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Biopsy
23%
18/77
Radical orchiectomy
64%
49/77
Chemotherapy
3%
2/77
Three month re-imaging
8%
6/77
No further workup, instruct patient to return if symptomatic
1%
1/77
Select Answer to see Preferred Response
The patient’s presentation and workup is consistent with testicular cancer, despite the normal blood work. All testicular cancers should undergo radical orchiectomy. Testicular cancer is the most common malignancy in males of age 15-35, the vast majority of which are germ cell tumors. They typically present as a non-acute, painless testicular mass, although some patients do report discomfort. Other manifestations may include gynecomastia, paraneoplastic hyperthyroidism, and paraneoplastic limbic encephalitis. Workup of a hard testicular mass includes ultrasound, serum tumor markers, and CT scan. Once diagnosed, the first step is radical inguinal orchiectomy with possible retroperitoneal lymph node dissection to evaluate for metastases. Following surgery and staging, chemotherapy, radiation therapy, or active surveillance are all viable options. Overall survival rates for testicular cancer are quite high. Tiemstra and Kapoor discuss the evaluation of scrotal masses, and present an algorithm (Illustration A) for appropriate diagnosis. They emphasize a complete understanding of the anatomy and being able to identify the source of the pathology. Doppler ultrasonography is also mentioned as an important diagnostic tool in the evaluation of testicular pathology. Groll et al. performed a literature review on the role of testicular germ cell tumor surveillance following surgery as opposed to adjuvant therapies. Because the outcomes for early stage testicular cancer are so good, they take into consideration other factors such as quality of life, impact on sex and fertility, and compliance. They conclude that surveillance is a preferred approach in stage I seminoma and non-seminomatous germ cell tumors, although they recommend that further research is conducted to explore other psychosocial aspects of post-surgical management. Figure A is an ultrasound of the right testis revealing a well-defined hypoechoic lesion without cystic areas. Illustration A is an algorithm for diagnosing scrotal masses. Incorrect answers: Answer 1: Biopsy is very rarely indicated in testicular cancer. Answer 3: Chemotherapy is generally used as an adjuvant therapy following radical orchiectomy. Answer 4: This presentation is consistent with testicular cancer. Delay in surgery would not be appropriate. Answer 5: Testicular cancer is often painless, and requires treatment.
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