Testicular Tumours Case Study in Pathology

This is another case study this time we are going to read about Testicular Tumours Case Study in Pathology case No.15. This case is taken from a reference book which is given at the bottom of this book. I only posted cases from authentic books.

History of Testicular Tumours:

A 26-year-old man presented to the  urology clinic with a palpable nodule in the left testicle on self-examination. There is a history of groin injury during a rugby match three weeks ago; however, the nodule is not painful.

Examination:

A 1.5 cm firm nodule is palpable at the lower pole of the left testis. There is no transilluminate and the penis and scrotum are normal. There is no inguinal lymphadenopathy.

Investigations:

An ultrasound of the left testicle shows that the lesion is solid and with poorly defined margins. The right testicle is normal and there are no abdominal lymphadenopathy. Serum lactate dehydrogenase (LDH) is moderately elevated, while alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) are normal.

Requirement:

1. What is the differential diagnosis in this case?
2. What is the value of serum markers in the clinical management of this condition?
3. What pathological features are important in predicting the clinical outcome?

 

Solution:

A testicular nodule can represent a tumor, a cyst, a loculated hydrocele, or an inflammatory condition. A solid nodule with poorly defined borders on imaging is likely to be a malignant tumor, whereas one with an acute circumscription is more likely to be benign; however, there are many exceptions to this rule.

Cysts can also arise in the testicle, but more commonly in its remnant vestiges (testicular appendix and epididymis appendix) and are benign, although they can become enlarged and twisted. Loculated hydrocele can develop as a result of trauma or inflammatory conditions. Fluid collections around the testicles may be fluctuating and transilluminant on physical examination, and an ultrasound will confirm the fluid content. Inflammatory conditions such as epididymo-orchitis (mumps, tuberculosis) are accompanied by systemic symptoms such as fever and a painful testicular mass. Syphilitic gum can be painless, indicating a depletion disease (tertiary syphilis). Serum tumor markers play an important role in the diagnosis, staging, risk stratification, and post-treatment follow-up of testicular cancer. On the other hand, serum markers are normal in testicular cysts and benign tumors such as Leydig cell adenoma. Serum LDH is elevated in seminoma, but it is a relatively nonspecific marker, since LDH is secreted by other organs such as the liver. Serum AFP is elevated in yolk sac tumors, whereas hCG is produced in large amounts in choriocarcinoma. Monitoring serum tumor marker levels after tumor removal is useful, since it would be accompanied by a sharp decrease in serum levels, which may progressively increase again if there is a recurrence of the tumor. Testicular tumors often present in mixed forms, such that one or more of these serum markers may be elevated.

Pathological examination of the testis following orchidectomy plays a vital role in predicting clinical outcome (Figure 54.1). Malignant tumours (95%) are much more common than benign tumours. Broadly speaking, these are germ cell tumours and are subdivided into seminoma and non-seminomatous histological types. Seminoma is the commonest subtype (80%) while embryonal carcinoma, yolk sac tumour and choriocarcinoma are collectively referred to as non-seminomatous germ cell tumours (NSGCT). Teratomas are another interesting subtype of testicular cancer characterized by presence of somatic (epithelial and connective tissue) elements. NSGCT may transform into the less aggressive teratoma following good response to chemotherapy.

Other adverse pathologic features that influence clinical outcome include lymphovascular invasion and invasion of the rete testis, spermatic cord, peritoneal lining (tunica vaginalis), and scrotal skin. Ultrasound and CT scans are important to identify metastases in the lymph nodes and other organs such as the lungs, liver, and bones. Treatment of seminoma in the absence of the aforementioned adverse features is orchidectomy, which is curative in 80-85% of cases. Adjuvant chemotherapy is required if there are adverse features or for NSGCT with markedly elevated serum tumour markers. It is also important to remember that germ cell tumours can arise in an extratesticular location anywhere along the midline from the base of the skull to the sacrococcygeal tip.

REFERENCE BOOK: 100 Cases in Clinical Pathology by Eamon Shamil, Praful Ravi and others

 

Read: Ambiguous genitalia case here

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