A 32-year-old man comes to the urology clinic after noticing a firm swelling in his left t… — USMLE Step 2 CK

A 32-year-old man comes to the urology clinic after noticing a firm swelling in his left testicle approximately two weeks ago. He reports no pain, dysuria, urinary frequency, or recent trauma. He has no history of sexually transmitted infections. Vital signs are within normal limits. On physical examination, the overlying scrotal skin appears normal. Palpation of the left testicle reveals a $3\text{-cm}$ , rock-hard, non-tender nodule located at the lower pole. The lesion does not transilluminate and cannot be separated from the testis. The right testicle and bilateral epididymides are soft and normal to palpation. A scrotal ultrasound confirms the presence of a solid, hypervascular, hypoechoic intratesticular mass. Serum laboratory testing demonstrates an alpha-fetoprotein (AFP) level of $145\text{ ng/mL}$ (normal $< 10\text{ ng/mL}$ ) and a $\beta$ -hCG level of $92\text{ mIU/mL}$ (normal $< 2\text{ mIU/mL}$ ). Which of the following is the most appropriate next step in management?

A
Percutaneous transscrotal needle biopsy
B
Empiric antimicrobial therapy with ceftriaxone and azithromycin
C
Reassurance that this represents a benign spermatocele
Radical inguinal orchiectomyAnswer
E
Conservative management with serial scrotal ultrasounds

Answer

Radical inguinal orchiectomy is the definitive diagnostic and therapeutic step for a solid testicular mass highly suspicious for malignancy.

The clinical presentation of a painless, solid, rock-hard intratesticular mass that does not transilluminate is highly suspicious for testicular cancer. This suspicion is definitively confirmed by the ultrasound findings of a solid, hypoechoic mass with internal vascularity alongside markedly elevated serum tumor markers (AFP and beta-hCG), which are characteristic of non-seminomatous germ cell tumors. The standard of care and next best step for any highly suspicious solid testicular mass is definitive surgical removal via radical inguinal orchiectomy. This procedure is both diagnostic (providing tissue for histologic evaluation) and therapeutic. An inguinal approach is mandatory because it allows for early vascular control at the deep inguinal ring, thereby preventing the spread of tumor cells into the systemic circulation.

Step-by-Step Solution

Identify the primary clinical problem from the physical exam

A young man presenting with a painless, rock-hard, non-transilluminating intratesticular mass.

These physical exam findings are the classic, pathognomonic presentation of testicular cancer.

Analyze the diagnostic imaging and laboratory data

Ultrasound confirms a solid hypervascular mass; serum markers (AFP, beta-hCG) are markedly elevated.

This confirms the mass is a non-seminomatous germ cell tumor, effectively ruling out benign cysts or infectious etiologies.

Determine the definitively required surgical step

Radical inguinal orchiectomy must be performed.

Surgical removal via the inguinal approach provides a definitive histologic diagnosis, serves as the primary treatment, and crucially prevents altering lymphatic drainage or seeding the scrotal skin.

Key Concept

The standard of care for a solid, suspicious testicular mass is a radical inguinal orchiectomy. Transscrotal biopsy is strictly contraindicated due to the high risk of tumor seeding and altering natural lymphatic drainage.

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