29-year-old man with a testicular mass
Objectives
- Recognize that testicular pain persisting despite antibiotic treatment requires re-evaluating the diagnosis.
- Order and correctly interpret testicular ultrasound and tumor markers.
- Understand why negative markers do not rule out testicular cancer.
- Apply the correct management of a suspicious testicular mass: inguinal radical orchiectomy, not transscrotal biopsy.
- Recognize the importance of the retroperitoneum in staging and follow-up.
- Incorporate fertility preservation into decision-making.
Reason for consultation
It was initially interpreted as a probable inflammatory/infectious condition and he received various antibiotic regimens. The pain partially decreased, but a testicular abnormality persisted that prompted urologic evaluation.
He has no fever or significant urinary symptoms.
In a young adult with a persistent testicular abnormality despite antibiotic treatment, what should be the next step?
Testicular ultrasound
Testicular ultrasound with Doppler
Right intratesticular lesion of approximately 1.9 cm, solid, with vascularization on Doppler.
The finding is considered suspicious for testicular neoplasm.
Which laboratory tests should be ordered when a testicular tumor is suspected?
Tumor markers
Marker results
- AFP: normal
- β-hCG: normal
- LDH: no significant elevation
Do negative markers rule out testicular cancer?
What do we do now?
- Young patient
- Solid intratesticular mass
- Positive Doppler
- Negative markers
What is the most appropriate management?
Surgical result
Pathology reports: PURE TERATOMA.
This result is particularly important. Teratoma belongs to the group of non-seminomatous germ cell tumors and has particular biological characteristics that shape subsequent decisions.
Staging CT
Imaging results
Chest CT: no evidence of disease.
Abdominal and pelvic CT: an interaortocaval retroperitoneal lymph node of approximately 15 mm is identified.
Tumor markers remain negative.
Why should we pay special attention to the retroperitoneum in a patient with testicular cancer?
Answer
Because it is one of the main routes of lymphatic drainage and spread of testicular tumors.
Testis → spermatic vessels → retroperitoneal lymph nodes.
This anatomical concept explains why reviewing the retroperitoneal imaging is essential during staging and follow-up.
Uro-oncology tumor board
- Right testicular tumor treated with orchiectomy
- Pathology: pure teratoma
- Negative tumor markers
- Interaortocaval retroperitoneal lymphadenopathy
- Chest with no evidence of disease
It is decided to continue evaluating the retroperitoneal lesion and ultimately to recommend surgical treatment.
Before moving on
The patient is young and has no children. A semen analysis is performed and sperm cryopreservation is discussed.
Why should fertility be discussed before treatment?
Answer
Because certain treatments for testicular cancer can affect fertility, and when possible, preservation should be discussed before potentially gonadotoxic treatments or surgeries that may affect ejaculation.
Retroperitoneal lymph node dissection
Retroperitoneal lymph node dissection has specific indications in the management of certain non-seminomatous germ cell tumors and should be performed in properly selected patients.
The key takeaway
testicular tumor → retroperitoneal lymphatic drainage → retroperitoneal lymphadenopathy → need to define treatment according to histology, markers and stage
For the student, the goal is not yet to memorize all its technical indications. The essential concept is to understand this relationship.
Follow-up
CT with no evidence of residual disease
and
negative tumor markers.
The patient then continues with periodic imaging and marker surveillance. Subsequent follow-ups remain free of disease.
Final result
What does this case teach us?
- Not all testicular pain is an infection: persistent symptoms or a persistent testicular abnormality require the diagnosis to be reassessed.
- Ultrasound is essential: a solid intratesticular mass should be considered suspicious.
- Markers may be negative: normal markers do not rule out testicular cancer.
- Do not biopsy transscrotally: for a suspicious testicular mass, the classic approach is radical inguinal orchiectomy.
- Pathology defines the path forward: seminoma and non-seminomatous tumors behave differently and call for different treatment strategies.
- Look at the retroperitoneum: understanding testicular lymphatic drainage helps explain the pattern of spread.
- Do not forget fertility: in young patients, fertility preservation should be discussed before treatments that may compromise it.
- Treatment does not end with surgery: follow-up with markers and imaging is an integral part of testicular cancer management.
Final concept
Young man + solid intratesticular mass = testicular tumor until proven otherwise.
Pain relief with antibiotics and normal tumor markers should not provide false reassurance in the face of a suspicious ultrasound lesion.