Testicular Mass (Case 32)
Christopher Greenleaf MD, Tamara Donatelli DO, Jennifer Sherwood MD, and Mary Denshaw-Burke MD
Case: You are consulted by your hospital urologist: “A 19-year-old male presents with a 3.0-cm firm asymptomatic testicular mass of concern. By exam, this does not appear to be a hernia, hydrocele, or varicocele. Please evaluate.”
Differential Diagnosis
Benign |
Malignant |
The urologist seeing a patient with an asymptomatic scrotal mass directs the physical examination toward differentiating the benign from the malignant causes. An inguinal hernia can be invaginated at the inguinal ring. A hydrocele will have a cystic consistency. A varicocele will often feel like a “bag of worms.” These benign conditions result in relatively soft, compressible masses of the scrotum. A malignant mass, however, palpates as a firm lump with a “woody” or heavy consistency. Almost all scrotal masses should be imaged to further define anatomic features. If the suspicion is high for malignancy, the next step is to obtain an ultrasonogram. A trans-scrotal biopsy should never be performed, because it can disrupt the lymphatic channels and lead to metastases or obscure the anatomy during future inguinal orchiectomy. If a malignant tumor is suspected on exam and imaging, surgical intervention must be instituted quickly (ideally within 48 hours due to the rapid tumor doubling time).
The medical oncologist consulted on this patient with a possible testicular cancer suggested by physical exam and ultrasonography should order testing for the preoperative tumor markers α-fetoprotein (AFP), lactate dehydrogenase (LDH), and the β subunit of human chorionic gonadotropin (β-hCG). Metastatic workup for a testicular tumor should include a chest radiograph and a CT scan of the abdomen and pelvis, and occasionally a CT scan of the chest.
PATIENT CARE
Clinical Thinking
• All solid/hard scrotal masses are considered malignant until proven otherwise.
History
• Has there previously been pain?
• Is there associated erythema or edema?
• If it is persistent, is it staying stable in size or getting bigger or smaller?
Physical Examination
The importance of the physical exam is to differentiate benign from malignant processes and to evaluate for possible metastases.
Tests for Consideration
When you have diagnosed a likely testicular cancer by physical exam and ultrasonography:
• Serum markers of AFP, β-hCG, and LDH should be obtained immediately. |
$24, $21, $9 |
Clinical Entities* | Medical Knowledge |
Seminomas |
|
Pφ |
A seminoma is derived from spermatogonia/spermatocytes. |
TP |
A tumor may present as a solid, painless mass in the scrotum or along the cord structures within or above the scrotum. With hormone-producing tumors, precocious puberty ensues. |
Dx |
Testicular ultrasonography is indicated if the diagnosis is in question or a solid component is suspected (i.e., bilateral scrotal ultrasonography should be performed in every case of suspected tumor). A chest radiograph, CT of the abdomen and pelvis with IV contrast, and tumor markers (AFP, β-hCG, and LDH) should be obtained preoperatively if tumor is suspected. |
Tx |
Testicular tumors should be treated initially with radical inguinal orchiectomy and may require further medical treatment. Further treatment includes: • Clinical stage I seminomas: Active surveillance (in compliant patients) vs. radiation therapy (XRT) vs. one to two cycles of single-agent carboplatin. • Clinical stage II seminomas: XRT vs. etoposide and cisplatin (EP) for four cycles vs. bleomycin, etoposide, and cisplatin (BEP) for three cycles. • Clinical stage III seminomas: Good risk—EP for four cycles, BEP for three cycles. Intermediate risk—BEP for four cycles. See Cecil Essentials 72. |
*Please note that only malignant diagnoses are presented in the Clinical Entities. |
Nonseminomatous Germ Cell Tumors |
|
Pφ |
NSGCTs can be composed of one or more histologic subtypes that include embryonal carcinoma, yolk sac tumor, choriocarcinoma, and teratoma. |
TP |
A tumor may present as a solid, painless mass in the scrotum or along the cord structures within or above the scrotum. With hormone-producing tumors, precocious puberty ensues. |
Testicular ultrasonography is indicated if the diagnosis is in question or a solid component is suspected (i.e., bilateral scrotal ultrasonography should be performed in every case of suspected tumor). A chest radiograph, a CT of the abdomen and pelvis with IV contrast, and tumor markers (AFP, β-hCG, and LDH) should be obtained preoperatively if tumor is suspected. |
|
Tx |
Testicular tumors should be treated initially by radical inguinal orchiectomy and may require further medical treatment. Further treatment includes: Stage IS (persistent elevation of tumor markers): EP for four cycles or BEP for three cycles. • Clinical Stage II NSGCT: EP for four cycles vs. BEP for three cycles. See Cecil Essentials 72. |
Practice-Based Learning and Improvement: Evidence-Based Medicine
Title
Improved chemotherapy in disseminated testicular cancer
Institution
Indiana University Medical Center
Reference
Einhorn LH, Donohue JP. Improved chemotherapy in disseminated testicular cancer. J Urol 117:65–69, 1977
Problem
Patient mortality from testicular cancer was greater than 50% before 1970.
