What are the next steps for a 1 cm coarse calcified mass in the testicle identified on ultrasound?

Management of a 1 cm Coarse Calcified Testicular Mass on Ultrasound

A 1 cm coarse calcified mass in the testicle identified on ultrasound should be managed as a potential testicular malignancy with immediate referral for radical inguinal orchiectomy unless specific criteria for testis-sparing surgery are met. 1

Initial Evaluation

When a testicular mass is identified on ultrasound, a systematic approach is required:

1. Serum Tumor Markers:

   • Obtain AFP, β-hCG, and LDH before any intervention including orchiectomy 1
   • These markers are critical for diagnosis, staging, and prognosis

2. Imaging Considerations:

   • Scrotal ultrasound with Doppler has already been performed, confirming the mass
   • Calcification patterns are important but not definitive for benign vs. malignant
   • MRI should not be used as the initial evaluation tool 1

3. Pre-treatment Counseling:

   • Discuss fertility preservation and offer sperm banking before any intervention 1
   • This is especially important if the contralateral testis is abnormal or absent

Decision Algorithm for Management

Option 1: Radical Inguinal Orchiectomy (Standard Approach)

• Indicated for most testicular masses as the primary treatment 1
• Provides definitive diagnosis and is therapeutic for localized disease
• Should be performed via an inguinal approach with early vascular control

Option 2: Testis-Sparing Surgery (Selected Cases Only)

Consider only if ALL of the following criteria are met:

• Mass is <2 cm
• Normal tumor markers (AFP and β-hCG)
• AND one of the following:
  • Patient has a congenital or acquired solitary testis
  • Patient has bilateral testicular masses
  • Patient has known subfertility 1

Important Considerations

• Calcification Patterns: While calcification may suggest certain benign entities (epidermoid cyst, Sertoli cell tumor), malignant tumors can also present with calcification 2
• Benign vs. Malignant: Up to 50-80% of non-palpable or incidentally detected masses <2 cm may be benign 1, but calcified masses still require definitive management
• Risk of Malignancy: More than 90% of patients diagnosed with germ cell tumors are cured, including 70-80% with advanced disease 1, making aggressive management appropriate

Post-Orchiectomy Management

If orchiectomy confirms testicular cancer:

1. Obtain abdominopelvic CT scan to assess retroperitoneal nodes
2. Chest CT if abdominopelvic CT shows retroperitoneal adenopathy or chest X-ray is abnormal
3. Further management depends on histology (seminoma vs. nonseminoma) and stage 1

Common Pitfalls to Avoid

1. Delay in Diagnosis: A delay correlates with higher stage at presentation 1
2. Scrotal Approach: Never perform a transscrotal biopsy or orchiectomy as this can compromise staging and treatment
3. Misinterpreting Calcifications: While calcifications may suggest benign pathology in some cases, they can also be present in malignant tumors 2
4. Neglecting Fertility Preservation: Sperm banking should be discussed before any intervention 1

Remember that testicular microlithiasis alone (without a mass) does not require intervention, but a discrete calcified mass requires definitive management 1.