Proceed Immediately to Tissue Diagnosis via Radical Inguinal Orchiectomy
A testicular mass that has doubled in size despite a prior negative ultrasound requires immediate repeat scrotal ultrasound with high-frequency probe (>10 MHz) and color Doppler, followed by urgent urologic referral for radical inguinal orchiectomy if any intratesticular mass is identified—do not delay for additional imaging or observation. 1, 2, 3
Critical First Steps
Obtain repeat scrotal ultrasound immediately with high-frequency probe (>10 MHz) and color Doppler assessment, as ultrasound has nearly 100% sensitivity for detecting intratesticular masses and 98-100% accuracy for distinguishing intratesticular from extratesticular processes 2, 3
Draw serum tumor markers (AFP, β-HCG, LDH) before any surgical intervention, as these are essential for diagnosis, staging, and monitoring—this must be done even if you proceed urgently to surgery 1, 3
The history of breast cancer is highly relevant: men with breast cancer have increased risk of testicular cancer due to shared familial/genetic factors, and testicular cancer patients have increased risk of breast cancer in first-degree relatives 4, 5
Why the Initial Negative Ultrasound Doesn't Rule Out Malignancy
A mass that has doubled in size represents aggressive growth kinetics that overrides the prior negative imaging—clinical examination findings take precedence when there is clear progression 1
The initial ultrasound may have been falsely negative due to technical factors, small tumor size at that time, or misinterpretation 2
Any palpable testicular mass is pathognomonic for testicular tumor until proven otherwise, and persistent or enlarging masses warrant tissue diagnosis regardless of prior imaging 1
Management Algorithm
If Repeat Ultrasound Shows Intratesticular Mass:
Proceed directly to radical inguinal orchiectomy without delay—this is both diagnostic and therapeutic 1, 3, 6
The orchiectomy must be performed through an inguinal incision at the level of the internal inguinal ring, never through a scrotal approach, as scrotal violation can alter lymphatic drainage and worsen prognosis 3
Discuss sperm banking before orchiectomy in this reproductive-age patient, as this can be done quickly and should not significantly delay definitive treatment 1, 3
If Repeat Ultrasound is Again Negative:
Proceed to tissue biopsy (core needle or excisional) through inguinal approach if a palpable mass persists, as clinical examination supersedes imaging 1
Consider that the mass may be extratesticular (epididymal, spermatic cord), but any solid mass requires histologic diagnosis 2
Post-Orchiectomy Management
Repeat tumor markers minimum 7 days after orchiectomy to determine half-life kinetics and guide further staging 3
Obtain CT chest/abdomen/pelvis for staging once pathology confirms germ cell tumor 1, 3
Elevated AFP indicates nonseminoma and requires management as such, even if histology shows pure seminoma 1
Critical Pitfalls to Avoid
Never perform scrotal biopsy or scrotal incision for suspected testicular malignancy—only inguinal orchiectomy is appropriate, as scrotal violation can seed tumor cells and alter lymphatic drainage 3, 6
Do not delay evaluation or treatment because of the breast cancer history—the testicular mass takes absolute priority, as delay in testicular cancer diagnosis correlates with higher stage at presentation and worse outcomes 1, 6
Do not rely on tumor markers to exclude malignancy—normal markers do not exclude germ cell tumors, particularly seminomas, which have low marker sensitivity 3
Do not observe a growing testicular mass—any solid intratesticular mass must be managed as malignant until proven otherwise 6
Special Considerations Given Breast Cancer History
The patient's breast cancer history suggests possible genetic predisposition (BRCA2 mutations, Klinefelter syndrome, or other familial cancer syndromes) that increases testicular cancer risk 4
Consider genetic counseling referral after acute management is complete 4
Ensure long-term surveillance of the contralateral testis with regular self-examination and clinical follow-up 6