Metastatic abdominal mass in seminoma

Clinical History

A 41-year-old man was admitted to ER for left leg and scrotal oedema and mild dyspnoea. The physicians found a palpable abdominal mass. Vital signs were normal. When he was 4 years old, he had undergone right orchiectomy due to cryptorchidism.

Imaging Findings

The patient underwent US of the abdomen (Fig. 1a, b) and legs (Fig. 2a, b).
Also CT of the abdomen and chest were performed (Fig. 3-5).
The CT of the abdomen (Fig. 3a-c) showed a pathological lymph-nodal enlargement, which had transverse diameters of max 12x11cm (DC diameter is about 30 cm).
The left testicle had markedly subverted structure, transverse diameter of 10x12 cm (Fig. 4b), with heterogeneous parenchymal component in the upper-right lateral side. We can see the thrombosis of the left common femoral vein (Fig. 4a).
The CT of the chest found a pathological lymph-nodal enlargement in the mediastinum and scattered left pulmonary embolism (Fig. 5).

Discussion

Testicular germ cell tumours (TGCT) account for between 1% and 1.5% of male neoplasms [1] and cause approximately 0.1% of cancer-related mortality in men. Histologically, TGCT are divided into: seminomas (50%), non-seminomas (40%). The remaining 10% of testicular cancers are combined tumours. [2] Seminomas comprehend 3 histological sub-types: classic, anaplastic, and spermatocytic. [3] They typically appear between the ages of 15–34. [4] The incidence rates are higher in northern European countries and lower in Asian, African and Afro-American men. The development of TGCT has several risk factors: prior history of TGCT, cryptorchidism, testicular dysgenesis, Klinefelter's syndrome, environmental factors (maternal smoking during pregnancy, body mass index and diet), [2] family history [1] and genetic factors (linkage to Xq27 locus and duplication or amplification of the short arm of chromosome 12). [2] Cryptorchidism presents a relative risk of 3.7–7.5 times higher than the scrotal testis population. According to studies, the degree and length of time of environment insults on the cryptorchid gonad, such as heat, increase the likelihood of developing TGCT. [4] Testicular cancer is usually a painless, unilateral intra-scrotal mass, discovered via physical examination, [5] although it may lead to testicular enlargement and pain. In approximately 25% of patients, metastatic disease is found. Retro-peritoneal lymph-nodes are the first metastatic site. [6] In advanced stages, back pain (due to para-aortic nodal involvement) and para-neoplastic syndromes may arise. [7] At US, using a 7.5 MHz probe, [5] seminoma is characterized as a round, hypo-echoic and homogeneous mass, usually confined within the tunica albuginea. [7] Testicular microlithiasis (calcifications within the lumina of the seminiferous tubules) is a benign condition, but is also a risk factor for seminoma. [7] CT is the gold standard for detecting metastases. [8] Alpha-fetoprotein (AFP), beta-human chorionic gonadothropin (B-HCG) and lactase dehydrogenase (LDH) are useful in the diagnosis, prognosis and follow-up of testicular cancer. AFP levels are typically not elevated in seminomas, [2] whereas B-HCG is increased in 10% of them. [1] LDH is less specific and related to advanced testicular cancer, since it reflects the growth rate and tumour burden. [7] Other markers like neuro-specific enolase (NSE) and placental alkaline phosphatase (PLAP) are of limited value in monitoring patients with pure seminoma. [5] Although physical examination, US and markers are important steps, orchiectomy and hystopathology are necessary for the final diagnosis. [7] In this case, hystopathology findings revealed a CD117+, CD30-, AFP-, PAN-cytokeratine- classical seminoma, with low reactivity to B-HCG, infiltration of the spermatic cord and positivity of the resection margin, micro-vascular infiltration, collateral hydrocele and pachyvaginalitis.

Differential Diagnosis List

Final Diagnosis

Primary testicular seminoma with abdominal and mediastinal lymph-nodal metastases.

URL:	https://www.eurorad.org/case/11824
DOI:	10.1594/EURORAD/CASE.11824
ISSN:	1563-4086