What is the appropriate management for testicle atrophy identified on a radiograph?

Management of Testicular Atrophy Identified on Radiograph

In patients with testicular atrophy identified on imaging, perform testicular ultrasound to confirm atrophy (volume <12 ml), assess for underlying pathology including malignancy, and strongly consider contralateral testis biopsy to evaluate for testicular intraepithelial neoplasia (TIN), particularly in high-risk patients (age <40 years, atrophic testis, or extragonadal germ cell tumor). 1, 2

Initial Diagnostic Workup

Imaging Confirmation

• Scrotal ultrasound is mandatory to confirm testicular atrophy, define testicular volume, characterize any masses, and evaluate the contralateral testis 3, 2
• Testicular volume <12 ml defines atrophy and warrants comprehensive evaluation 1, 2
• Look specifically for solid masses, heterogeneous echogenicity, or suspicious features that would indicate malignancy 3, 4

Laboratory Assessment

• Measure serum tumor markers (AFP, β-HCG, LDH) to screen for occult germ cell tumors 1, 4, 2
• Obtain hormonal evaluation including total testosterone, LH, and FSH to assess testicular function 2
• Complete metabolic panel if malignancy is suspected 4

Risk Stratification for Malignancy

High-Risk Features Requiring Aggressive Management

Patients with testicular atrophy have significantly elevated risk of testicular cancer and TIN, particularly when combined with: 1, 2

• Age <40 years with testicular volume <12 ml: ~30% risk of contralateral TIN 1
• History of cryptorchidism (undescended testis) 4, 2
• Extragonadal germ cell tumor 1
• Family history of testicular cancer 3
• Synchronous or metachronous contralateral testicular cancer (2-5% risk) 1

Contralateral Testis Biopsy Decision

• Strongly consider biopsy in patients with atrophic testis (<16 ml), especially if age <40 years 1, 2
• The European Germ Cell Cancer Consensus Group notes that while routine biopsy is not universally indicated, it should be performed in high-risk scenarios 1
• If biopsy is performed and TIN is diagnosed, management options include surveillance, orchiectomy, or radiotherapy (20 Gy in 2 Gy fractions) 1

Management Based on Clinical Context

If Atrophic Testis with Normal Contralateral Testis

• Orchiectomy is preferred over radiotherapy to eliminate cancer risk and avoid scattered radiation damage to the healthy contralateral testis 1
• This is particularly appropriate when the atrophic testis is non-functional 1
• Consider fertility preservation (sperm banking) before any intervention 1, 2

If Bilateral Atrophy or Solitary Testis

• Organ-preserving surgery may be considered in experienced centers if a small tumor is identified 1, 2
• Mandatory postresection testicular radiotherapy (20 Gy) is required, which renders tissue azoospermic but preserves some testosterone production 1
• Sperm cryopreservation must be discussed before any intervention 1, 2

If TIN Diagnosed in Setting of Planned Chemotherapy

• Postpone definitive TIN treatment until after chemotherapy, as cisplatin-based chemotherapy eradicates TIN in approximately two-thirds of patients 1
• Consider re-biopsy no earlier than 6 months post-chemotherapy to assess for persistent TIN 1
• This avoids excessive Leydig cell damage from combined chemotherapy and radiation 1

Testosterone Monitoring and Replacement

• Regular testosterone monitoring is essential after radiotherapy or organ-preserving surgery, as both can impair Leydig cell function 1
• Offer hormone replacement therapy to all patients with subnormal testosterone levels and clinical signs of androgen deficiency 1
• Long-term follow-up is necessary to monitor for hypogonadism 2

Surveillance Protocol

For Patients with Atrophic Testis Under Observation

• Teach testicular self-examination due to increased malignancy risk 3, 2
• Regular monitoring of hormone levels and testicular volume 2
• Maintain high index of suspicion for development of solid masses 3

If Orchiectomy Performed for Malignancy

• Follow-up depends on histology and stage with specific protocols for seminoma versus non-seminoma 4
• Post-chemotherapy patients require clinical review, chest X-ray, and tumor markers every 2 months for year 1, every 3 months for year 2, then every 6 months to 5 years 1

Critical Pitfalls to Avoid

• Never delay evaluation of testicular atrophy with suspicious features—delayed diagnosis correlates with higher stage at presentation 4
• Never perform scrotal approach for suspected testicular tumors, as this increases local recurrence risk; always use inguinal approach 4
• Never overlook fertility preservation before definitive treatment in reproductive-age men 1, 2
• Do not assume benign etiology in atrophic testis—the increased cancer risk persists throughout life, particularly with cryptorchidism history 2, 5
• Avoid routine biopsy for isolated testicular microlithiasis without other risk factors, as this alone does not increase malignancy risk 3