Intraabdominal testicular tumor on undescended testicle: a case report [624455]

Intraabdominal testicular tumor on undescended testicle: a case report
Suciu M 1,2 ; Badea R , Tomuta AI 1, Marica NA. 1,2 ;
Author information
1 Institute of Urology and Renal Transplantation, Cluj-Napoca, Romania.
2 Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
3 Department of Medical Imaging, Iuliu Hatieganu University of Medicine and Pharmacy,
Regional Institute of Gastroenterology and Hepatology "Prof. Dr. Octavian Fodor", Cluj-
Napoca, Romania.
Abstract
Cryptorchidism , alone or as component of the dysgenesis syndrome, is one of the main risk
factors for the development of testicular tumors. Although the vast majority of undescended
testicles are diagnosed and treated in the early years of life, there are adult patients left untreated,
which present higher risk of malignancy.
Here we present the case of a 36 years old patient, known with left cryptorchidism, who
presented with an intraabdominal tumoral mass of high volume originating from the undescended
left testicle. Surgical excision and retroperitoneal lymphadenectomy was performed . The
histological result revealed embryonal carcinoma; without tumor involvement of the lymphnodes.
Adult patients with cryptorchidism should be thoroughly investigated, as they present a
major risk factor for developing testicular cancer.
Introduction
Testicular cancer represents 1% of male neoplasms and 5% of urological tumors, with three
to ten new cases occurring per 100,000 males/per year in Western societies [1,2] . Seminomas are
most often diagnosed in the 25- to 40-year-old age group, whereas nonseminomatous tumors occur
in even younger men (adolescence to 30 years). [3,4]
Cryptorchidism represents the undescended testicle , while it has been stated that “the truly
cryptorchid testis is the testis that lies above the external inguinal ring, either within the inguinal
canal or within the abdomen, and is nonpalpable in the unanesthetized patient.” [5] . It occurs when
there is a congenital defect in the regulatory or anatomical process of testicular descent [6] .
Cryptorchidism increases the risk of cancer appearance up to 5-10 time than in the rest of
population [ 7].
Case Report
We present the case of a 36 years old patient, male, known with left cryptorchidism, who was
admitted to hospital with left iliac fossa pain, fatigue. The clinical examination revealed that the
left testicle was not palpable in the left hemiscrotum , as well as in the inguinal channel ; the
palpation of the abdomen revealed a swelling in the left iliac fossa. Serum tumoral markers revealed
elevated Alpha-fetoprotein (258 U/I) , human chorionic gonadotrophin – hCG ( 15000mIU/ml),
Lactate dehydrogenase (507 U/I). Scrotal ultrasound described only the right testicle in the scrotum,
which was normally structured, while the abdominal ultrasound pointed out a pelvic tumor, with
11x10x7 cm , with inomogen structure, well limited, hyperenhancing from periphery to the center,

inhomogeneous ( Fig.1).
Fig 1 : Abdominal ultrasonography : standard and SonoVue-enhanced
Abdominal contrast-enhanced computed tomography raised concerns over tumoral infiltration in the
anterior rectal wall (Fig.2) , but the MRI described an incapsulated tumor , in contact with rectum,
sigma, bladder, seminal vesicles and ileus (Fig.3). Enlarged left paraaortic lymphnodes were also
assessed.
(Fig. 2 : computed tomography) ( Fig. 3 : MRI)

Surgical exploration through laparotomy was performed which revealed a large retroperitoneal
tumor (330 mL) (Fig 4) , well defined, without penetration of nearby organs , and enlarged left
paraaortic lymphnodes. (Fig 5)
(Fig. 4 : intraoperative asspect of the tumor)
Tumor excision and modified left template retroperitoneal limphadenectomy were performed (Fig.
6) . There were no intraoperative or postoperative complications.
(Fig.5: enlarged paraaortic lymphnodes) (Fig. 7 : left RPNLD)
Histopathological examination of the retroperitoneal mass was reported as embryonal carcinoma
( Fig. 6 – Tumor with solid pattern, composed of primitive epithelial type cells, with minimal
features of differentiation. There are mainly high grade features consisting of large, epithelioid cells
with prominent nucleoli, indistinct cell borders with nuclear overlapping, pleomorphism, frequent
mitoses) , with important syncytiotrophoblastic components (Fig. 7) , but not more than 10% of
tumoral areas. Necrosis and intratumoral hemorrhage was present. No other malignant cells were
identified in order to sustain the diagnosis of teratoma. All excised lymphnodes contained
histiocytosis, but without tumoral invasion .
The patient was sent for oncological surveillance and has followed postoperative chemotherapy.
Fig. 7 . Embryonal cell carcinoma, H&E stain 10x.

( Fig. 8 Syncytiotrophoblast component, H&E stain 20x. )

Discussion
Cryptorchidism affects 2% – 4% of male infants , and can be considered as a common
pathology . [8] It occurs when the testicle fails to descend from the lumbar region to the scrotum
during natural migration. Long term cryptorchidism can lead to infertility , hormonal changes and
neoplastic degeneration [9] . The risk of malignancy increases the higher the region of testicle
descent is ( inguinal, abdominal) [10] . The recommended age for orchidopexy has fallen
progressively over the last 50 years, from adolescence in the 50s and 60s to 6-12 months in recent
times [11] . Because during the first months of life the testicle may descend spontaneously,
orchidopexy should not be performed in the first 6 months [12] , and ideally before 12 months, in
order to optimize fertility outcomes [13] . Concerning testicular malignancy, it has been stated that
the risk for cancer highly increases if orchidopexy is performed after 11 years [14] , although
studies have shown that even in cases where orchidopexy was performed earlier than 10 years, the
risk of developing malignancy was 2.6 higher . [15]
Regarding management of undescended testis, the RR of malignant pathology in
undescended testes is 40 times higher than in descended ones [16] . Although earlier studied ,
taking into account the risk of death due to cancer and the surgical risks associated with
orchiectomy , have suggested 32 years old should be the age limit for orchiectomy in undescended
testicles [17] , a 2002 study stratified anesthetic risk by ASA classification and recommended
performing orchiectomy up to 50 years in ASA I and II , and may also be considered in healthy
ASA I for patients up to 60 years [18].
Of malignant tumors developing in uncorrected abdominal or inguinal testes 74% are
seminoma , while corrected cryptorchid or scrotal testicles that undergo malignant transformation
are most likely to become nonseminomatous (63%) , presumably because of a decreased risk of
seminoma. [19] . Embryonal carcinoma is one of the most common component in mixed germ cell
tumors , while pure embryonal carcinoma only occurs in 3-4% of cases [20] , usually occurring in
the second and third decade [21] . It is an aggressive tumor associated with a high rate
of metastasis, often in the context of normal serum tumor markers. Embryonal carcinoma is known
to have the highest probability of lymphatic and vascular invasion and also of extension into
paratesticular tissue [22], as it also has the tendency to early hematogenous spread. Patients
diagnosed with embryonal carcinoma usually have metastatic disease, and half of them have distant
metastases [23]. Mediastinal primary tumor , nonpulmonary visceral metastasis or post-orchiectomy
markers any of: AFP > 10,000 ng/mL , hCG > 50,000 iu/L , LDH > 10 × upper limit of normal , are
considered prognostic factors for poor risk non-seminoma [24].
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