Presentation
Painless left scrotal swelling for three years. History of emergency department visit with acute scrotum (scrotal trauma) three years back.
Patient Data
First scrotal ultrasound examination: mildly enlarged left testis with heterogeneous echo pattern and increased vascularity. Mildly enlarged left epididymis. The right testis is normal in size, shape and echo pattern. Diagnosis of left epididymo-orchitis was raised; however, close observation and follow up ultrasound examination was recommended to exclude the possibility of underlying mass lesion. Unfortunately, the patient was lost to follow up.
Second scrotal ultrasound examination 3 years later: showed a large heterogeneous left testicular mass. No internal calcifications or cystic components are seen. It has mild internal vascularity on Doppler ultrasound examination. Enlarged and heterogeneous left epididymis, being invaded by the testicular mass. Large left para-aortic nodal mass measuring 9 x 9 cm at the level of left renal hilum.
Heterogeneously enhancing left scrotal mass with a large regional retroperitoneal nodal mass at the level of left renal hilum.
Rest of the CT abdomen is unremarkable. CT chest is also unremarkable.
MRI shows a heterogeneous left testicular mass measuring 5 x 5 x 3.5 cm. It has mixed solid and cystic components. Solid components are isointense on T1 and hypointense on T2 weighted images to the normal testis and show moderate enhancement on post-contrast scan. Multiple enhancing septa (low signal on T2 weighted images) are also seen in it. Solid components show diffusion restriction. The testicular lesion is involving the enlarged left epididymis. Minimal left hydrocele. The spermatic cord is normal.
Right testis and epididymis are normal. A few small bilateral inguinal lymph nodes.
These radiological features are suggestive of an aggressive neoplastic lesion (possibly seminoma).
Case Discussion
After imaging, testicular serum tumor markers were done which showed: AFP=1.9 ng/ml (<8), HCG=48.5 IU / L (0.0-5.0) and LDH=528 (125-220 U/L). Patient underwent left radical orchiectomy and histopathology revealed 3 x 4 x 4.5 cm left testicular seminoma (pT2), invading epididymis and rete testis. Atrophic changes were noted in left testis. Spermatic cord was clear.
A final diagnosis of left testicular seminoma (pT2N3M0) was made. The case was discussed in tumor board and referred to medical oncologist for chemotherapy.
Such patients typically present with a painless testicular swelling; however, approximately 10% of patients may have tenderness on clinical examination. About one-third of patients (like this case) are misdiagnosed as epididymitis, orchitis, epididymo-orchitis or hydrocele on initial presentation and approximately 20% of patients can have metastatic disease at initial presentation.
Both ultrasound and MRI (both having high sensitivity and specificity in differentiating benign and malignant testicular lesions), can be used in the evaluation of scrotal lesions; however, at present, ultrasound is the initial imaging modality of choice and MRI is reserved for problematic cases with non-conclusive sonographic features.
In seminomas, b-hCG serum levels are elevated in a minority (10%) of individuals and alpha fetoprotein levels are almost invariably normal. LDH is a less sensitive and less specific marker for germ cell tumors and is used as a marker of total tumor burden. These serum tumor markers are also used in monitoring treatment response and surveillance to detect recurrence.
Unable to process the form. Check for errors and try again.