From the Guidelines
The next appropriate investigation for a 22-year-old man with a firm, smooth, non-tender, and non-transilluminating 2 cm testicular mass is testicular ultrasonography. This recommendation is based on the most recent and highest quality study, which emphasizes the importance of high-frequency testicular ultrasonography (>10 MHz) in confirming the presence of a testicular mass and characterizing its features, such as whether it is intratesticular or extratesticular, its size, and the presence of multifocal disease or characteristics of the contralateral testicle 1.
Key Considerations
- The patient's presentation with a firm, non-transilluminating testicular mass is concerning for testicular cancer, particularly germ cell tumors, which have a peak incidence between ages 15-35.
- Early diagnosis of testicular cancer is critical, as it is highly curable when detected early, with survival rates exceeding 95% for localized disease.
- Testicular ultrasonography is a crucial diagnostic tool in this context, as it can help determine the nature of the mass and guide further management.
Management Approach
- Following ultrasonography, serum tumor markers, including alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (β-hCG), and lactate dehydrogenase (LDH), should be obtained as baseline measurements to aid in diagnosis, prognosis, and monitoring treatment response 1.
- If ultrasonography confirms an intratesticular mass, prompt referral to urology for consideration of radical inguinal orchiectomy is recommended for definitive diagnosis and initial treatment.
Evidence Support
The European Association of Urology guidelines on testicular cancer (2023 update) and other recent studies support the use of testicular ultrasonography as the initial diagnostic step for suspected testicular masses 1. The American Urological Association guideline (2019) also recommends scrotal ultrasound with Doppler for patients with a unilateral or bilateral scrotal mass suspicious for neoplasm 1.
From the Research
Next Steps in Management
The patient presents with a firm, smooth, non-tender, and non-transilluminating 2 cm mass in his left testicle. Given the characteristics of the mass and the patient's history, the next appropriate step in management is to further investigate the nature of the mass.
Investigation Options
- Testicular Ultrasonography: This is the most appropriate next step in management. Ultrasonography can help differentiate between various testicular lesions, including benign and malignant tumors 2, 3, 4, 5. It can also guide further management, such as the need for biopsy or surgical intervention.
- Other Options:
- Review in 3 months (Option A) may not be appropriate as it may delay the diagnosis and treatment of a potentially malignant lesion.
- Nucleic acid testing for chlamydia and gonorrhea (Option B) may not be relevant in this case as the patient denies recent sexual activity and the mass is non-tender and non-transilluminating.
- Measurement of carcinoembryonic antigen (Option C) is not typically used in the diagnosis of testicular masses.
Rationale for Testicular Ultrasonography
Testicular ultrasonography is a non-invasive and highly sensitive imaging modality that can help characterize testicular lesions 6, 5. It can differentiate between solid and cystic lesions, and can also guide further management, such as the need for biopsy or surgical intervention. In this case, ultrasonography can help determine the nature of the 2 cm mass in the patient's left testicle and guide further management. As noted in studies 3 and 5, ultrasonography is a valuable tool in the diagnosis and management of testicular lesions, and can help avoid unnecessary surgical interventions.