Testicular Cancer: The Daily PANCE Blueprint
A 24-year-old man noticed a lump in his right testicle while showering. It is painless and has been slowly enlarging over two months. On exam there is a firm, non-tender intratesticular mass that does not transilluminate; the overlying scrotum is normal and there is no fever or urethral discharge. Scrotal ultrasound shows a solid, hypoechoic intratesticular mass. Serum β-hCG and lactate dehydrogenase are elevated and alpha-fetoprotein is normal. Which of the following is the most appropriate next step in management?
A. Radical inguinal orchiectomy
B. Trans-scrotal needle biopsy of the mass
C. A two-week course of antibiotics and NSAIDs
D. Aspiration of the mass
E. Observation with repeat examination in 6 months
Answer and topic summary
The answer is A. Radical inguinal orchiectomy
A painless, firm, solid intratesticular mass in a young man is testicular cancer until proven otherwise, and the next step is radical inguinal orchiectomy — an operation that is simultaneously the definitive diagnostic biopsy and the first treatment. The trap, and the single highest-yield fact on this topic, is the approach. A trans-scrotal biopsy or aspiration is contraindicated: the testis drains to the retroperitoneal lymph nodes, while the scrotal skin drains to the inguinal nodes, so cutting through the scrotum seeds tumor into a whole new nodal basin and changes the staging and the treatment. Go through the inguinal canal and clamp the cord first. The workup order matters too: ultrasound first, tumor markers (AFP, β-hCG, LDH) before surgery so they can be trended, then orchiectomy, then CT of the abdomen and pelvis for staging. Solid does not transilluminate; a hydrocele does, and a varicocele is the classic “bag of worms” that a mass is not. Antibiotics chase epididymo-orchitis, which is painful and tender, and observing a solid mass for six months wastes the window in a malignancy that is highly curable when caught early. Risk factors worth knowing: cryptorchidism (even after orchiopexy), a prior contralateral tumor, and family history.
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