What are the next steps in the ER for an 87-year-old male with a scrotal ultrasound showing a heterogeneous mass concerning for malignancy in the left testicle?

Emergency Department Workup for Suspected Testicular Malignancy in an 87-Year-Old Male

For an 87-year-old male with a scrotal ultrasound showing a heterogeneous testicular mass concerning for malignancy, the next steps in the ER should include serum tumor marker testing (AFP, β-hCG, LDH), chest X-ray, and prompt urology consultation for likely inguinal orchiectomy. 1

Initial Diagnostic Workup

1. Serum Tumor Markers (to be drawn before any surgical intervention):

   • Alpha-fetoprotein (AFP)
   • Beta-human chorionic gonadotropin (β-hCG)
   • Lactate dehydrogenase (LDH)

   These markers are critical for diagnosis, staging, and prognosis 1. While they have limited sensitivity (especially in seminoma), they provide valuable baseline information.

2. Basic Laboratory Studies:

   • Complete blood count
   • Comprehensive metabolic panel (including creatinine, electrolytes, liver enzymes)
   • These tests help assess overall health status and organ function 1

3. Imaging:

   • Chest X-ray (mandatory)
   • Consider CT scan of abdomen and pelvis if the patient is stable and it can be performed during the ED visit 1

Consultation and Disposition

1. Urgent Urology Consultation:

   • The patient should be referred to a urologist for evaluation and planning for radical inguinal orchiectomy 1
   • Orchiectomy is both diagnostic and therapeutic

2. Disposition Planning:

   • This is not a surgical emergency requiring immediate intervention 1
   • Depending on the urologist's assessment, the patient can be scheduled for outpatient orchiectomy if stable
   • If there are signs of advanced disease or the patient is unstable, admission may be warranted

Important Considerations

• Age Factor: At 87 years old, this patient is significantly older than the typical testicular cancer patient (mean age 33 years) 2. While testicular cancer is most common in younger men, it can occur at any age.

• Fertility Considerations: Given the patient's advanced age, sperm banking (which would be discussed in younger patients) is likely not a priority 1

• Differential Diagnosis: While the ultrasound is concerning for malignancy, other conditions such as orchitis, epididymitis, or benign tumors should be considered 1

Common Pitfalls to Avoid

1. Delaying Tumor Marker Testing: Serum markers should be obtained before any surgical intervention, as they provide baseline values for staging and monitoring 1

2. Performing Scrotal Exploration: Any surgical approach should be inguinal, not scrotal, to prevent lymphatic spread 1

3. Rushing to Emergency Surgery: Orchiectomy should be timely scheduled but is not an emergency procedure unless there are signs of life-threatening disease 1

4. Inadequate Imaging: While ultrasound has already confirmed an intratesticular mass, additional imaging is needed to assess for metastatic disease 1

By following this structured approach, the emergency physician can ensure appropriate initial management of this patient with a suspected testicular malignancy, setting the stage for definitive treatment by urology.