention that may compromise fertility, including surgery, radiation therapy, and chemotherapy 1.
• Further management should be dictated by histology and stage, with consideration of adjuvant therapy or surveillance as appropriate 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Next Steps for Suspicious Testicular Mass

• The patient should be referred to a urologist for definitive diagnosis, orchiectomy, and further evaluation with abdominal computed tomography and chest radiography, as indicated by scrotal ultrasonography showing an intratesticular mass 2, 3.
• A thorough examination should be performed, including a complete history and physical examination, to identify any symptoms or risk factors for testicular cancer, such as cryptorchidism, family history, or infertility 2, 3.
• Scrotal ultrasonography is the preferred initial imaging study for evaluating testicular masses, and if a solid intratesticular mass is discovered, orchiectomy is both diagnostic and therapeutic 3.
• Staging through chest radiography, chemistry panel, liver function tests, and tumor markers guides treatment, and active surveillance, chemotherapy, retroperitoneal lymph node dissection, and radiation therapy are treatment options following orchiectomy 3, 4.
• For patients desiring future fertility, sperm banking should be discussed early in the course of treatment, as testicular cancer and its treatment can affect fertility 2, 3.

Diagnostic Imaging and Staging

• Diagnostic imaging plays a crucial role in initial staging, specifically in assessing the primary tumor prior to orchiectomy and evaluating for regional and/or distant metastasis 4.
• Multimodality imaging is used for initial staging, with ultrasound and computed tomography (CT) most commonly utilized, and magnetic resonance imaging (MRI) and positron emission tomography (PET) serving as adjunct modalities 4.
• CT is typically used for response assessment and surveillance, with MRI and PET serving as adjunct modalities 4.

Treatment and Management

• Radical orchiectomy is the mainstay of treatment for seminomatous testicular tumors, and management following surgery is dependent upon staging 5.
• Treatment varies for each retroperitoneal mass, and accurate and prompt diagnosis is challenging, but essential for effective treatment 5, 6.
• Surgery in metastatic disease may even be beneficial for patients with recurrent tumors, patients with persisting marker elevations during chemotherapy, or patients with late relapse of the disease 6.