I have a firm, painless testicular mass; how should it be evaluated and managed?

Evaluation and Management of a Firm, Painless Testicular Mass

A firm, painless testicular mass must be treated as testicular cancer until proven otherwise, requiring immediate scrotal ultrasound with Doppler and serum tumor markers (AFP, β-HCG, LDH) before any intervention. 1

Immediate Diagnostic Workup

Scrotal Ultrasound with Doppler

• Obtain scrotal ultrasound with Doppler immediately as the mandatory first-line imaging study—this modality provides approximately 100% sensitivity for detecting intrascrotal masses and 98-100% accuracy for distinguishing intratesticular from extratesticular lesions. 2, 3
• Use a high-frequency linear array transducer (12-17 MHz) with both grayscale and color/power Doppler evaluation for optimal anatomic detail. 3
• Any hypoechoic mass with vascular flow on ultrasound is highly suggestive of malignancy. 1
• Approximately 90% of intratesticular solid masses are malignant, whereas extratesticular masses are usually benign. 2, 4, 5

Serum Tumor Markers

• Draw serum tumor markers (AFP, β-HCG, LDH) before any treatment, including orchiectomy—these are essential for diagnosis, staging, and subsequent monitoring. 1, 2, 4
• These markers must be obtained prior to surgical intervention to establish baseline values. 2, 4

Additional Laboratory Studies

• Obtain complete blood count, creatinine, electrolytes, and liver enzymes if an intratesticular mass is identified on ultrasound. 2

Pre-Treatment Counseling

Fertility Preservation

• Discuss and offer sperm banking before any definitive treatment in all patients of reproductive age, as orchiectomy and subsequent treatments may compromise fertility. 1, 2, 4
• This is particularly critical in patients without a normal contralateral testis or with known subfertility, and should be completed prior to orchiectomy. 1

Risk Discussion

• Counsel patients about the risks of hypogonadism and infertility associated with treatment. 1

Definitive Management Based on Ultrasound Findings

For Intratesticular Solid Mass

• Proceed with radical inguinal orchiectomy as the primary treatment—this serves as both diagnostic and therapeutic intervention. 2, 4, 6, 7
• Early clamping of the spermatic cord during surgery prevents hematogenous dissemination. 2
• Never perform a scrotal approach for suspected testicular tumors, as this violates lymphatic drainage patterns and is associated with higher local recurrence rates. 2, 4

For Indeterminate Findings

• If ultrasound findings are indeterminate and serum tumor markers (hCG and AFP) are normal, repeat imaging in 6-8 weeks. 1
• Up to 50-80% of non-palpable or incidentally detected masses less than 2 cm are not cancerous, making serial observation reasonable in select cases. 1

MRI Considerations

• Do not use MRI as the initial evaluation for a testicular lesion suspicious for neoplasm. 1

Post-Orchiectomy Staging and Follow-Up

Repeat Tumor Markers

• Repeat serum tumor markers 7 days post-orchiectomy to evaluate half-life kinetics and assess for normalization. 2, 4

Imaging for Staging

• Obtain chest radiography and abdominal/pelvic CT scans to evaluate for retroperitoneal lymph node involvement and metastases. 2

Adjuvant Treatment

• Further management depends on histology (seminoma vs. nonseminoma) and stage, with options including surveillance, chemotherapy, radiotherapy, or retroperitoneal lymph node dissection. 2

Critical Pitfalls to Avoid

• Do not delay evaluation of a persistent testicular mass—delay in diagnosis correlates with higher stage at presentation and worse outcomes. 2, 4
• Never biopsy through a scrotal approach—always use an inguinal approach if tissue diagnosis is needed. 2, 4
• Do not skip tumor markers before surgery—they are irreplaceable for staging and monitoring. 2, 4
• Do not rely solely on physical examination to differentiate benign from malignant masses, as ultrasound is essential for accurate diagnosis. 2

Special Considerations

Testicular Microlithiasis

• Testicular microlithiasis (>5 small echogenic non-shadowing foci) in the absence of a solid mass and risk factors does not confer increased malignancy risk and does not require further evaluation. 1
• Further workup is only needed if other risk factors are present (cryptorchidism, family history, personal history of germ cell tumor, or atrophy). 1

Small Masses (<2 cm)

• For small, non-palpable masses less than 2 cm, management options include serial examinations with repeat ultrasound in 6-8 weeks, inguinal orchiectomy, or testis-sparing surgery with intraoperative frozen section. 1