ASYMPTOMATIC COMPLEX TESTICULAR NEOPLASIA ASSOCIATED WITH ORCHIEPIDIDYMITIS. CASE REPORT

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1 Rev. Med. Chir. Soc. Med. Nat., Iaşi 2017 vol. 121, no. 4 SURGERY CASE REPORTS ASYMPTOMATIC COMPLEX TESTICULAR NEOPLASIA ASSOCIATED WITH ORCHIEPIDIDYMITIS. CASE REPORT Ș. Iacob 1, R. Vrînceanu 2,3, B. Novac 2,3* Grigore T. Popa University of Medicine and Pharmacy Iasi Faculty of Medicine 1. Senior student 2. Department of Surgery (II) Dr. C.I. Parhon Clinical Hospital Iasi 3. Department of Urology *Corresponding author. bogdannvc@gmail.com ASYMPTOMATIC COMPLEX TESTICULAR NEOPLASIA ASSOCIATED WITH OR- CHIEPIDIDYMITIS-CASE REPORT (Abstract): Testicular germ cells tumors (TGCTs) are rare (2-3 new cases per 100,000 men per year) accounting for 1-2% of male malignancies and ranking fourth among genitourinary cancers. Testicular cancer is the most common cancer in young men 15 to 35-year-old. With approximately 50% of the TGCTs being pure seminomas and 50% non-seminomas, radical orchiectomy provides the histological diagnosis and should be performed before any further treatment, unless the clinical situation requires immediate chemotherapy in patients with a clear germ cell malignancy based on e l- evated tumor markers. Any testicular mass of uncertain ranking must be explored by the i n- guinal approach to verify or exclude malignancy. We present the case of a 30-year-old patient admitted to the Urology unit of the Dr. C.I. Parhon Clinical Hospital for pain in the right hemiscrotum for two weeks. Physical examination revealed the increase in size and l o- cal inflammatory changes of the right hemiscrotum. Later during hospital stay, the patient mentioned that the hemiscrotum had been progressively increasing in size over the past 6 months. An ultrasound exam was performed, and serum tumor markers were determined. Based on the results, the patient underwent radical orchiectomy by inguinal approach. Keywords: ORCHIEPIDIDYMITIS, GERM CELL TUMOR, TREATMENT. Testicular germ cells tumors (TGCTs) are divided into two categories: seminomas and nonseminomas. The last category can subsequently be divided into choriocarcinoma, teratoma, embryonal cell carcinoma and yolk-sac tumor. Risk factors for TGCT are: family history, cryptorchidism, testicular dysgenesis, Klinefelter syndrome, Down syndrome, feminized testicle syndromes, persistent Müllerian duct syndrome and hermaphroditism (1). The serum tumor markers alphafetoprotein (AFP) ( 5.80 IU/mL or <10 ng/ml), human chorionic gonadotropin (hcg) (<2.6 miu/ml) and lactate dehydrogenase (LDH) ( U/L) are essential in determining the presence of tumor and its prognosis, and for assessing the postoperative outcome (1). The recommended treatment for TGCTs is radical orchiectomy (2). 730

2 Asymptomatic complex testicular neoplasia associated with orchiepididymitis. Case report CASE REPORT We present the case of R.C., a 31-yearold male patient admitted to the Urology Department of the Dr. C.I. Parhon Clinical Hospital from Iasi for fever and shivers which started a few days before his admission and pain in and increase in size of the right hemiscrotum over the last two weeks. His personal medical history included: hepatic steatosis, ulcerative pancolitis in the remission phase (treated with Infliximab) and stage I-II pulmonary sarcoidosis (on corticotherapy). Physical examination revealed class II obesity, painful right hemiscrotum both spontaneously and on palpation, warm and with overlying congested tissue. Laboratory tests showed no biochemical or blood count changes suggestive for the febrile syndrome. Based on the collected data, our first diagnostic supposition was suppurative right orchiepididymitis and the patient was given Cefuroxime 0.5g, the fever diminishing within the first 24 hours. Later during his admission to the Urology Clinic, the patient mentioned that his right hemiscrotum had been slowly increasing in size over the past 6 months. The scrotal ultrasound revealed an inhomogeneous right testicle (fig. 1), increased in size, with imprecise limits and negative Doppler signal. Fig. 1. Ultrasonography of the right hemiscrotum. This result was suggestive for a highly disorganized testicular parenchyma either due to suppuration or neoplastic process. Tumor markers AFP, hcg and LDH were determined as part of the preliminary diagnosis. The blood results came back positive: AFP IU/mL, hcg miu/ml, LDH U/L. As a result, the surgical intervention for the drainage of the supposed suppuration was canceled to prevent the tumor from metastasizing. The patient was discharged on Cefuroxime 0.5g for the treatment of orchiepididymitis with the recommendation to return after two weeks to undergo radical orchiectomy. Abdominal and pelvic CT scan for the detection of lymphadenopathy was not performed due to the lack of certainty in differentiating inflammatory from metastatic lymphadenopathies. In this case, waiting for the disappearance of inflammatory lymphadenopathies might have taken long enough for the testicular tumor to disseminate. After two weeks the patient was readmitted for surgical intervention. With the patient in dorsal decubitus, under general anesthesia and orotracheal intubation, a 10- cm oblique incision just 2 cm superiorly and parallel with the inguinal ligament was performed. After the section of the muscular and aponeurotic layers and dissection of the fascia of the external oblique muscle, the right spermatic cord (or funiculus spermaticus) was exposed. The spermatic cord was not isolated with ease, due to the adherences resulted from the previous inflammation. The spermatic cord was clamped (fig. 2); the testicle was ascended through the inguinal canal and brought to surface through the surgical wound. The funiculus spermaticus was sectioned 731

