What is the appropriate treatment for a 23-year-old male with a 3 cm testicular mass suspicious for testicular cancer based on ultrasonography?

Treatment of a 3 cm Testicular Mass Suspicious for Testicular Cancer

The appropriate treatment for a 23-year-old male with a 3 cm testicular mass suspicious for testicular cancer on ultrasonography is radical inguinal orchiectomy, which should be performed as the primary management. 1

Initial Evaluation

Before proceeding with treatment, the following steps are essential:

• Obtain serum tumor markers (STM) including alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH) prior to any treatment, including orchiectomy 1
• Scrotal ultrasound with Doppler has already been performed, showing a hypoechoic mass, which is highly suggestive of malignancy 1
• Counsel the patient about the risks of hypogonadism and infertility 1
• Offer sperm banking before orchiectomy, especially important in this young patient 1, 2

Primary Treatment

• Radical inguinal orchiectomy is the standard of care for a 3 cm testicular mass suspicious for cancer 1, 3
• The procedure should be performed through an inguinal incision with early vascular control at the internal inguinal ring 1
• Any scrotal violation for biopsy or open surgery should be avoided as it may lead to tumor seeding 1
• The timing of orchiectomy should be prompt but not emergent unless there are signs of life-threatening metastatic disease 1

Considerations for Testis-Sparing Surgery

Testis-sparing surgery (TSS) is generally not recommended for this patient with a 3 cm mass for several reasons:

• TSS is only considered for highly selected patients with masses <2 cm, and this patient has a 3 cm mass 1
• TSS is primarily considered for patients with:
  • Equivocal ultrasound/physical exam findings and negative tumor markers 1
  • Congenital, acquired, or functionally solitary testis 1
  • Bilateral synchronous tumors 1

Post-Orchiectomy Management

After orchiectomy, the following steps are crucial:

• Repeat serum tumor markers (AFP, hCG, LDH) at appropriate half-life intervals to establish nadir levels for staging and risk stratification 1
• Perform staging imaging studies:
  • CT scan of abdomen and pelvis with IV contrast or MRI abdomen and pelvis without and with IV contrast 1
  • Chest X-ray (for seminoma) or CT chest with IV contrast (for non-seminoma) 1

Subsequent Treatment Based on Staging

Treatment after orchiectomy depends on histology, stage, and risk classification:

• Stage I (confined to testis): Options include active surveillance, adjuvant chemotherapy, or retroperitoneal lymph node dissection (for non-seminoma) or radiation therapy (for seminoma) 2, 4
• Stage II (retroperitoneal lymph node involvement): Treatment typically involves chemotherapy and/or retroperitoneal lymph node dissection 2
• Stage III (distant metastases): Chemotherapy based on the International Germ Cell Cancer Collaborative Group (IGCCCG) risk stratification 1

Important Considerations and Pitfalls

• Avoid scrotal approach for orchiectomy as it increases risk of local recurrence and altered lymphatic drainage 1
• Be aware that retroperitoneal hematoma can occur post-orchiectomy and may mimic metastatic disease on imaging 5
• Monitor for potential complications of treatment, including:
  • Infertility (sperm banking should be offered before treatment) 1, 2
  • Hypogonadism requiring testosterone replacement 1
  • Cardiovascular complications in long-term survivors 4, 6

Prognosis

With appropriate treatment, testicular cancer has excellent outcomes:

• 5-year survival rates are approximately 99% for stage I, 92% for stage II, and 85% for stage III disease 2
• Treatment at high-volume centers with multidisciplinary expertise may improve outcomes 2