Intervention
Addition of platinum-based drugs to chemotherapy regimens
Comparison/control (quality of evidence)
This study compared the then standard chemotherapy regimen of adriamycin, bleomycin, and vincristine against platinum, vinblastine, and bleomycin.
Outcome/effect
The adriamycin, bleomycin, and vincristine group had an 87.5% overall response rate with a 50% partial remission rate and a 37.5% complete remission rate. The group receiving platinum, vinblastine, and bleomycin (which ultimately became known as the Einhorn regimen) had a 100% overall response rate with a 20% partial remission rate and an 80% complete remission rate.
Historical significance/comments
Testicular cancer has become one of the most curable cancers in the United States. In 1997, there was less than 5% patient mortality.
Interpersonal and Communication Skills
Communicate Effectively about Potential Diagnoses
In the setting of a testicular mass, this patient is already concerned that he may have cancer. During the examination, describe your impression of the testicular exam and explain the implications of this to the patient (who is often accompanied by a parent, given the relatively young age at diagnosis). It is preferable to be direct about the concern for a testicular tumor, if the examination warrants this concern. Communicate to the patient that an ultrasonogram should be performed to obtain further information. As testicular cancer has a very rapid doubling time and surgery should be performed expeditiously, the patient must be given a clear understanding of the likely diagnosis so that he can cooperate with immediate testing. Throughout this time, support the patient and family by answering any questions and by explaining that should this be diagnosed as a testicular malignancy, it has a very high cure rate.
Professionalism
Maintain Appropriate Patient Relations in Performing a Testicular Exam
In a time when female medical students constitute approximately 50% of medical school classes, many testicular exams will be performed by female physicians. Before approaching the male patient for a genital exam, a female physician should always be accompanied by a chaperone (male or female is acceptable). Privacy and confidentiality should be respected at all times. Great care and professionalism must be conveyed when approaching the patient so as to gain the patient’s confidence and establish a level of comfort that will facilitate both a thorough physical exam and a nontraumatic experience for the patient. The female physician might also explain that care of the male patient is what she does on a daily basis and that she is very comfortable in that role. A patient’s genitalia should be covered during all parts of the physical exam until the time for the genital exam. Verbalize to your patient what you plan to do and what you are doing throughout the exam. Often this simple “warning” of what is to come will facilitate the exam. If a patient is still uneasy despite your efforts, it is often helpful to emphasize both your role as the physician and the importance of the exam for diagnostic purposes. The most important aspect of this encounter is demeanor; if you convey a sense of serious and confident professionalism, the patient will respond to you appropriately.
Systems-Based Practice
Effective Use of Health Information Resources on Patient Options and Patient Care
In certain clinical circumstances, namely stage IA and IB seminomas and nonseminomas, the patient has the option of aggressive surveillance in lieu of systemic therapy. Surveillance as a management option for early-stage testicular cancer requires a series of regimented studies over several years to monitor disease, so this option is historically reserved only for compliant patients. Reports have indicated that 21% of seminoma patients on surveillance were lost to follow-up after approximately 5 years. One tool that has been instrumental in facilitating compliance with follow-up is the electronic medical record (EMR). EMR has the capacity to organize surveillance schedules and enhance patient compliance with follow-up care. Additionally, it has been suggested that providing effective access to EMR data as a reference source for patients with early-stage testicular cancer contributes to patient reassurance and to enhanced compliance with surveillance.