What is the greatest risk factor for a 20-34 year old male patient with a firm, fixed, modular testicular mass, history of smoking, multiple sex partners, and recent trauma to the genital area?

Greatest Risk Factor for Testicular Mass

Age between 20 and 34 years is the greatest risk factor for this patient's testicular cancer, as this demographic represents the peak incidence for germ cell testicular tumors (GCTT), which constitute approximately 95% of all testicular malignancies. 1

Clinical Context and Risk Factor Analysis

The patient presents with a firm, fixed, nodular testicular mass—the classic presentation of testicular cancer—which occurs most commonly in men aged 20-34 years. 2 This age range represents the highest risk period, with GCTT being the most frequently diagnosed cancer in young men during this time. 1

Why Age 20-34 is the Primary Risk Factor

• Peak incidence: Testicular cancer has its highest occurrence between ages 20-34, representing 0.5% of all new malignancies but the most common solid tumor in this age group. 1, 3
• Germ cell tumor predominance: Approximately 95% of testicular tumors in this age range are germ cell tumors, with 52% seminomas and 48% nonseminomas. 1
• Population-level risk: An estimated 1 in 250 men will develop GCTT during their lifetime, with the vast majority occurring in the 20-34 age bracket. 1

Comparison with Other Listed Risk Factors

Cryptorchidism (the second most significant risk factor):

• Carries a relative risk of 3.18 for testicular cancer overall. 1
• The patient's surgical history "at a young age" could suggest orchiopexy for cryptorchidism, but this is not explicitly stated. 1
• Even with cryptorchidism history, the RR of 2.75-8 is substantially lower than the baseline risk conferred by being in the 20-34 age group. 4

Trauma to the genital area:

• Not a recognized risk factor for testicular cancer development. 5, 6
• The trauma history (one week before mass appeared) is temporally inconsistent with cancer development and likely represents coincidental discovery of a pre-existing mass. 2
• No major guidelines or research evidence support trauma as causative for testicular malignancy. 1, 6

Other factors mentioned:

• Cryptorchidism exposure: Not applicable (refers to parasitic infection, not relevant to testicular cancer). 1
• Benzene exposure: Not established as a testicular cancer risk factor in current evidence. 5
• Recurrent arthritis: No association with testicular cancer. 1

Additional Clinical Risk Factors Present

While not among the answer choices, this patient has other concerning features:

• Smoking history (10 years): Some evidence suggests possible association, though not definitively established. 5
• Multiple sexual partners: May increase STI risk but not directly linked to testicular cancer. 6
• Previous antibiotic treatment: Suggests possible prior infection, but infections are not established testicular cancer risk factors. 6

Critical Clinical Pitfall

Do not attribute the testicular mass to recent trauma. 2 The temporal relationship (trauma one week before mass appeared, mass present for two weeks) suggests the cancer was already present and the trauma simply drew attention to it. Testicular cancer develops over months to years, not days. 1, 7

Immediate Management Implications

• Transscrotal ultrasound with Doppler is the next diagnostic step to confirm intratesticular mass. 2
• Serum tumor markers (AFP, β-hCG, LDH) should be obtained before any surgical intervention. 2
• Radical inguinal orchiectomy (never scrotal approach) provides definitive diagnosis and treatment. 2
• The 5-year survival rate exceeds 95% when diagnosed and treated appropriately, even in this high-risk age group. 1, 3