What is the workup for a testicular lump?

Workup for Testicular Lump

A scrotal ultrasound with Doppler should be the initial imaging modality for evaluating any testicular lump, as it can accurately differentiate between testicular and extratesticular masses and determine if the mass is solid, cystic, or complex. 1, 2

Initial Evaluation

• Any solid mass in the testis identified by physical exam or imaging should be managed as a malignant neoplasm until proven otherwise 1
• Serum tumor markers (alpha-fetoprotein [AFP], human chorionic gonadotropin [hCG], lactate dehydrogenase [LDH]) should be drawn and measured prior to any treatment, including orchiectomy 1
• Scrotal ultrasound with Doppler should be obtained in all patients with a unilateral or bilateral scrotal mass suspicious for neoplasm 1, 2
• Hypoechoic masses with vascular flow are highly suggestive of malignancy 1
• Patients should be counseled about the risks of hypogonadism and infertility prior to definitive management, and sperm banking should be offered when appropriate 1

Ultrasound Findings and Management

For Solid Intratesticular Masses

• Solid intratesticular masses have a high likelihood (approximately 90%) of being malignant 3
• Management options include:
  • Radical inguinal orchiectomy (standard of care) 1, 4
  • Testis-sparing surgery with intraoperative frozen section (in select cases) 1

For Small (<2 cm) Non-Palpable or Incidentally Detected Masses

• Up to 50-80% of these masses are not cancerous 1
• Management options include:
  • Serial examinations and repeat ultrasound in 6-8 weeks 1
  • Inguinal orchiectomy 1
  • Testis-sparing surgery with intraoperative frozen section 1

For Indeterminate Findings

• Patients with normal tumor markers and indeterminate findings on physical exam or testicular ultrasound should undergo repeat imaging in 6-8 weeks 1

For Testicular Microlithiasis

• Testicular microlithiasis (>5 small echogenic non-shadowing foci) in the absence of solid mass and risk factors does not confer an increased risk of malignancy and does not require further evaluation 1
• Risk factors include cryptorchidism, family history, personal history of germ cell tumor, or Germ Cell Neoplasia In Situ (GCNIS) 1

Further Imaging for Suspected Testicular Cancer

• CT scan of abdomen and pelvis is mandatory if testicular cancer is suspected 1
• Chest CT scan (not mandatory for seminoma stage I) 1
• MRI should not be used as the initial evaluation and diagnosis of a testicular lesion suspicious for neoplasm 1

Common Benign Scrotal Masses

• Epididymal cysts/spermatoceles (most common finding, 27% of referred cases) 3
• Hydroceles (fluid collection between the parietal and visceral layers of the tunica vaginalis, 11% of referred cases) 3
• Varicoceles 4

Important Clinical Considerations

• Testicular cancer represents only about 4% of referred testicular lumps 3
• The key diagnostic question is whether the lump is intra- or extra-testicular, as intratesticular lesions have a high likelihood of malignancy 3
• Painful or tender masses within the testis that are not suggestive of infection should be referred urgently 3
• Testicular torsion presents with acute pain and is a urologic emergency requiring immediate surgical exploration 4

Pitfalls to Avoid

• Misclassifying a testicular mass as epididymitis can lead to delayed diagnosis 1
• Assuming all testicular lumps are malignant can lead to unnecessary procedures 3
• Failing to obtain appropriate tumor markers before orchiectomy can complicate staging and treatment planning 1
• Performing scrotal biopsy or open surgery through the scrotum should be strongly avoided as it may lead to tumor seeding 1