Management of a 70-Year-Old Male with Right Testicular Mass
Proceed immediately with scrotal ultrasound (high-frequency >10 MHz with Doppler), serum tumor markers (AFP, β-HCG, LDH), and urgent urology referral for radical inguinal orchiectomy, as any solid intratesticular mass must be managed as malignant until proven otherwise. 1, 2
Immediate Diagnostic Workup
Imaging
- Obtain scrotal ultrasound with Doppler immediately using a high-frequency transducer (>10 MHz) to confirm whether the mass is intratesticular or extratesticular, assess size, evaluate the contralateral testis, and detect any multifocal disease 1, 2
- Approximately 90% of intratesticular masses are malignant, most commonly germ cell tumors (seminoma 50%, non-seminoma 50%), making urgent imaging essential 2
- Do not delay imaging even if clinical examination seems reassuring—physical examination alone cannot reliably differentiate benign from malignant masses 3
Laboratory Studies
- Draw serum tumor markers (AFP, β-HCG, LDH) before any surgical intervention, including orchiectomy, as these are essential for diagnosis, staging, risk stratification, and post-treatment monitoring 1, 2, 3
- Obtain complete blood count, creatinine, electrolytes, and liver enzymes to establish baseline organ function before treatment 1
Surgical Management
Radical Inguinal Orchiectomy
- Perform radical inguinal orchiectomy through an inguinal incision with division of the spermatic cord at the internal inguinal ring—this is the standard of care for suspected testicular cancer 1
- Never use a scrotal approach for biopsy or surgery, as this violates lymphatic drainage patterns and is associated with higher local recurrence rates 1, 2, 3
- Early clamping of the spermatic cord during surgery prevents hematogenous dissemination 3
Special Considerations for Age 70
- At age 70, testis-sparing surgery is generally not indicated, as this approach is reserved for younger patients with bilateral tumors, solitary testis, or strong fertility preservation needs 1
- Contralateral testicular biopsy is not indicated in patients >40 years without risk factors (testicular volume <12 mL or history of cryptorchidism) 1
Post-Orchiectomy Staging and Risk Assessment
Tumor Marker Kinetics
- Repeat tumor markers 7 days after orchiectomy to assess half-life kinetics and determine if levels are normalizing or rising, which provides critical staging and prognostic information 1, 2
- Continue monitoring markers until normalization is achieved 1
Imaging for Metastatic Disease
- Obtain CT scan of chest, abdomen, and pelvis for staging and evaluation of retroperitoneal lymph nodes 1
- MRI of the central nervous system is needed only in advanced stages or with neurologic symptoms 1
- Bone scan should be performed only if there are symptoms or elevated alkaline phosphatase suggesting bone involvement 1
- PET scanning does not contribute to initial staging and routine use is not recommended 1
Risk Stratification
- Classify patients according to the International Germ Cell Cancer Collaborative Group (IGCCCG) prognostic index using histology, tumor markers, and metastatic sites 1
- For seminoma, tumor size >4 cm and rete testis invasion are associated with higher relapse risk (32% vs. 12% for low-risk features) 1
Histology-Specific Management
For Seminoma (40% of testicular cancers)
- Stage I disease: Options include surveillance, adjuvant carboplatin (AUC 7 for one cycle), or radiotherapy to para-aortic strip—surveillance and carboplatin are preferred given lower long-term risk of second malignancy compared to radiotherapy 1
- Radiotherapy carries long-term risk of second malignancy and should be avoided when possible 1
For Non-Seminoma (60% of testicular cancers)
- Management depends on stage and IGCCCG prognostic group, with options including surveillance, retroperitoneal lymph node dissection, or chemotherapy 1, 3
- For residual masses >3 cm after chemotherapy, PET scan is recommended (minimum 6 weeks post-chemotherapy) 3
Critical Pitfalls to Avoid
- Never delay evaluation of a testicular mass—delay correlates with higher stage at presentation and worse outcomes 2, 3
- Never perform scrotal violation for biopsy or open surgery, as this dramatically increases recurrence risk 1, 2
- Never start treatment without obtaining pre-orchiectomy tumor markers, as these cannot be accurately interpreted after surgery 1, 2, 3
- Do not assume benign disease based on age—while testicular cancer peaks in younger men, it can occur at any age and requires the same aggressive diagnostic approach 1