What is the appropriate next step for a 23-year-old male with a 3 cm testicular mass and sonogram findings suspicious for cancer?

Appropriate Next Step for 23-Year-Old Male with Suspicious Testicular Mass

The appropriate next step is to obtain serum tumor markers (AFP, β-HCG, and LDH) immediately, followed by prompt radical inguinal orchiectomy. 1

Immediate Pre-Operative Workup

Mandatory Serum Tumor Markers

• Obtain AFP, β-HCG, and LDH before any surgical intervention 2, 1
• These markers are critical for diagnosis, staging, prognosis, and monitoring treatment response 2
• Timing is essential: markers must be drawn before orchiectomy to establish baseline values and calculate half-life kinetics post-operatively 2

Additional Pre-Operative Considerations

• Discuss sperm banking before orchiectomy - this is the last opportunity before treatment that may compromise fertility 2, 1, 3
• Obtain complete blood count, creatinine, electrolytes, and liver enzymes 2
• Chest X-ray should be performed as part of initial staging 2

Definitive Surgical Management

Radical Inguinal Orchiectomy

• Perform radical inguinal orchiectomy through an inguinal incision with early vascular control at the internal inguinal ring 2, 1
• This is both diagnostic and therapeutic, serving as the standard of care for testicular masses suspicious for malignancy 2, 1, 3
• Surgery should be timely but not emergent unless life-threatening metastatic disease is present 2, 1

Critical Surgical Pitfalls to Avoid

• Never use a scrotal approach - this violates proper oncologic principles and increases risk of local recurrence due to altered lymphatic drainage 1
• Do not perform scrotal biopsy - any suspicious intratesticular mass requires complete orchiectomy, not biopsy 2, 1
• The only exception: in life-threatening metastatic disease with unequivocally elevated AFP or HCG, chemotherapy takes precedence and orchiectomy can be postponed 2

Post-Orchiectomy Management

Repeat Tumor Markers

• Reassess AFP, β-HCG, and LDH at appropriate half-life intervals (AFP <7 days; β-HCG <3 days) to establish nadir levels and confirm declining kinetics 2, 1

Staging Imaging

• CT abdomen and pelvis with IV contrast to assess retroperitoneal lymph nodes 2, 1
• CT chest with IV contrast for non-seminoma or if retroperitoneal adenopathy present 2, 1
• Chest X-ray alone may suffice for stage I seminoma 2, 1

Why Not Other Options?

Biopsy is Inappropriate

• Testicular biopsy is only considered for suspicious ultrasound findings when the diagnosis is uncertain, not when a 3 cm hypoechoic mass is already identified 2
• A 3 cm hypoechoic mass on ultrasound is highly suspicious for malignancy and warrants definitive surgical excision 1, 4

Antibiotics and Observation are Dangerous

• While a trial of antibiotics may be reasonable for testicular discomfort suggesting epididymitis, any persistent palpable mass or confirmed intratesticular mass on ultrasound requires surgical exploration 2, 5
• Delay in diagnosis correlates with higher stage at presentation and worse outcomes 2, 3

Organ-Sparing Surgery is Not Standard

• Organ-preserving surgery is highly experimental and limited to clinical trials, except in bilateral tumors, metachronous contralateral tumors, or solitary testicles 2
• For a 3 cm mass, radical orchiectomy remains standard 2, 1

Subsequent Treatment Pathway

Further management depends on final histology (seminoma vs. non-seminoma), pathologic stage, and risk stratification using the International Germ Cell Cancer Collaborative Group (IGCCCG) criteria 1, 3, 6. Options include surveillance, chemotherapy, radiation therapy, or retroperitoneal lymph node dissection based on these factors 2, 1.