Japanese Journal of Clinical Oncology Advance Access originally published online on December 9, 2008
Japanese Journal of Clinical Oncology 2009 39(2):124-126; doi:10.1093/jjco/hyn141
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© The Author (2008). Published by Oxford University Press. All rights reserved
Non-palpable Testicular Embryonal Carcinoma Diagnosed by Ultrasound: A Case Report
1 Department of Urology, Keio University School of Midicine, Tokyo
2 Department of Urology, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan
For reprints and all correspondence: Masaru Ishida, Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan. E-mail: m-ishida{at}kc5.so-net.ne.jp
Received August 13, 2008; accepted November 11, 2008
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Abstract |
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With the extensive use of scrotal ultrasound (US), incidental non-palpable testicular tumors have thus been unexpectedly discovered. This report documents the case of 24-year-old male with a non-palpable testicular tumor that contained non-seminomatous germ cell components detected by US. Radical orchiectomy was performed and histological examinations confirmed a diagnosis of a mixed tumor of seminoma and embryonal carcinoma. Serum alpha-fetoprotein (AFP) rose from 7.8 to 43 ng/ml and CT scan revealed multiple metastases only 1 month after the operation. Systemic chemotherapy was introduced immediately, and the serum level of AFP decreased to the normal range and the metastatic lesions had disappeared after three courses of the chemotherapy. No recurrence was observed at 18 months follow-up after the chemotherapy. This is the first case of non-palpable testicular embryonal carcinoma, which metastasized soon after the resection. The obscurity and implications of such a diagnosis are also discussed.
Key Words: testicular neoplasms • germ cell tumor • metastasis • orchiectomy • ultrasound
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INTRODUCTION |
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TOPAbstractINTRODUCTIONCASE REPORTDISCUSSIONReferences |
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The majority of testicular cancers usually present as a palpable mass and 95% of palpable testicular tumors are malignant germ cell tumors (1). However, with the extended use of scrotal ultrasound (US) for other indications, such as infertility, scrotal or testicular pain or varicocele, incidental non-palpable testicular tumors have also been unexpectedly discovered. Most of these cases are benign tumors or seminoma; however, a non-seminomatous germ cell tumor has not yet been reported. This report describes a case of a non-palpable testicular embryonal carcinoma which metastasized soon after the operation. In addition, the pertinent literature is also reviewed in order to elucidate the optimal management of such cases.
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CASE REPORT |
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A 24-year-old male presented at the emergency room of our hospital with left inguinal pain on 11 September 2005. Physical examination did not show inguinal hernia, CVA tenderness, varicocele or any palpable mass on the testes. CT scan revealed only tiny calcifications on the left kidney without hydronephrosis. However, US showed two hypoechoic masses in the left testis of 11 and 6 mm in size, respectively (Fig. 1A). The serum levels of testicular tumor markers were within normal range (LDH 155 IU/l, hCGβ <0.1 ng/ml and alpha-fetoprotein (AFP) 3.8 ng/ml) and the chest X-ray findings were also normal. The US findings were thought to indicate focal orchitis but the diagnosis was not established. US was repeated every month, and it showed the masses remained almost at same status for subsequent 4 months. At 5 months after the first visit, US showed that the masses had enlarged and the number had increased to three. Since T2 weighted MRI showed low intensity masses suggesting malignant tumors, an operation was recommended, but the patient strongly opted for a timely follow-up. US study performed after another month showed that the size of the tumors increased to 19 mm of diameter in size and the echogenicity of the tumors changed to isoechoic (Fig. 1B). A left high inguinal orchiectomy was thus performed on 26 March 2006 and the operation was undergone by typical procedure. A histological examination revealed pT2 mixed testicular tumors consisting of seminoma and embryonal carcinoma (Fig. 2A, B). The testicular lesions still remain non-palpable at the time of the operation and no metastasis was detected by CT scan evaluating from lung to pelvis, which was performed on the day before the operation, although the serum level of AFP was elevated to 10.0 ng/ml, which is slightly above the normal limit (<10.0 ng/ml). Although AFP decreased to 7.8 ng/ml just after the operation, it increased to 43 ng/ml only 1 month after the operation. Multiple lung metastases, and mediastinal and paraaortic lymph nodes metastases were then revealed by CT scan (Fig. 3). Systemic chemotherapy with PEB regimen was introduced immediately, and the serum level of AFP decreased to the normal range and the metastatic lesions had disappeared after three courses of the chemotherapy (Fig. 3). Because chemotherapy achieved a complete response and this patient is categorized as good risk group of IGCCC, the patient selected surveillance. No recurrence was observed at 18 months follow-up after the chemotherapy.
