A 50-year-old man presents with a painless scrotal swelling. Ultrasound shows a 2 cm well-defined hypoechoic intratesticular nodule with internal vascularity on colour Doppler. Serum AFP and beta-hCG are normal; LDH is mildly elevated. What is the most likely diagnosis and how should it be managed?
- A Testicular epidermoid cyst; managed with enucleation sparing the testis
- B Testicular lymphoma; managed with chemotherapy alone
- C Leydig cell tumour; managed with testis-sparing surgery
- D Pure seminoma; managed with radical orchidectomy followed by staging CT ✓
Explanation
A hypoechoic intratesticular mass with vascularity in a male aged 15-50 is a testicular germ cell tumour until proven otherwise. Normal AFP and beta-hCG with only mild LDH elevation is characteristic of pure seminoma, as non-seminomatous tumours (embryonal carcinoma, yolk sac tumour) typically produce AFP and/or beta-hCG. The management standard is radical inguinal orchidectomy (trans-scrotal approach is avoided to prevent lymphatic spread to inguinal nodes), followed by CT chest, abdomen, and pelvis for staging. Epidermoid cysts are avascular with an 'onion ring' laminated pattern. Lymphoma occurs in older men and is often bilateral.
Reference: Grainger & Allison's Diagnostic Radiology, 7th ed.
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Written and medically reviewed by the StethoPrep medical team.