From the Guidelines
Non-vascular testicular masses should be considered malignant until proven otherwise and require prompt evaluation and treatment, including a thorough physical examination, scrotal ultrasound with color Doppler, and serum tumor markers (alpha-fetoprotein, beta-hCG, and LDH) as the initial assessment. The characteristics of non-vascular testicular masses include a variety of abnormal growths within the testicle that are not primarily composed of blood vessels. According to the most recent guidelines 1, a solid mass in the testis identified by physical exam or imaging should be managed as a malignant neoplasm until proven otherwise.
Key Characteristics
- Non-cancerous masses include epidermoid cysts, which appear as well-circumscribed avascular lesions with an "onion skin" appearance on ultrasound 1
- Testicular adrenal rest tumors, which occur in patients with congenital adrenal hyperplasia
- Granulomatous orchitis, which may mimic malignancy
- Testicular microlithiasis, characterized by multiple tiny calcifications, may be associated with an increased risk of testicular cancer but typically requires only surveillance if isolated, as stated in the guidelines 1
Management
- Management depends on the specific diagnosis - testicular cancer generally requires radical orchiectomy followed by potential adjuvant therapy based on histology and stage, while benign lesions may be managed with testis-sparing surgery or observation 1
- Any solid testicular mass should be considered malignant until proven otherwise, as testicular cancer has excellent cure rates when detected early but poorer outcomes with delayed diagnosis.
- The initial evaluation should include scrotal ultrasound with Doppler, as recommended by the guidelines 1, and serum tumor markers (alpha-fetoprotein, beta-hCG, and LDH) to determine the nature of the mass.
Risk Factors
- Cryptorchidism, hypospadias, inguinal hernia, and other birth-related factors are associated with an increased risk of testicular cancer 1
- Testicular microlithiasis in the absence of a solid mass or other risk factors for GCTT does not confer an increased risk of malignant neoplasm and does not require further evaluation or follow-up, as stated in the guidelines 1
From the Research
Characteristics of Non-Vascular Testicular Masses
- Non-vascular testicular masses can be benign or malignant, with malignant masses being more common in intratesticular locations 2
- The size of non-palpable incidental testicular masses can range from 5-19 mm in diameter 3, 4
- Benign lesions can be found in non-vascular testicular masses, with a reported proportion of 40% in one study 4
- Non-vascular testicular masses can be evaluated using scrotal ultrasound, which can help characterize the mass and determine the need for further intervention 2, 5
- Serum tumor markers can be negative in patients with non-palpable incidental testicular masses, even in cases where malignancy is present 3, 4
- Frozen section examination (FSE) can be used to determine the nature of the lesion, with complete concordance between FSE and permanent histopathology examination reported in one study 4
Diagnosis and Management
- A careful history and inguinoscrotal examination are necessary when evaluating a patient with a scrotal mass 5
- Scrotal ultrasound can confirm the precise location of a mass or rule out the presence of an inguinal hernia 5
- Surgical exploration is mandatory for non-palpable incidental testicular masses, with testicular sparing surgery (TSS) being a safe and effective option for patients with small benign lesions 4
- Milocondus and further intervention, such as radical orchiectomy, may be necessary in cases where malignancy is present 3, 4