The patient is a forty-one-year-old man with an unremarkable medical history presented with a two-month history of scrotal swelling and discomfort. He denied a history of mal-descent, and there was no family history of testicular cancer. Physical exam was pertinent for an enlarged, nontender left testicle. An ultrasound revealed well-circumscribed hypo-echoic, heterogeneous lesions in both testicles (). The left testicular mass measured 3.0 × 2.6 × 4.3 cm, while the mass in the right testicle measured 2.1 × 3.1 × 0.5 cm. Doppler was suggestive of normal blood flow. Pertinent labs included (AFP) alpha fetoprotein 6.2 µg/L, (beta HCG) beta human chorionic gonadotropin <3 IU/L, (LDH) lactase dehydrogenase levels 572 U/L, and serum testosterone 375 ng/dL, and all prognostic markers are within normal limits. CT of the chest, abdomen, and pelvis was negative for evidence of metastatic disease or lymphadenopathy.\nHe underwent bilateral inguinal orchiectomy. Final pathology () revealed classical seminoma in both specimens. Both right and left tumors exhibited invasion of the rete testis. There was possible angiolymphatic space invasion noted within the left testicular mass. There was no tumor extension through the tunica albuginea, epididymis, or spermatic cord. Surgical margins were free. Both tumors were pathologically staged IA.\nThe patient did not have concerns regarding fertility and declined to consider an organ preserving approach. Our patient was uncomfortable with surveillance as an option. He declined medical oncology referral for discussion about systemic therapy and was therefore treated with external beam radiotherapy. He received 2550 cGy in 17 fractions at 150 cGy per fraction via 6 MV/18 MV photons with AP/PA fields. Field borders () included superior border at T10/11 interspace, inferior border at L5/S1 interspace, and lateral borders of vertebral transverse processes (field width approximately 10 cm). The patient did not have a history of previous pelvic surgery, and only the paraaortic lymph nodes were targeted. He tolerated treatment well, experiencing grade I nausea (as per Common Terminology Criteria for Adverse Events, version 3.0). He is currently disease-free, 18 months from completion of radiation therapy. His serum testosterone levels fell to 248 ng/dL after treatment, and he uses testosterone gel for hormone replacement.
An 18-year-old man, without any known risk factor for testicular malignancy, presented to our hospital with a painful right testicular mass with 1 month of evolution. Physical examination detected a small lump, confirmed by testicular ultrasound as a hypoechoic nodule. A CT-scan revealed no metastatic disease. α-fetoprotein (AFP) and lactate dehydrogenase (LDH) were above the normal limit. A right inguinal orchiectomy was performed and the histological exam revealed a mixed germ cell testicular tumor (composed by embrionary carcinoma and mature teratoma). Tumoral markers normalized after surgery, and the tumor was staged as pT1N0M0S0 - IA, according to the American Joint Committee on Cancer guidelines. The patient remained under surveillance. Twelve years later he developed bilateral gynecomastia and a high human chorionic gonadotropin (HCG). CT-scan found a 1cm lateroaortic adenopathy and a PET-scan revealed hyperfixation in the referred adenopathy and left testicle. At that time a scrotal ultrasonography was done, and a voluminous testicle of 5 x 5 x 3 cm with hypoechogenic and hypervascularized areas were found. This was followed by a left radical inguinal orchiectomy with testicle prosthesis introduction. Histological exam revealed a mixed TGCT (with seminoma, embrionary carcinoma and immature teratoma components) and a pathological stage pT2N1M0S1 – IIA. Chemotherapy was started with BEP protocol (bleomycin, etoposide and cisplatin), administered every 21 days for 3 cycles. Retroperitoneal adenopathy disappeared, HCG normalized and a surveillance program was initiated. The patient was disease-free in the 5 months after having finished his treatment.