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

Infection: epididymo-orchitis

Benign tumors: Sertoli-Leydig cell

Seminomas

Nonseminomatous germ cell tumors (NSGCTs)

Speaking Intelligently

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.

• Groin pathology may present as abdominal complaints and vice versa; however, testicular tumors are usually asymptomatic.

• Suspected testicular tumors require urgent surgical removal (radical orchiectomy via an inguinal approach).

• Patients with testicular tumors frequently require additional therapy (such as chemotherapy or radiation therapy), depending on the tumor pathology discovered after resection.

• After radical orchiectomy, tumor markers (AFP, β-hCG) will have to be monitored until they reach the lowest possible point.

History

• A careful history of the onset and course of a painless mass should be obtained. Particularly helpful are the following questions:

• How long has it been there?

• Does it come and go?

• 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?

• Review of systems should focus on the presence of systemic symptoms such as fever and chills, weight loss, and night sweats; back pain; abdominal symptoms such as pain, distension, nausea, and bowel changes; and genitourinary symptoms such as dysuria and urethral discharge.

Physical Examination

The importance of the physical exam is to differentiate benign from malignant processes and to evaluate for possible metastases.

• The physical exam should begin with particular attention to the lymph nodes (especially supraclavicular area). The lungs should be auscultated carefully, particularly with attention to any pulmonary findings that may be problematic for potential future use of bleomycin (a critical chemotherapeutic agent for treatment of testicular cancer).

• The abdominal exam should pay close attention to any scars and/or tenderness in any quadrants. Most importantly, one should carefully feel for any masses (in the setting of testicular cancer, an abdominal mass can indicate massive retroperitoneal lymph node metastases).

• An inguinal exam focuses on signs of lymphadenopathy or inguinal hernias, and potential involvement of the spermatic cord with tumor. The scrotum should be invaginated through the internal ring to inspect for any laxity or bulges within the inguinal canal that may signal an inguinal hernia. The patient should cough and perform a Valsalva maneuver to increase intra-abdominal pressure, which aids in revealing an occult hernia.

• The scrotal exam includes inspection of skin and rugations, and palpation of testicles, epididymides, and spermatic cords. One should evaluate for skin changes (i.e., loss of normal rugation), erythema, edema, induration, and tenderness. The posterolateral portion of the testis is covered by the epididymis, which should be nontender. The spermatic cord runs in the most superior aspect of the scrotum and should be palpated gently between thumb and forefinger. The testes should be examined with the patient in both the recumbent and standing positions. Start at the base of the scrotum and palpate the testes, which should be firm but not hard. It should be noted whether fluid is present around the testicles and whether a mass is palpable (frequently the testicle itself cannot be palpated because of the presence of scrotal fluid or a mass replacing the testicle).

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
• Seminomas can be associated with elevated β-hCG (in ~10% of cases), but usually the tumor markers are normal.
• NSGCTs produce AFP and/or β-hCG.
• LDH, a nonspecific marker of tumor burden, may be elevated in patients with either seminomas or NSGCTs.
• These tumor markers should be obtained both before and after orchiectomy, as it is critical to follow their values as a measure of residual disease after initial orchiectomy. Each tumor marker has a specific half-life, and time to normalization of elevated markers is highly predictable. Normalization of tumor markers within the expected time line implies absence of residual disease (in the scrotum/groin and lymph nodes). Persistently elevated tumor markers beyond the date of expected normalization portend a worse prognosis with presence of ongoing cancer (typically lymph node disease).

IMAGING CONSIDERATIONS

→ Ultrasonography: For clinically suspicious masses or when unsure of the diagnosis, ultrasonography is the imaging modality of choice for the majority of scrotal masses. It can differentiate solid from cystic masses and testicular from paratesticular masses.	$96
→ MRI: If the diagnosis is still uncertain, an MRI scan is appropriate and effective. MRI has been reported to have a negative predictive value of 100% and a positive predictive value of 71%.	$534
→ CT scan: If the mass is found to be malignant, the next step is to obtain a CT scan of the abdomen and pelvis (with IV contrast) and a chest radiograph (posteroanterior and lateral views) to evaluate for metastatic disease. In the event of a positive abdominal CT scan or an abnormal chest radiograph, a chest CT scan would be indicated. These images will differentiate clinical stages I, II, and III.	$334
Clinical stage I disease is confined to the testis. Clinical stage II disease is characterized by enlarged retroperitoneal lymph nodes. Clinical stage III disease involves metastatic disease to any viscera or any disease above the diaphragm.