What is the next step in managing a 3mm hypoechoic testicular mass suspicious for testicular cancer?

Management of 3mm Hypoechoic Testicular Mass

For a 3mm hypoechoic testicular mass suspicious for malignancy, obtain serum tumor markers (AFP, β-HCG, LDH) immediately and proceed with radical inguinal orchiectomy, as this represents the standard of care for any suspicious intratesticular mass regardless of size. 1, 2

Immediate Diagnostic Workup

Before any surgical intervention, the following must be obtained:

• Serum tumor markers including alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (β-HCG), and lactate dehydrogenase (LDH) should be drawn prior to orchiectomy 1, 2
• Complete blood count, creatinine, electrolytes, and liver enzymes to complete the baseline assessment 1
• Chest radiograph as part of initial staging workup 1

Critical caveat: Even though this is a small 3mm lesion, the hypoechoic appearance on ultrasound makes it highly suspicious for malignancy, and size alone should not delay definitive surgical management. 1

Fertility Preservation

• Sperm banking must be discussed with all patients of reproductive age before any therapeutic intervention that may compromise fertility 1, 2
• This discussion should occur before orchiectomy, though sperm banking may be performed either before or after orchiectomy but certainly before any subsequent therapy 1
• Patients should be counseled about risks of hypogonadism and infertility 2

Definitive Surgical Management

Radical inguinal orchiectomy is the primary treatment for this suspicious testicular mass and should be performed through the following approach:

• Inguinal incision with early vascular control at the internal inguinal ring 2
• Never use a scrotal approach for biopsy or surgery, as this increases risk of local recurrence, tumor seeding, and altered lymphatic drainage 2, 3
• The procedure is both diagnostic and therapeutic 1

Alternative Consideration: Testis-Sparing Surgery

While radical orchiectomy remains standard, recent evidence suggests that intraoperative ultrasound-guided localization and excisional biopsy may be considered for very small nonpalpable masses (5-6mm range), though this carries significant caveats 4:

• Frozen section analysis must be performed intraoperatively 4
• Excisional biopsy with margins showing normal testicular tissue is essential 4
• Patients must understand that final pathology may reveal malignancy requiring delayed radical orchiectomy 4
• In one series, 2 of 4 patients with benign frozen sections ultimately had seminoma on permanent pathology, requiring delayed orchiectomy 4

However, given the high stakes of missing testicular cancer in a young patient and the excellent outcomes with radical orchiectomy, the conservative approach of immediate radical inguinal orchiectomy is strongly preferred for any suspicious intratesticular mass. 1, 2

Post-Orchiectomy Management

After surgical removal:

• Repeat serum tumor markers (AFP, β-HCG, LDH) at appropriate half-life intervals to establish nadir levels for staging and risk stratification 2
  • β-HCG has a half-life of approximately 1-3 days 1
• Staging imaging including CT abdomen/pelvis and chest imaging based on histology 2
• Further management is dictated by histology (pure seminoma vs. nonseminoma), pathological stage, and risk classification 1

Important Clinical Pitfalls

• Do not delay surgery based on small size alone - even small germ cell tumors have metastatic potential 5
• Do not perform scrotal biopsy or use a scrotal surgical approach - this violates oncologic principles 2, 3
• Do not interpret elevated β-HCG without clinical context - hypogonadism and marijuana use may cause benign elevations 1
• Do not skip sperm banking discussion - this is a young patient population where fertility preservation is paramount 1, 2

The timing should be prompt but not emergent unless there are signs of life-threatening metastatic disease 2. The 5-year survival for stage I testicular cancer is 99%, making early definitive treatment highly effective 6.