TESTICULAR TUMOR:
Dear Sumner:
I need your help with Joe, a 32 year old man, whose wife noticed a firm area on the bottom of his right testicle about one week ago. The mass appears to be localized and. palpation of the testis does not elicit pain. I found no other abnormalities on physical examination. The family’s anxiety level is increased by the fact that one of Joe’s cousins was recently diagnosed with testicular cancer. (I have known his family for many years and they have been “surfing the net” for any information about testicular tumors). What diagnostic and therapeutic steps should be taken at this time? What about doing a biopsy of the testicle to see if we are, indeed, dealing with a cancer and if no cancer were found, the testis could be saved? It does not seem right to remove the testis on the basis of suspicion alone.
Dear Harry:
Except for the finding of the distinct area of firmness at the base of Joe’s right testicle, I found nothing unusual on exam. For “starters,” I am obtaining a testicular ultrasound study to ascertain if the firm area that we feel is within the testis itself and if it is solid or cystic. I feel that any solid mass within the testis itself is highly suspicious for malignancy. However, since testicular tumors usually spread via the retroperitoneal lymph nodes, I will be ordering staging procedures to include abdominal/pelvic and chest CT scans.
One of the most challenging of your inquiries was about doing a biopsy on the testis prior to possible removal. This point is controversial. The standard approach for the surgery is via an inguinal approach, exposing the spermatic cord and putting some type of tourniquet around the entire cord prior to delivering the testis into view. If the mass in question is confirmed to be within the testis itself, given the high probability that there is a cancer within, along with the chance of causing spread of the tumor by cutting into it, most urologists (including myself) would be to proceed with its removal, with analysis of the tissue being done in the laboratory. However, in the event we were dealing with a solitary testicle and/or the patient stated that even though he realized the risk of possible spread if there was a cancer present, he wanted that testis saved if at all possible, then I would go ahead with a biopsy, obtain a frozen section, but leave the tourniquet in place until I got the results of the biopsy and proceed with removal of the testis only if the pathologist finds a definite cancer therein.
I will be proceeding with a radical orchiectomy (via an inguinal approach) in the near future. Statistically the tumor, if present, is most likely to be a seminoma, in which case the cure rate is very high. Since an elevation of the tumor markers, beta sub-unit human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP), could occur from other testicular tumors such as embryonal cell carcinoma or choriocarcinoma, I will be getting these studies prior to any surgery. It is interesting that his cousin also had a testicular carcinoma, suggesting the possibility of a genetic (or maybe even an infectious or immunological) component with this tumor; studies are currently going on re these possibilities
