Presentation
Swelling with painless in palpable left testicular mass about three months in a patient with previous left cryptorchidism treated with orchiopexy (two years ago).
Patient Data
Hypoechoic heterogeneous large mass infiltrating and enlarging the left testis, containing tiny calcifications and small cystic foci. Color Doppler ultrasound demonstrates increased vascularity throughout the mass. The right testis and epididymis are normal without signs of albuginea infiltration. Focal ectasia of the scrotal lymphatics is appreciable anteriorly.
Laboratory results before surgery:
Beta HCG: 197 mIU / ml (N.V. 0-5 mIU/mL)
Alpha-fetoprotein: 14 ng/ml (V.N. 0-7 ng/mL)
Surgical report: Left orchifunicolectomy.
Two weeks after surgery:
Beta HCG value is 3 mIU / ml (N.V. 0-5 mIU/mL)
Alpha-fetoprotein: 1.08 ng/mL (V.N. 0-7 ng/mL)
Translation Italian-English
Left testicle: malignant testicular neoplasm of the germ line. Histotype: classic seminoma with isolated syncytiotrophoblastic cells (sec. WHO 2022). The tumor does not invade the full thickness of the tunica albuginea with involvement of the visceral layer of the tunica vaginalis, the epididymis, the soft tissues of the testicular hilum and the rete testis. The tumor does not invade the spermatic cord due to contiguity. Lymphovascular tumor invasion: absent. Discontinuous involvement of the spermatic cord: absent. Germ cell neoplasia in situ/GCNIS (sec. WHO 2022): present. Resection margin of the spermatic cord free of tumor. Pathological staging: (sec. AJCC 8th): pT1b Nx Mx Sx. Left hemiscrotum: morphological picture compatible with the results of a previous surgical scar.
Case Discussion
B-mode ultrasound with color Doppler is the first-line investigation in the study of scrotal swelling, capable of diagnosing most intratesticular and extratesticular lesions. Lesions with a rich vascular supply are malignant. Hematomas, infarcts, abscesses and epidermoid cysts sometimes mimic neoplastic lesions. In the case of recent trauma or infection, a follow-up ultrasound is recommended to define the visualized finding and rule out an underlying testicular tumor.
Untreated cryptorchidism is a risk factor that increases the probability of a patient developing testicular cancer by eight times, while prepubertal orchiopexy reduces this risk to two times that of the general population3. Approximately 30% of patients with pure seminoma of the testis may have mild elevation of Beta-hCG due to the presence of syncytiotrophoblastic giant cells. Levels are usually less than 500 IU/L4. The lymphatics from the scrotum drain into the superficial inguinal lymph nodes.
Case courtesy Dr. Gianluigi Valentini
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