A 20-year-old man finds an asymptomatic mass in his scrotum. He denies fever, dysuria, or hematospermia.
Which of the following is the most appropriate first step in evaluating this mass?
The first step in evaluating a scrotal mass is to determine whether the mass is in the testis or outside it. Most solid masses arising from within the testis are malignant. Palpation of the scrotal mass and transillumination (holding a flashlight directly against the posterior wall of the scrotum) will distinguish testicular lesions from other masses within the scrotum, such as hydrocele. Ultrasonography will confirm a solid testicular mass. The tumor markers β-hCG and αfetoprotein are not used in the initial evaluation of a scrotal mass, but will be important for staging if a solid mass suggestive of testicular carcinoma is found. β-hCG or AFP will be elevated in about 70% of patients with disseminated nonseminomatous testicular cancer. Seminomas are associated with normal tumor cell markers. The lymphatic drainage of the testis is into the periaortic nodes, not to the inguinal nodes. The periaortic nodes must be assessed radiographically, usually by CT scanning, if a testicular neoplasm is found. Orchiectomy is often used diagnostically, but it is not the best initial diagnostic step.
A 65-year-old man presents with painless hematuria. He has a 45-year history of tobacco use. He denies fever, chills, and dysuria. General physical examination is unremarkable. On rectal examination, the prostate is small, non-nodular, and nontender. A urinalysis shows 100 red blood cells per high-power field. No white cells or protein are present. Three months previously, the patient had an abdominal ultrasound for right upper quadrant pain; on review, both kidneys were normal.
Which of the following is the most useful diagnostic test at this time?
Unexplained gross hematuria requires evaluation. Patients who have gross hematuria in association with clear-cut urinary tract infection are usually treated and followed with a repeat urinalysis to confirm clearing of the RBCs, but this patient has no symptoms of urinary tract infection. Although benign causes (prostatitis, renal stones) are most common, as many as 15% of patients with gross hematuria will have bladder or ureteral cancer. Cigarette smoking increases the risk of bladder cancer two- to fourfold. Exposure to aniline dyes, chronic cyclophosphamide treatment, external beam radiation, and Schistosoma infection of the bladder are other risk factors. This patient should be referred to a urologist for cystoscopy to rule out transitional cell carcinoma of the bladder; the urologist will usually do a contrast retrograde pyelogram to assess for a ureteral cancer as well. If no lesion is found, CT scanning of the kidneys would be indicated despite the previous negative sonogram. The bladder scan is an ultrasonographic technique that assesses the volume of urine in the bladder. It does not visualize the bladder mucosa. Gross hematuria is uncommon inprostate cancer, which can be associated with an elevated PSA.
A 43-year-old woman complains of fatigue and night sweats associated with itching for 2 months. On physical examination, there is diffuse nontender lymphadenopathy, including small supraclavicular, epitrochlear, and scalene nodes. CBC and chemistry studies (including liver enzymes) are normal. Chest x-ray shows hilar lymphadenopathy.
Which of the following is the best next step in evaluation?
The long-term nature of these symptoms, the fact that the nodes are nontender, and their location (including scalene and supraclavicular) all suggest the likelihood of malignancy. Although infectious mononucleosis and toxoplasmosis can cause diffuse lymphadenopathy, these infections are usually associated with other evidence of infection such as pharyngitis, fever, and atypical lymphocytosis in the peripheral blood. It would be unusual for the lymphadenopathy associated with these infections to persist for 2 months. Serum angiotensin-converting enzyme level is a nonspecific test for sarcoidosis but is also elevated in other granulomatous diseases and is not sensitive or specific enough to be used as an initial diagnostic test. Lymphadenopathy associated with sarcoidosis requires a biopsy for diagnosis. In this patient, an excisional biopsy is necessary primarily to rule out malignancy, particularly lymphoma. Needle aspiration biopsy, useful for the diagnosis of metastatic carcinoma, is insufficient to diagnose suspected lymphoma, where assessment of the lymph node architecture is important.
A 19-year-old woman presents for evaluation of a nontender left axillary lymph node. She is asymptomatic and denies weight loss or night sweats. Examination reveals three rubbery firm nontender nodes in the axilla, the largest 3 cm in diameter. No other lymphadenopathy is noted; the spleen is not enlarged. Lymph node biopsy, however, reveals mixed-cellularity Hodgkin lymphoma. Liver function tests are normal.
The staging of Hodgkin disease is important so that proper treatment can be planned. Stage I (single lymph node bearing area) or stage II (more than one lymph node site on the same side of the diaphragm) patients with good prognostic features may be treated with radiation therapy. Those with stage III (affected lymph nodes on both sides of the diaphragm) or stage IV (extranodal disease) are treated with combination chemotherapy. CT or MRI of the abdomen and pelvis will show evidence of lymph node involvement below the diaphragm. Staging laparotomy with splenectomy, formerly done to provide pathology of the periaortic nodes and spleen, is rarely done today. Gallium scans can be useful in difficult cases. Bone marrow biopsy can later be performed to exclude bone marrow disease, which would imply stage IV, if less invasive studies have not clarified the proper stage. Liver biopsy is rarely indicated and the ESR is a nonspecific test.
A 69-year-old African American man presents with weight loss and back pain. Over the past 2 months he has developed hyperglycemia with a fasting glucose of 153 mg/dL. He does not have nocturia. His appetite is decreased; he has noticed mild constipation. The back pain is constant and keeps him awake at night. On examination he appears cachectic and pale. He does not have scleral icterus. Laboratory studies reveal a mild normochromic anemia. Liver and kidney function studies are normal.
What diagnostic study is most likely to reveal the cause of his symptoms?
Anorexia, weight loss, and back pain are common presenting symptoms of adenocarcinoma of the pancreas. Some patients present with new-onset diabetes. Although diabetes itself can cause weight loss, this would usually be associated with nocturia. Polyphagia rather than anorexia would characterize the weight loss of diabetes and malabsorption. In this patient, a CT scan would likely show a mass in the pancreas. Although cancer in the head of the pancreas can present with obstructive jaundice, cancer of the body or tail of the pancreas is often associated with normal liver enzymes. This patient’s symptoms are not suggestive of colon cancer, and the anemia associated with colon cancer is usually microcytic. Although PET scan may be used to stage certain cancers, it is rarely indicated as an initial test when cancer is suspected. Malabsorption is associated with diarrhea, not constipation. A glucose tolerance test will not add to the evaluation of this patient with known diabetes.
Click to expand