A Case of Synchronous Bilateral Testicular Seminoma

Box 1.

Guidelines for the Implementation of a Testis-sparing Approach to Testicular Cancer.^[16]

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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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Discussion of Diagnosis

The differential diagnosis of bilateral testicular masses includes lymphoma, bilateral germ cell tumors, and benign entities such as epidermoid cysts or Leydig cell tumors. The current patient did not present with any abnormalities on laboratory analysis or evidence of lymphadenopathy, ruling out the possibility of lymphoma. Scrotal ultrasonography revealed bilateral hypoechoic intratesticular masses suspicious for testicular neoplasia. While the borders of the tumors were well defined, the appearance and echogenicity of the lesions were not consistent with benign intrascrotal processes. Furthermore, no endocrine abnormalities associated with Leydig cell malignancy, such as elevated serum level of total or free testosterone, were identified. Thus, bilateral germ cell tumors seemed the most likely preoperative diagnosis.

The incidence of testicular cancer continues to rise in white populations.^[1] Testicular carcinoma accounts for approximately 1% of all malignancies in men and usually presents, as in this case, as a painless testicular mass, noted incidentally either on testicular self- examination or after a minor trauma. Testicular cancer remains, however, the most common solid malignancy in men aged 15–35 years.^[2] A distinct subset of patients present initially with synchronous bilateral testicular germ cell tumors, with the reported incidence ranging from 0.1% to 0.8% of all testicular malignancies.^[3-6] The largest series of such patients to date reviewed 151 cases of synchronous bilateral testicular cancer. The authors found that 75.8% of patients had bilateral seminomatous disease on pathologic analysis.^[7] This finding has, however, been challenged by more-recent data. Holzbeierlein and colleagues,^[4] in their series from Memorial Sloan–Kettering Cancer Center (MSKCC), found that 70% of patients presenting with synchronous bilateral testicular tumors had discordant histology. Additionally, two other series found 38% and 54% of patients with synchronous bilateral testis tumors to have discordant histology.^[6,8]

Patients with synchronous bilateral testicular germ cell tumors might generally fare well, as they often present with early-stage disease.^[6] Indeed, this suggestion has been borne out by published data, with 90% of patients in the MKSCC series^[4] and 72% of patients in the Munich series^[6] presenting with stage I or II disease. Outcomes paralleled these data, with 100% and 64% of the patients displaying no evidence of disease at median follow-up durations of 29.5 months and 37.0 months in the MSKCC and Munich series, respectively. By contrast, in perhaps the largest series to study the risks of bilateral testicular cancer, 45% of patients with synchronous bilateral testicular cancer had regional or distant disease, compared with 32% of those with unilateral testicular cancer, suggesting that patients who present with bilateral tumors are actually more likely to have advanced disease.^[3]

Consistent with these previous observations, the current patient presented with concordant pathology and low-stage disease. Interestingly, however, he presented at a relatively advanced age (51 years) and had successfully fathered two children without any conception difficulties. Men with testicular cancer have been reported to demonstrate impaired spermatogenesis and an abnormal reproductive hormonal milieu.^[9] Impaired fertility might even precede the development of frank tumor. Nonetheless, as in this case, men can present with bilateral testis tumors despite having no history of infertility.