A 25-year-old male patient presented to the emergency department with 4 weeks of intermittent right flank pain occasionally radiating to the testicle. He reported minimal relief with acetaminophen or ibuprofen. Patient reported he was otherwise healthy. He was treated for one episode of right scrotal swelling 10 months prior with ibuprofen and antibiotics, with regression of the swelling. He reported that no imaging was done at that time. He denied any dysuria, urgency, frequency, hematuria, nausea/vomiting, fever, chills, or shortness of breath.
Physical examination revealed a well-developed 25-year-old male. He had no right costovertebral angle tenderness. Testicular exam revealed palpable testicles bilaterally that were normal in shape and size. The right testicle was soft compared to that of a normal testicle. Both testicles were non-tender to palpation.
A computed tomography scan obtained in the emergency department demonstrated a 7-cm partially necrotic retroperitoneal mass at the level of the right renal vein and an additional 2-cm lesion overlaying the right psoas muscle (figure 1). Tumor markers including AFP, HCG, and LDH were ordered and slightly elevated to 211, 27, and 317, respectively. A scrotal ultrasound was obtained at this time, which showed a normal-sized right testicle with a heterogeneous appearance and poorly delineated mass within the right testicle. The left testicle was normal.