Uroradiology & genital male imagingCase Type
1Nirmal Prasad Neupane, 2Ongden Yonjen Tamang, 3Rudra Prasad Upadhyaya, 3Keshika KoiralaPatient
17 years, male
A 17-year-old male presented to the urology outpatient department with a history of painless enlargement of the left testis. No history of associated fever or preceding trauma was noted. Except for an on-and-off history of chronic cough and chest pain, his past medical history was unremarkable.
Based on the clinical history, ultrasonogram of the inguinoscrotal region and plain chest X-ray was advised. Ultrasonographic evaluation of the scrotum revealed a hypoechoic lesion in the left testis with minimal vascularity (Fig 1). Right testis showed presence of multiple echogenic foci within it suggestive of testicular microlithiasis. Chest x-ray showed well defined round homogenously radiodense lesion in the right lower zone. Similar well defined radiodense lesion was also noted in the retrocardiac region (Fig 2).
Further evaluation with contrast enhanced computed tomography of chest and abdomen was performed The study showed a large heterogeneously enhancing lesion in the left testis (Fig 3). Heterogeneously enhancing lymph nodes were noted in the left para-aortic region (Fig 4). Ill defined peripherally enhancing lesions were noted in in segment VI and IVA of liver (Fig 5). Heterogeneously enhancing well defined round to elliptical shaped lesions were noted in the posterior basal segment of lower lobes of bilateral lungs (Fig 6, Fig 7).
Testicular malignancy is the most common non-hematologic malignancy seen in men between 15-49 years of age . Testicular malignancies have both genetic and environmental factors associated with them. Epidemiological factors associated with development of testicular tumours include testicular dysgenesis syndrome, first-grade relatives with testicular cancer and presence of a contralateral tumour or testicular intraepithelial neoplasia. In accordance to the 2016 WHO pathological classification three major subcategories have been described; 1) Germ cell tumours 2) sex cord/gonadal stromal tumours 3) miscellaneous non-specific stromal tumours . Currently, ultrasound serves to confirm the presence of a testicular mass and to explore the contralateral testis. US sensitivity is almost 100% and it has an important role in determining whether a mass is intra- or extratesticular . The retroperitoneal lymph nodes are the most common site for metastatic disease. The primary metastatic site for left-sided tumours includes the para-aortic and pre-aortic lymph nodes, followed by the aortocaval nodes . Pulmonary metastases are seen in up to 81 % of patients with testicular choriocarcinoma, 19% with seminoma and 18% with non-seminomatous testicular tumours . However, brain, liver and bone Involvement is also seen. Abdominopelvic CT has a sensitivity of 70-80% in finding the retroperitoneal nodal involvement . Chest CT is considered the most sensitive way to evaluate the thorax and mediastinal nodes which is recommended in all patients with testicular cancer as up to 10% of cases present with small subpleural nodes that are radiologically occult . Serum tumour markers are evaluated both before and 5-7 days after orchiectomy. Inguinal exploration and orchiectomy with en bloc removal of testis, tunica albuginea, and spermatic cord is the standard intervention.
Take-Home Message / Teaching Points
This case showcases the importance of general understanding of the common sites of metastases in testicular malignancy. This helps in promoting the search for metastases in common metastatic sites and using the correct imaging study which not only improves detection of metastatic organ involvement but also facilitates differentiation between benign and malignant pathology. Presence of metastases is a key component in the staging of the disease which dictates further management. The retroperitoneal lymph nodes are the most common site for metastases in testicular cancer. Hematogenous spread is also seen; predominantly in the lungs. Our patient as described showed involvement of the retroperitoneal lymph node, lungs and liver; the common metastatic sites usually seen in testicular cancer. Thus it is important to always consider the possibility of metastasis in proven or suspected testicular cancer and further investigate its presence judiciously.
 Kreydin EI, Barrisford GW, Feldman AS, Preston MA. Testicular cancer: what the radiologist needs to know. American Journal of Roentgenology. 2013 Jun;200(6):1215-25. PMID: 23701056
 Idrees MT, Ulbright TM, Oliva E, et al. The World Health Organization 2016 classification of testicular non-germ cell tumours: a review and update from the International Society of Urological Pathology Testis Consultation Panel. Histopathology. 2017;70(4):513–521. doi:10.1111/his.13115 PMID: 27801954
 Kim, Woojin & Rosen, Mark & Langer, Jill & Banner, Marc & Siegelman, Evan & Ramchandani, Parvati. (2007). US-MR Imaging Correlation in Pathologic Conditions of the Scrotum. Radiographics : a review publication of the Radiological Society of North America, Inc. 27. 1239-53. 10.1148/rg.275065172.
 Hale GR, Teplitsky S, Truong H, Gold SA, Bloom JB, Agarwal PK. Lymph node imaging in testicular cancer. Translational andrology and urology. 2018 Oct;7(5):864.
 Lin D, Tan AJ, Singh-Rai R. A literature review and case report of metastatic pure choriocarcinoma. Case reports in oncological medicine. 2015;2015.
 Laguna MP, Klepp O, Horwich A, Algaba F, Bokemeyer C, Pizzocaro G, Cohn-Cedemark G, Albers P. Guidelines on testicular cancer. European Association of urology. 2004 Mar.