How should a 71-year-old man with a newly discovered testicular lump be evaluated and managed?

Immediate Referral for Urgent Scrotal Ultrasound and Urology Evaluation

A 71-year-old man with a newly discovered testicular lump requires immediate scrotal ultrasound with Doppler to confirm whether the mass is intratesticular or extratesticular, followed by urgent urology referral if an intratesticular mass is identified, as approximately 90% of intratesticular masses are malignant. 1, 2

Initial Diagnostic Workup

Scrotal Ultrasound with Doppler (First-Line Test)

• Perform scrotal ultrasound with both grayscale and color Doppler immediately as the definitive first-line diagnostic test, which provides approximately 100% sensitivity for detecting intrascrotal masses and 98-100% accuracy for distinguishing intratesticular from extratesticular lesions. 1
• The critical distinction is whether the lump is intra- or extra-testicular: palpable intratesticular lesions carry approximately 90% malignancy risk, whereas extratesticular masses are usually benign (epididymal cysts, hydroceles). 2
• High-frequency probes (>10 MHz) should be used to maximize resolution and accurate caliper placement for precise measurement. 1

Serum Tumor Markers (Pre-Treatment)

• Draw serum tumor markers (AFP, β-HCG, LDH) before any surgical intervention, as these are essential for diagnosis, staging, and monitoring purposes. 1, 3
• These markers must be obtained before orchiectomy because post-operative values guide adjuvant treatment decisions. 1, 4

Management Algorithm Based on Ultrasound Findings

If Intratesticular Mass Confirmed

• Urgent urology referral for radical inguinal orchiectomy is the standard of care, as this procedure serves both diagnostic and therapeutic purposes. 1, 3
• The inguinal approach with early clamping of the spermatic cord prevents hematogenous dissemination; never use a scrotal approach for suspected malignancy, as scrotal violation increases local recurrence rates. 1, 5
• Complete blood count, creatinine, electrolytes, and liver enzymes should be obtained once an intratesticular mass is identified. 1

If Extratesticular Mass (Likely Benign)

• Epididymal cysts (27% of scrotal masses) and hydroceles (11%) are the most common benign findings. 2
• Routine urology referral for further characterization and management of benign lesions is appropriate but not urgent. 2

Fertility and Hormonal Considerations

Sperm Banking Discussion

• Discuss and offer sperm cryopreservation before orchiectomy in all patients who may desire future fertility, as treatment carries gonadal toxicity risk. 1, 4
• In cases of azoospermia, cryopreservation of testicular tissue should be considered. 4

Hormonal Evaluation

• Determination of total testosterone, LH, and FSH should be performed before operation, particularly in older men who may have age-related hypogonadism. 5

Staging After Orchiectomy (If Cancer Confirmed)

Imaging Studies

• Chest radiography and abdominal/pelvic CT scans are mandatory for staging, evaluating retroperitoneal lymph nodes and pulmonary metastases. 1, 4
• In cases of hematogenous spread, bone scan and brain CT or MRI are performed additionally. 4

Post-Operative Tumor Markers

• Tumor markers must be repeated after orchiectomy until normalization, allowing adequate time for marker half-lives (β-HCG: 24-36 hours; AFP: 5-7 days). 1, 5
• Failure of markers to normalize indicates residual disease and guides adjuvant therapy. 1

Prognosis and Treatment Outcomes

• At diagnosis, testicular germ cell tumors are stage I (localized) in 70-75% of patients, stage II (retroperitoneal nodes only) in 20%, and stage III (widely metastatic) in 10%. 3
• Five-year survival rates are 99% for stage I, 92% for stage II, and 85% for stage III disease. 3
• Early diagnosis and prompt treatment starting with radical inguinal orchiectomy are critical to optimize outcomes. 3

Critical Pitfalls to Avoid

• Never delay ultrasound evaluation of a testicular mass; delay in diagnosis correlates with higher stage at presentation. 1
• Never perform scrotal biopsy or scrotal incision for suspected malignancy—only the inguinal approach is appropriate. 1, 5
• Never start testosterone replacement without first clarifying fertility intentions and obtaining tumor markers, as exogenous testosterone can suppress spermatogenesis. 6
• Do not rely solely on physical examination to differentiate benign from malignant masses; ultrasound is essential for accurate diagnosis. 1

Age-Specific Considerations for This 71-Year-Old Patient

• While testicular cancer peaks in men aged 20-40 years, it remains the most common solid malignancy in younger men and can occur at any age. 3, 7
• The same diagnostic and treatment algorithms apply regardless of age, though fertility preservation discussions may be less relevant in older patients. 1
• Cardiovascular disease risk assessment is particularly important in older patients, as treatment-related cardiovascular complications are a long-term concern. 3