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DISCUSSION |
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With an improvement in the quality of US and the expanded use of scrotal US, the detection of unexpected non-palpable testicular tumors has been more frequent. Since US cannot distinguish benign from malignant lesions (2) and the US appearance of germ cell tumors is non-specific other than different echogeneity from normal testis, the management of non-palpable testicular lesion remains clinically difficult.
In the series of patients observed by Carmignani et al. (3), 10 non-palpable testicular lesions were detected in 1320 of scrotal US for other indications, such as infertility, scrotal pain or varicocele. Seven of 10 lesions were hypoechoic and three of the 10 were mixed with hyper- and hypoechoic lesions. All of the 10 cases were pathologically confirmed to be benign by explorative surgery through inguinotomy. In contrast, Comiter et al. (4) reported that 11 (73%) of the 15 non-palpable testicular lesions were malignant, although the series included retroperitoneal masses or palpable contralateral testicular tumor. Powell summarized that cancer was present in 12 (30%) of 40 incidental non-palpable testicular lesions and all of those were seminoma except for a single case of a mature teratoma (5).
Radical orchiectomy is a standard treatment for patients with testicular tumors since the majority of these tumors are malignant. However, an organ sparing surgery has also been performed in patients with bilateral testicular tumors or a germ cell tumor occurring in a solitary testicle (6,7). The German Testicular Cancer Study Group reported that 72 (98.6%) of the 73 patients with such background who underwent organ sparing surgeries had no evidence of disease after a median follow-up of 91 months (8). However, 15 (20.5%) of 73 patients had embryonal carcinoma elements and three patients developed systemic progression. One of those died as a result of metastatic spread to the retroperitoneum, lungs, mediastinum and brain.
In other series (3,5,9,10), testis sparing surgeries with an excisional biopsy were performed for non-palpable testicular lesions with intact contralateral testis. If malignant components were found by frozen or permanent sections, then the patients underwent radical orchiectomy, and those patients had no recurrence. The conclusion of those reports is that organ sparing surgery appears to be useful for avoiding overtreatment in patients without malignancy, although frozen section examinations were not consistent with permanent sections in some cases (5,9).
In the present case, the patient had non-palpable testicular lesions with an intact contralateral testis. Since the size of those lesions enlarged and the number of lesions increased, radial orchiectomy was performed without an excisional biopsy and the pathological study revealed a mixed tumor of seminoma and embryonal carcinoma. Since systemic metastases were observed soon after the operation, it was implicated that the tumor cells had already begun spreading by the time of operation. If testis sparing surgery with an excisional biopsy had been performed on this patient, even at an earlier time, a pathological misdiagnosis resulting from the limitations of frozen section analysis might have occurred, and furthermore, dissemination of the tumor cells might have occurred as well.
Incidental findings of non-palpable testicular tumors have been increasing and all of those were benign or seminoma. Since non-palpable testicular tumors which contain non-seminomatous germ cell components with intact contralateral testis have not yet been reported, except in one case of a mature teratoma (5), the prognosis thus remains uncertain. This is the first case of non-palpable testicular embryonal carcinoma which metastasized soon after the operation. Based on this experience, radical orchiectomy is therefore considered to be preferable for patients who have non-palpable testicular lesions with an intact contralateral testis.
Conflict of interest statement
None declared.
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References |
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