Young male with scrotal swelling

Interesting Cases in PR

|

September 4, 2023

In this case, a 28-year-old male who recently visited the urologist refers dull pain in the left groin and an increase in the size of the left testicle over the last 8 weeks. The patient reports that during childhood he underwent an urethroplasty procedure due to hypospadias. During the examination, an enlarged, indurated, and irregular left testicle was observed, suggestive of a testicular tumor. An ultrasound was performed and yielded a possible localized nodule measuring 28 x 25 x 22 mm. Alpha-fetoprotein and βhCG tumor markers were within normal parameters and the requested CT scan revealed a localized testicular mass.

As a result, a left inguinal orchiectomy was performed and after successful antibiotics therapy, the patient was discharged home 6 days later.

‍

What is the most likely diagnosis?

A. Testicular Seminoma

B. Segmental Testicular Infarction

C. Testicular Sertoli Cell Tumor

D. Testicular Teratoma

E. Mixed Germ Cell Tumor

‍

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

Figure 6.

Read full article

Click here to open the document

Click here to see the answer

Germ cell tumors of the testis can be classified into two main groups: seminomatous and non-seminomatous. Non-seminomatous histologies include embryonal cell carcinoma, yolk sac tumor, choriocarcinoma, and teratoma. In most cases, more than one histological pattern is identified, the most frequent combination being embryonal carcinoma, yolk sac tumor, and teratoma. As in this case, Mixed testicular germ cell tumors represent 40-60% of testicular neoplasms, they can occur in descended or non-descended testicles, and in extratesticular sites.

They are associated with conditions such as cryptorchidism, testicular atrophy, and inguinal hernias and may present symptoms such as a unilateral increase in scrotal volume. Microscopically, various combinations of germinal histological components are observed which are essential to determine the percentage of each of them and the measurement of tumor markers due to their prognostic implications. The forefront treatment is radical orchiectomy and, depending on the stage, complementary chemotherapy and/or radiotherapy. In well-managed patients, the survival rate is high, even in the advanced stages of the disease. Typically, in these cases, serological tumor markers such as LDH, beta-chorionic gonadotropin (βhCG) and alpha-fetoprotein (AFP) could be elevated depending on the histological components present.

‍

References

Alrehaili, M., & Tashkandi, E. (2020). Testicular Mixed Germ Cell Tumor Combined with Malignant Transformation to Chondrosarcoma: A Very Rare and Aggressive Disease. The American Journal of case reports, 21, e922933. https://doi.org/10.12659/AJCR.922933.

Aneja, A., Bhattacharyya, S., Mydlo, J. et al. Testicular seminomatous mixed germ cell tumor with choriocarcinoma and teratoma with secondary somatic malignancy: a case report. JMed Case Reports 8, 1(2014). https://doi.org/10.1186/1752-1947-8-1.

‍

Gopalan, A., Dhall, D., Olgac, S. et al. Testicular mixed germ cell tumors: a morphological and immunohistochemical study using stem cell markers, OCT3/4, SOX2 and GDF3, with emphasis on morphologically difficult-to-classify areas. Mod Pathol 22,1066–1074 (2009). https://doi.org/10.1038/modpathol.2009.66.

Testicular Germ Cell Tumors: Classification, Pathologic Features, Imaging Findings, and Management. Venkata S. Katabathina, Daniel Vargas-Zapata, Roberto A. Monge, Alia Nazarullah, Dhakshina Ganeshan, Varaha Tammisetti, and Srinivasa R. Prasad. RadioGraphics 2021 41:6, 1698-1716.

Collaborators

José Lev Alvarez Gómez, BS, MA, MA (Content), Juan C. Santa Rosario, MD (Edition and Images) and Dario Sanabria Bellassai (Peer Review Contribution).