Testicular Mass in a 40-Year-Old Man

Abstract

Patient: A 40-year-old male with a painless left testicular mass and back pain History of Present Illness: The patient described a 2-month history of progressive scrotal swelling. He also noted lower back pain that worsened with heavy lifting. The patient denied a history of prior scrotal trauma or surgery. He also noted decreased appetite and an unintentional 20-pound weight loss over the past 2 months. Past Medical History: Mild untreated hypertension Past Surgical History: None Family History: Non-contributory Physical Exam Vital Signs: Temperature, 36.9°C; heart rate, 114 beats per minute; respiratory rate, 16 per minute; blood pressure, 142/97 mmHg. Pertinent physical exam findings included tachycardia, hypertension, mild gynecomastia, a palpable mildly tender midline abdominal mass, and a firm enlarged non-tender left testicle measuring ∼10 cm. Laboratory values at presentation are noted in Table 1. 1. What are this patient’s most striking clinical and laboratory findings? 2. What is the differential diagnosis for a testicular mass? 3. What additional testing is necessary for the diagnosis? 4. How are serological tumor markers used in the differential diagnosis? 5. What is the most likely diagnosis based on the clinical, radiologic, laboratory, and histologic findings? 6. What is the pathophysiology of this disease? 7. How is this disease treated and how can laboratory testing be used to assess treatment efficacy? 1. The most striking physical finding in this patient is the large painless testicular mass. The associated lumbar pain and gynecomastia are also significant, as is the unintended weight loss. Laboratory data from this patient are shown in Table 1 and reveal hypercalcemia, low hemoglobin, total iron binding capacity (TIBC), transferrin, and increased ferritin. The patient has increased blood urea nitrogen (BUN) and creatinine values with an associated decrease in the estimated glomerular filtration rate. There are also isolated elevations of amino aspartate transferase (AST) and alkaline phosphatase (ALP), but …