What is the appropriate management for a 29-year-old male with a growing longstanding testicular mass?

Management of a 29-Year-Old Male with a Growing Longstanding Testicular Mass

A 29-year-old male with a growing testicular mass should undergo immediate radical inguinal orchiectomy as this is the standard diagnostic and therapeutic approach for suspected testicular cancer. 1

Initial Evaluation

History and Physical Examination

• Duration of mass and growth pattern
• Pain or discomfort
• Risk factors: cryptorchidism, family history of testicular cancer, infertility
• Examine both testicles, abdomen, supraclavicular fossae, and chest for gynaecomastia

Diagnostic Workup (Prior to Orchiectomy)

1. Serum tumor markers (must be drawn before any treatment) 1:

   • Alpha-fetoprotein (AFP)
   • Human chorionic gonadotropin (hCG)
   • Lactate dehydrogenase (LDH)

2. Testicular ultrasound with Doppler 1:

   • Confirm intratesticular location of mass
   • Assess size, vascularity, and characteristics
   • Evaluate contralateral testicle

3. Fertility counseling and sperm banking 1:

   • Must be offered before any intervention
   • Especially important in this young patient

Primary Management

Radical inguinal orchiectomy is both diagnostic and therapeutic 1:

• Approach must be inguinal with early vascular control
• Avoid scrotal violation which increases risk of local recurrence
• Spermatic cord division at the level of internal inguinal ring
• Consider testicular prosthesis placement

Important caveat: In rare cases of life-threatening widespread disease with highly elevated tumor markers, chemotherapy may be initiated before orchiectomy 1. However, this doesn't appear to be the case for this patient.

Post-Orchiectomy Staging

After orchiectomy, the following should be performed:

1. Pathological assessment 1:

   • Tumor type (seminoma vs. non-seminoma)
   • Size, multiplicity, extension
   • Presence/absence of vascular invasion
   • Presence of testicular intraepithelial neoplasia (TIN)

2. Post-orchiectomy tumor markers 1:

   • Follow until normalization, progression, or plateau

3. Imaging 1:

   • Abdominopelvic CT scan to assess retroperitoneal nodes
   • Chest CT if abdominopelvic CT shows adenopathy or abnormal chest X-ray
   • Brain MRI or bone scan only if metastases to these organs are suspected

Further Management Based on Staging

Management after orchiectomy depends on histology (seminoma vs. non-seminoma) and stage:

For Seminoma

• Stage I: Options include surveillance, single-agent carboplatin, or radiotherapy 1
• Stage II-III: Chemotherapy with regimens based on risk classification 1

For Non-Seminoma

• Stage I: Options include surveillance or retroperitoneal lymph node dissection (RPLND) 1
• Stage II-III: Chemotherapy based on risk classification 1

Follow-Up

Regular follow-up is essential and should include 1:

• Physical examination
• Tumor marker assessment
• Imaging studies at intervals determined by histology, stage, and treatment

Common Pitfalls to Avoid

1. Scrotal approach for biopsy or surgery - increases risk of local recurrence and compromises staging 1

2. Delaying diagnosis - testicular cancer is highly curable when detected early 1

3. Neglecting fertility preservation - sperm banking should be discussed before any intervention 1

4. Misdiagnosing as epididymitis - persistent testicular abnormalities after antibiotic treatment warrant further evaluation 1

5. Inadequate follow-up - regular surveillance is essential for early detection of recurrence 1