What is the most appropriate next step for a 23-year-old male with a 3 cm hypoechoic mass in the left testicle suspicious of cancer?

From the Guidelines

The most appropriate next step for a 23-year-old male with a 3 cm hypoechoic testicular mass suspicious for cancer is urgent referral to a urologist for radical inguinal orchiectomy (surgical removal of the affected testicle). This procedure involves making an incision in the groin area and removing the entire testicle with its blood and lymphatic supply intact, rather than through the scrotum, to prevent potential cancer spread 1. Prior to surgery, the patient should undergo tumor marker blood tests (alpha-fetoprotein, beta-hCG, and LDH) and staging imaging such as CT scans of the chest, abdomen, and pelvis to assess for metastatic disease 1. Sperm banking should also be offered before any intervention as both the disease and subsequent treatments may affect fertility. Testicular ultrasound findings cannot definitively diagnose cancer without tissue examination, and needle biopsy is contraindicated due to risk of tumor seeding. Prompt surgical intervention is crucial as testicular cancer is highly treatable when addressed early, with excellent survival rates, particularly in young patients. Following orchiectomy, pathological examination will determine the cancer type and guide further treatment decisions.

Some key points to consider in the management of this patient include:

• The importance of avoiding a scrotal approach for biopsy or surgery due to the higher risk of local recurrence 1
• The need for thorough staging, including imaging and tumor marker assessment, to guide treatment decisions 1
• The potential benefits of sperm banking prior to treatment, given the risk of infertility associated with testicular cancer and its treatment
• The excellent prognosis for testicular cancer when diagnosed and treated promptly, with high survival rates for patients with early-stage disease 1

From the Research

Next Steps for Testicular Mass

The most appropriate next step for a 23-year-old male with a 3 cm hypoechoic mass in the left testicle suspicious of cancer is:

• Radical orchiectomy, as it is the mainstay of treatment for seminomatous testicular tumors 2
• This procedure is typically followed by staging to determine the extent of the disease
• Management following surgery is dependent upon staging, and may include active surveillance, radiotherapy, or chemotherapy 3

Importance of Accurate Diagnosis

It is crucial to accurately diagnose the nature of the testicular mass to determine the appropriate course of treatment:

• A hypoechoic mass can be indicative of various conditions, including testicular cancer or sarcoidosis 4
• Intraoperative frozen section analysis can be useful in avoiding unnecessary radical orchiectomy in cases of benign conditions 4

Role of Imaging and Tumor Markers

Imaging studies, such as ultrasound and CT scans, play a crucial role in the diagnosis and staging of testicular cancer:

• These studies can help identify the presence of a mass, as well as any potential metastases 2, 3, 5
• Tumor markers, such as β-human chorionic gonadotropin and lactate dehydrogenase, can also be useful in monitoring the response to treatment and detecting potential recurrence 2, 6