3 Ș. Iacob et al. and sutured with 2 double suture wires. Surgical hemostasis was performed, the anatomical defects were repaired, the surgery ending with the placement of sterile bandage. Microscopic examination highlighted germ cell tumor proliferation, with necrosis and hemorrhagic areas, which was invading the testicle and tunica albuginea. The microscopic appearance had a complex pattern: embryonal carcinoma with areas of mature and immature teratoma, associated with areas of seminoma (fig. 4-5). Fig. 2. The clamped spermatic cord Gross examination described an enlarged testicle due to a low-consistency and heterogeneous mass, which was occupying almost the entire testicular parenchyma and was invading the tunica albuginea (fig. 3). Fig. 4. Microscopy - embryonal carcinoma and teratoma Fig. 5. Microscopy - embryonal carcinoma and seminoma Fig. 3. The macroscopic appearance of the tumor The diagnosis was positive for pt2nxmx Mixed germ cell tumor. The patient s postoperative outcome was favorable and was discharged after three days and instructed to have the tumor marker levels determined after three and six postoperative weeks and an abdominal and pelvic CT scan six weeks postoperatively. After three weeks there was a decrease in tumor marker levels: AFP IU/mL, hcg 4.6 miu/ml, LDH 184 U/L. 732

4 Asymptomatic complex testicular neoplasia associated with orchiepididymitis. Case report After six weeks postoperatively, although the AFP reached normal blood levels (3.13 IU/mL) and LDH was still within normal range, the hcg levels were increasing (8.6 miu/ml). The CT exam at five months postoperatively revealed multiple mediastinum and abdominal lymphadenopathies (epiphrenic, epigastric, interportocaval, later aortic bilateral, peripancreatic), bilateral common iliac lymphadenopathies (left side = 12/27 mm, right side = 18/14 mm) and an adenopathic conglomerate located in the paraaortic lymph nodes, 52/32/60mm in size. At five months postoperatively, the tumor markers continued to rise (AFP=41.48 ng/ml, hcg=22.1 miu/ml, LDH=217 U/L). Following these results, the patient was admitted to the Oncology Unit, where he received, up until seven months postoperatively, 4 cycles of the recommended chemotherapeutic BEP Protocol (Bleomycin 30 Units x 3 cycles, Etoposide 240 mg x 4 cycles, Cisplatin 80 mg x 4 cycles) (fig. 6), during which he developed stage IV neutropenia. Fig. 6. Interaortocaval adenopathies A second CT scan at 8 months postoperatively revealed a slight decrease in size of the abdominal and mediastinal adenopathies, suggestive for a partial response to the chemotherapy treatment. The patient is now regularly followed-up at the Oncology and Urology Units. Fig. 6. Stage IIC postoperative recommended treatment 733

5 Ș. Iacob et al. TABLE I TNM Classification of Seminoma Testicular Cancer DISCUSSION Considering all the previous information, the patient was diagnosed with ct2n3m0 (tab. I), S1 (tab. II), stage IIC (tab. III) (4) testicular cancer. The particularity of the case is how a painful orchiepididymitis revealed a hidden neoplasia by forcing the patient to see a urology specialist, just like in a similar case reported by A. Baletti et al. (6), and how the associated pathology changed the patient management. Although the standard management in neoplasia is a preoperative CT/IRM scan to identify any lymphatic or extra lymphatic lesion suspected of being a metastasis, in our patient s case the preoperative CT scan was abandoned due to the existing orchiepididymitis, which caused inflammatory lymphadenopathies. Combining surgical and chemotherapy treatment, stage IIC seminomas are considered as having a good prognosis (1) and after the chemotherapy treatment is completed, the serum tumor markers are measured, and a thoraco-abdominopelvic CT scan is performed. If the residual tumor mass is absent and the tumor markers are within the normal range, the patients require only follow-up, but if the tumor mass persists, like in our patient, a PET scan is recommended (5). A positive PET scan requires a biopsy to be performed, followed by surgical excision or radiotherapy. On the other hand, a negative PET scan requires no further procedure. TABLE II Serum levels of tumor markers 734

6 Asymptomatic complex testicular neoplasia associated with orchiepididymitis. Case report TABLE III Testicular seminoma staging CONCLUSIONS Our paper presented the case of a young patient with an asymptomatic testicular germ cell tumor identified and later diagnosed during his hospitalization in the Urology department for another disease: acute orchiepididymitis on a tumoral testicle. If this inflammatory disease had not occurred, the tumor would have developed for a long period of time without any type of symptom, in which case it might have been identified only after systemic metastases might have occurred. Our paper also presents the investigations, as well as the surgical and medical treatments our patient underwent since the diagnosis. REFERENCES 1. Motzer R.J., et al., NCCN Clinical Practice Guidelines, testicular cancer, germ cell tumors, alphafetoprotein, lactate dehydrogenase, human chorionic gonadotropin, cisplatin, seminoma, nonseminoma. JNCCN 2009; 7: Oldenburg J, Fosså SD, Nuver J, et al. ESMO Guidelines Working Group. Testicular seminoma and non-seminoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol, 2013; 24(suppl 6): vi Russell SS Testicular cancer: overview and implications for health care providers. Urol Nurs. 2014; 34(4): Kush Sachdeva, et al. NCCN Clinical Practice Guidelines in Oncology: Testicular Cancer. V Available at gls/ pdf/testicular.pdf. (Accessed: January 16, 2014). 5. S. Hinz, et al., The role of positron emission tomography in the evaluation of residual masses after chemotherapy for advanced stage seminoma. J Urol 2008; 179: A. Baletti, et al., Scrotal pain as the first clinical manifestation of testicular seminoma: A case report, J Ultrasound 2008; 11(3):