What is the management approach for a patient with a palpable testicular mass?

Management of Palpable Testicular Mass

A solid testicular mass identified by physical examination must be managed as malignant until proven otherwise, requiring immediate scrotal ultrasound with Doppler, serum tumor markers (AFP, hCG, LDH) drawn before any intervention, and radical inguinal orchiectomy as definitive treatment. 1

Immediate Diagnostic Workup

Scrotal ultrasound with Doppler is mandatory as the first-line imaging study for any palpable testicular mass, with strong evidence supporting its use (Grade B recommendation). 1 This modality has nearly 100% sensitivity for detecting intrascrotal masses and 98-100% accuracy for distinguishing intratesticular from extratesticular processes. 2 Any hypoechoic mass with vascular flow is highly suggestive of malignancy. 1

Serum tumor markers must be drawn and measured before any treatment, including orchiectomy (Grade C recommendation). 1 The required markers are:

• Alpha-fetoprotein (AFP)
• Human chorionic gonadotropin (hCG)
• Lactate dehydrogenase (LDH) 1

These markers are essential for diagnosis, staging, prognosis, and monitoring treatment response. 2 Pure seminoma does not secrete AFP; elevated AFP indicates non-seminomatous histology even if pathology suggests seminoma. 2

MRI should not be used as the initial evaluation for a testicular lesion suspicious for neoplasm (Grade C recommendation). 1

Pre-Treatment Counseling and Fertility Preservation

Before definitive management, patients must be counseled about risks of hypogonadism and infertility (Grade C recommendation). 1

Sperm banking should be offered to all appropriate patients, particularly those without a normal contralateral testis or with known subfertility. 1, 2 This must be completed before orchiectomy or chemotherapy. 2 In post-pubertal males, determination of total testosterone, LH, and FSH should be performed before operation. 2

Definitive Surgical Management

Radical inguinal orchiectomy through an inguinal incision is the standard surgical approach for any suspected malignant testicular tumor. 2, 3, 4 The tumor-bearing testis is resected with the spermatic cord at the level of the internal inguinal ring. 2

Critical Surgical Principles:

• Never use a scrotal approach for suspected malignancy, as scrotal violation is associated with higher local recurrence rates. 2, 5
• Never perform scrotal biopsy for suspected malignancy—only the inguinal approach is appropriate. 2
• The inguinal approach allows early control of the spermatic cord and prevents tumor dissemination through altered lymphatic drainage. 4

Management of Indeterminate Findings

For patients with normal serum tumor markers and indeterminate findings on physical exam or testicular ultrasound, repeat imaging should be performed in 6-8 weeks. 1 This approach is appropriate because 50-80% of non-palpable or incidentally detected masses less than 2 cm are not cancerous. 1

Management options for small indeterminate lesions include:

• Serial examinations and repeat ultrasound in 6-8 weeks
• Inguinal orchiectomy
• Testis-sparing surgery with intraoperative frozen section 1

However, incidentally discovered nonpalpable lesions managed conservatively should only be followed with ultrasound if there is strong clinical suspicion of a non-neoplastic lesion, such as recent trauma or infection. 6

Post-Operative Management

Tumor markers must be repeated after orchiectomy until normalization, allowing adequate time for marker half-lives (hCG: 24-36 hours; AFP: 5-7 days). 2

Staging imaging is mandatory:

• Chest imaging in all newly diagnosed germ cell tumors 2
• Abdominopelvic imaging (CT or MRI) to evaluate retroperitoneal lymph nodes 2

Special Populations

Post-pubertal adolescents must follow adult protocols for tumor behavior and treatment, not pediatric protocols, as inferior outcomes occur when post-pubertal males under 18 years are treated according to pediatric guidelines. 2

Elderly patients may be more susceptible to nephrotoxicity and peripheral neuropathy from chemotherapy. 7

Testicular Microlithiasis

Testicular microlithiasis in the absence of solid mass and risk factors for developing germ cell tumor does not confer increased risk of malignant neoplasm and does not require further evaluation (Grade C recommendation). 1 Men with incidentally detected microlithiasis should not undergo further evaluation unless other risk factors are present (cryptorchidism, family history, personal history of germ cell tumor, or Germ Cell Neoplasia In Situ). 1

Common Pitfalls to Avoid

• Never delay obtaining tumor markers before orchiectomy, as this information is essential for staging and treatment planning. 1, 2
• Never dismiss the need for fertility counseling in reproductive-age men before any intervention. 1, 2
• Never delay evaluation of a persistent testicular mass, as delay in diagnosis correlates with higher stage at presentation and worse outcomes. 5, 8
• Never assume a testicular mass is benign based on patient age or associated conditions—cancer must be ruled out. 1