The clinical presentation of testicular cancer is usually quite obvious. The typical patient is a man aged 17 to 45 years who notices a growing and relatively painless mass in the scrotum and seeks medical attention. However, as many as 10% of patients present with atypical complaints, such as sudden pain in the scrotum, a new-onset hydrocele, or recent trauma. Some patients are misdiagnosed as having epididymitis, causing an unnecessary delay in diagnosis. A high index of suspicion is required when evaluating any man in this age group with testicular complaints, and the possibility of testicular cancer must be in the differential diagnosis. Patients diagnosed with presumed epididymitis should be observed until the testicular examination result returns to normal, which might take several months. Any patient with nonspecific orchialgia who is completely normal on examination should probably have at least one follow-up examination in 3 to 6 months to ensure that a small tumor was not missed. Because these cancers grow rapidly, there is little concern in regard to diagnosing subclinical tumors. Finally, a small percentage of patients present with symptoms of metastatic disease, such as a neck mass, back pain, hemoptysis, or gynecomastia. These patients may be unaware of the abnormality in the testis. Unless the physician considers testicular cancer in the differential diagnosis of these symptoms, the appropriate treatment may be unnecessarily delayed.
The widespread availability of high-quality scro-tal ultrasonography with Doppler blood flow analysis has nearly eliminated much of the diagnostic difficulty for these patients. Today, patients who are misdiagnosed are mostly those for whom ultrasonography was not ordered. The caveat of the availability of ultrasonography, however, has been an increase in the finding of minor abnormalities such as microcalcifications, which has caused considerable anxiety and debate recently. A number of studies have shown that testicular microcalcifications are commonly found by modern ultrasonography, and their presence does not indicate an increased risk of subsequent testicular cancer.3-5
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