Painless Testicular Mass, consult urology or CT scan first?

[seasurfer]

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These USMLE questions are driving me banana....

anyway...here is the dilemma,

In a 22 yo with painless testicular mass, with no inguinal lymphadenopathy.

A. Treat with abx and reevaluate
B. Do a CT scan of abd and pelvis
C. Reassure
D. Consult Urology

What is your answer?

 

[Musashi450]

No ultrasound? A CT of abd/pelvis is most likely the answer. For board purposes you almost NEVER pick consult X. I say almost but to be honest can never think of a time when that has been the answer. You cannot reassure in this case because you need to rule out malignancy.

 

[ACSurgeon]

These USMLE questions are driving me banana....

anyway...here is the dilemma,

In a 22 yo with painless testicular mass, with no inguinal lymphadenopathy.

A. Treat with abx and reevaluate
B. Do a CT scan of abd and pelvis
C. Reassure
D. Consult Urology

What is your answer?

I think the answer they're looking for is consult urology. The mass needs to come out. I think urology wouldn't even get a CT. They might get an US, some blood work (AFP, b-HCG, etc). "testiculat cancer is a disease where you cut out the mass/testicle first, and ask questions later" (urology attending). I can't see the utility of getting a CT scan in this case.

 

[ACSurgeon]

No ultrasound? A CT of abd/pelvis is most likely the answer. For board purposes you almost NEVER pick consult X. I say almost but to be honest can never think of a time when that has been the answer. You cannot reassure in this case because you need to rule out malignancy.

I thought of this rule. However, in urology clinic, we had a few patients with similar presentations and a CT was never considered since it doesn't change the management. I think the first step is determining the histologic type, and going from there.

 

[Musashi450]

I agree that I've never seen a CT performed either for a testicular mass as it is overkill and almost never needed. However ordering a urology consult without any type of imaging is an incomplete work up and histology would never be obtained without imaging. Hence why I say CT (not the best imaging) before the consult. That coupled with rule of never consult makes me think CT.

I will admit though that this is a tough question and I'm second guessing my answer.

 

[Winged Scapula]

Moving to USMLE Forum...

 

[cogwise]

No ultrasound? A CT of abd/pelvis is most likely the answer. For board purposes you almost NEVER pick consult X. I say almost but to be honest can never think of a time when that has been the answer. You cannot reassure in this case because you need to rule out malignancy.

You will have some questions on the CK where consult is the right answer, you have to learn to make the distinction. No need for a CT in this case, goes straight to urology. I agree completely with lazymed.

 

[MCYan]

no need to get imaging to look for mets first? i would pick CT as my answer...

 

[cogwise]

no need to get imaging to look for mets first? i would pick CT as my answer...

You do a CT only after doing an orchiectomy.

 

[Scaredshizzles]

You do a CT only after doing an orchiectomy.

Dumb question. They don't even tell you if it is a solid mass, and you would not use a CT scan to determine if it is solid.

Yes, in this case metastatic workup would come after orchiectomy. (Which is not to say you don't do any imaging before surgery. You want to be pretty clinically confident that it is a likely malignant mass before you remove some guy's testis!) Testicular cancer is the exception to the rule that you can't have complete cure once you have widespread mets. Testicular cancer mets respond very well to chemo, but you still want to remove that large primary site. (Amongst other reasons because large tumor masses themselves are very hormonally active-->they release substrates that can either encourage or ****** tumor growth at mestatatic sites.)

I just said it in another thread, but I despised the heme-onc questions on step 2. Not because they were difficult, but rather because they didn't have a correct answer and were clearly written by people who didn't have a clue of what they were talking about. (Perhaps general internists write these questions, in spite of the fact that most of the management of such patients in the hospital is through consultants.)