A Case of Synchronous Bilateral Testicular Seminoma

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Author(s)

Matthew J. Resnick, MD

second-year Resident in Urology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania

Disclosures

Disclosure: Matthew J. Resnick, MD, has disclosed no relevant financial relationships.

Daniel Canter, MD

fourth-year Resident in Urology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania

Disclosures

Disclosure: Daniel Canter, MD, has disclosed no relevant financial relationships.

Benjamin M. Brucker, MD

third-year Resident in Urology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania

Disclosures

Disclosure: Benjamin M. Brucker, MD, has disclosed no relevant financial relationships.

Alexander Kutikov, MD

Chief Resident in Urology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania

Disclosures

Disclosure: Alexander Kutikov, MD, has disclosed no relevant financial relationships.

Thomas J. Guzzo, MD

Fellow in Urologic Oncology, Johns Hopkins Medical Center, Baltimore, Maryland

Disclosures

Disclosure: Thomas J. Guzzo, MD, has disclosed no relevant financial relationships.

Alan J. Wein, MD

Chief of Urology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania

Disclosures

Disclosure: Alan J. Wein, MD, has disclosed no relevant financial relationships.

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Summary and The Case

Summary

Background: A previously healthy 51-year-old man with two children sustained a minor testicular trauma and subsequently sought medical care for persistent discomfort.
Investigations: Physical examination, scrotal ultrasonography, Doppler ultrasound evaluation of testicular blood flow, scrotal MRI, measurement of serum tumor markers and testosterone levels, CT of the chest, abdomen and pelvis, intraoperative frozen section analysis and final pathologic analysis.
Diagnosis: Bilateral testicular seminoma (clinical stage I).
Management: The patient initially underwent radical left orchiectomy with intraoperative frozen section analysis, which returned equivocal results. Final pathologic analysis revealed a 2.5 cm left testicular seminoma without vascular invasion. After careful discussion, he ultimately underwent radical right orchiectomy; pathologic analysis revealed a 2.7 cm right seminoma with vascular invasion. Testosterone replacement therapy was initiated. After further discussion, the patient elected to undergo adjuvant abdominal radiotherapy to a total of 25 Gy. The patient showed no evidence of disease over a post-treatment follow-up period of 24 months.

The Case

A 51-year-old man with two children sustained a minor trauma to his testes and sought medical care after discomfort persisted. He had initially noticed mild-to-moderate left hemiscrotal edema, which subsequently resolved, and he identified no persistent abnormalities on self-examination. The discomfort initially abated; however, it returned approximately 2 weeks after the injury and lasted for a further 4 weeks. The patient presented to his primary care physician who referred him to a urology clinic for evaluation.

The patient had a medical history remarkable for osteoarthritis and a family history notable for Hodgkin’s lymphoma in his father. Physical examination of the left testis revealed tenderness and a significant contour deformity in the mid-lower pole. The right testis felt normal. Scrotal ultrasonography showed a 2.7 cm hypoechoic solid mass in the right testis and two hypoechoic solid masses, measuring 2.5 cm and 1.0 cm, in the left testis. Doppler ultrasonography revealed normal blood flow to both testes. Scrotal MRI showed bilateral testicular masses, without providing any further insight into their nature. The patient had no history of testicular maldescent or previous scrotal trauma. His serum levels of α-fetoprotein, β human chorionic gonadotropin and lactose dehydrogenase were all within normal limits, and he did not have elevated serum levels of total or free testosterone. CT of the chest, abdomen and pelvis revealed no lymphadenopathy.

After discussing the differential diagnosis and his treatment options with the treating physician, the patient underwent left radical orchiectomy approximately 1 week after presentation. Intraoperative frozen section analysis of the left testis could not confirm the presence of a germ cell tumor; therefore, right radical orchiectomy was not performed at this time. Final pathologic analysis of the larger of the two left testicular masses revealed a 2.5 cm seminoma with areas of carcinoma in situ without any lymphovascular invasion or invasion into the tunica vaginalis or spermatic cord. The smaller left-sided mass was also identified as seminoma with focal areas of carcinoma in situ.

A second discussion was held with the patient and his family regarding treatment options for the right testis. The patient elected to undergo right radical orchiectomy, which was performed approximately 4 weeks after his initial surgery. The patient opted to defer placement of testicular prostheses at the time of surgery; bilateral prostheses were ultimately placed 6 months after his right orchiectomy. Final pathologic analysis revealed a 2.7 cm seminoma with vascular invasion. The patient’s left-sided and right-sided tumors were staged as T1N0M0 and T2N0M0, respectively; as such, the patient was classified as having clinical stage I testicular cancer.

The patient was started on testosterone replacement therapy (Androgel®; Laboratoires Besins International, Paris, France; 5 mg daily). He tolerated this therapy well, and although he experienced mild transient hot flashes and decreased libido around the time of initiation of androgen replacement, these symptoms improved dramatically with therapy. He was extensively counseled about adjuvant therapy for testicular seminoma. Specifically, the relative risks and benefits of surveillance, radiation therapy and chemotherapy were discussed at length. Ultimately, he elected to undergo adjuvant radiotherapy at a total dose of 2,520 cGy in 14 fractions delivered to the bilateral para-aortic lymph nodes and left renal hilum. The patient did not experience any adverse sequelae of radiation therapy. CT of the abdomen and pelvis at 3, 6, 12, and 24 months after therapy demonstrated no evidence of disease.