The Patient Journey Following Testicular Mass Diagnosis: Insights From Dr. Aditya Bagrodia

In a recent interview for GU Oncology Now, David Ambinder, MD, a urology resident at New York Medical College/Westchester Medical Center, spoke with Aditya Bagrodia, MD, FACS, of UC San Diego Health. Dr. Bagrodia gave a comprehensive overview of the journey patients experiences when dealing with a testicular mass. From initial presentation to potential treatment options, this interview provides valuable insights for both community oncologists and patients.

Initial Assessment

Dr. Bagrodia began by emphasizing the importance of a detailed patient history. When a patient, typically 18 to 40 years old, presents with a testicular concern, several key aspects should be addressed. These include a history of cryptorchidism (undescended testicles), family history of testicular cancer, scrotal injuries, and signs of systemic issues, such as back pain or infertility. Typically, testicular masses are painless, making them particularly noteworthy. A thorough physical examination—auscultation of the chest, abdominal assessment, and a scrotal examination—is essential. Information gained from that exam forms the basis for further evaluation.

Diagnostic Procedures

Patients with suspected testicular masses should undergo several diagnostic tests. First, serum tumor markers, such as AFP, hCG, and LDH, are measured. Dr. Bagrodia highlighted that while elevated tumor markers can raise suspicion, their absence does not rule out testicular cancer. Scrotal ultrasound is another mandatory step to establish a baseline assessment of the mass. Urinalysis helps exclude infectious causes. In most cases, patients can undergo these assessments on an outpatient basis.

Inpatient Considerations

Although most diagnostic workup occurs in an outpatient setting, there may be instances where inpatient evaluation is necessary. Factors such as socioeconomic considerations or insurance might affect this decision. Dr. Bagrodia suggested that in cases of high suspicion, patients can be admitted for a comprehensive evaluation, which includes staging computed tomography (CT) scans of the chest, head, and pelvis. During this time, sperm banking and discussions regarding testicular prostheses can be initiated.

Treatment Options

The decision to perform a partial or radical orchiectomy depends on various factors. Typically, a radical orchiectomy is the standard of care for unequivocal testicular masses. However, patients with solitary testicles, small masses, equivocal findings, or bilateral cancers may be considered for partial orchiectomy. Dr. Bagrodia noted that testicular cancer often arises from germ cell neoplasia in situ, which is present around 90% of the time. This means that even with a partial orchiectomy, patients might still have at-risk tissue, and decisions should be tailored to individual cases, considering fertility and patient preferences.

Postsurgery Prognosis

Once the mass is excised, the patient enters the postsurgery phase. Staging, including a CT scan of the abdomen and pelvis, is vital, and Dr. Bagrodia often prefers including a chest CT scan for higher-resolution imaging. Monitoring postorchiectomy tumor markers is essential to assign the appropriate stage. Dr. Bagrodia reassures patients that testicular cancer is highly treatable, but anxiety or depression are common in this situation, so he offers support services and consultations to address these concerns.

Prognosis and Differential Diagnosis

Patients are provided with complete staging information based on test results. Most seminoma or nonseminoma cases are stage I, indicating that cancer is confined to the testicle. Patients are encouraged to consider surveillance in these situations. Specific risk factors can influence the decision. For nonseminomas, factors like lymphovascular invasion and renal carcinoma predominance are considered. Patients meet with medical oncologists to discuss all their options.

Surveillance and Follow-Up

Surveillance schedules are generally guideline-directed, with more intensive monitoring during the first year, including history and physical checks and tumor marker assessments every 2 months, along with regular imaging. The frequency of imaging varies based on risk factors. Dr. Bagrodia explained that the goal is to reduce patient anxiety and exposure to unnecessary radiation. He highlighted that the field is slowly shifting away from over-treating patients with stage I disease and is focusing on preserving long-term health.

Later Stages and Treatment

For patients with stage III disease, risk stratification is performed based on postorchiectomy tumor markers and metastasis sites, which dictate the choice of systemic therapy. Patients with stage II disease, particularly those with nonseminoma, face a choice between chemotherapy and surgery. Surgery is a consideration when patients have limited disease. The selection between these options is based on the extent of the disease, patient preference, and individualized assessment.

Emerging Treatments

Dr. Bagrodia mentioned emerging treatments and advancements, particularly for patients with stage II disease. There is a shift away from chemotherapy when possible due to long-term side effects. The goal is to tailor treatments to individual patients, considering risk factors and personal preferences. The SEMS trial and other recent studies provide encouraging data on the use of surgery for stage II patients.

Conclusion

Dr. Bagrodia’s insights provide a comprehensive view of what patients experience when dealing with testicular masses. The emphasis on tailored treatments, the shift away from over-treatment, and the integration of emerging treatments reflect the evolution in the management of testicular cancer. Patients are reassured of the high curability of testicular cancer while receiving the support they need to navigate this challenging journey.

This interview sheds light on the patient experience and the latest strategies for managing testicular masses, ensuring the best possible outcomes for those affected by this condition.

David Ambinder, MD is a urology resident at New York Medical College/Westchester Medical Center. His interests include surgical education, GU oncology and advancements in technology in urology. A significant portion of his research has been focused on litigation in urology.