Presentation
Testicular pain. Background of HIV+ and cirrhosis.
Patient Data
The right testis has an ill-defined heterogeneous solid mass, which shows prominent internal vascularity and measures about 3.2 x 1.7 x 3.7 cm. The right testicle measures 4.3 x 3.20 x 2.1 cm.
The left testicle has a normal size and preserved vascularity, measuring 3.1 x 2.2 x 1.4 cm. Microlithiasis noted within both testicles.
There is no hydrocele. Both epididymides have normal sonographic appearances. The scrotal wall has normal thickness and appearances.
Both kidneys have normal size, cortical thickness, echogenicity. No hydronephrosis. The right kidney measures 10.1 cm and the left kidney measures up to 11 cm in length. Known cirrhotic liver partially imaged.
Conclusion: Right testicular mass suggestive of a primary malignancy, most likely seminoma.
Macroscopy: Labeled "Right testicle". A testis, 36 g and 50 x 28 x 26 mm. The epididymis is attached, 23 x 11 x 10 mm and spermatic cord 55 x 15 mm. The tunica vaginalis is untethered. On cut surface, there is a lobulated firm grey lesion comprising the entire parenchyma, 46 mm in greatest dimension. A thin rim (1 mm in radial thickness) of normal testicular parenchyma surrounds the lesion. It is 1 mm from the tunica albuginea, 1 mm from the epididymis, 2 mm from the hilum and 2 mm from the cord.
Microscopy: The sections of testes and spermatic cord show the testes almost entirely replaced by sheets and nests of atypical enlarged markedly pleomorphic cells with irregular nuclear membranes vesicular nuclei, prominent nucleoli and cleared cytoplasm. Frequent mitotic figures including atypical mitoses identified within the lesional cells with focal areas of necrosis and apoptosis also evident. There is surrounding fibrous stroma with mixed small lymphocytes and few adjacent background testes show marked atrophy with seminiferous tubules with residual Leydig cells are seen within the stroma. Areas of fibrosis with associated hemosiderin laden macrophages are present. The lesion is confined within the testes with no extension into the rete testes or epididymis identified. The atypical lesional cells show positive membranous staining with CD117, D240 and PLAPpatchy membranous staining with CD10, and is negative for CD20, PAX 5, MUM 1, CD3, CD5, BCL-2, BCL 6, CD30 and HCG. With CD3 CD5 BCL-2 highlighting the background mature lymphocytes. The Ki-67 is approximately 60% within the tumor cells. No lymphatic, vascular or perineural invasion is seen. The spermatic cord resection margin is clear.
Conclusion: Right testicle seminoma. Pathologic staging pT pT1b (AJCC TNM 8th edition, 2016)
Case Discussion
Sonographic features are those of a testicular malignancy, at this age group and epidemiology, seminoma is most likely.
Further staging CT was recommended and there was no nodal or metastatic disease. The patient was then submitted to orchiectomy, which confirmed a seminoma.
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