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.
A 40-year-old male presented at our outpatients department complaining about a testicular painless mass on the right testis, which had shown a gradual enlargement over the past two months. The only symptom the patient had was discomfort in the scrotum and a sensation of testicular heaviness. His medical history did not report any known risk factors for testis cancer, such as cryptorchidism, and he did not have any comorbidities. Physical examination revealed a firm and nontender mass both on the right and on the left testis, which were easily separable from the epididymis. No other constitutional signs were present. Laboratory workup revealed a moderately elevated b-hcG (24,7 mIU/mL) and CEA (1,97 ng/mL), a-FP (1,62 ng/mL), and LDH (180 IU/L) within normal levels. Firstly, he was submitted to a scrotal ultrasonography which revealed a testicular mass that measured approximately 2,3 × 3,1 cm on the right testis () and another testicular mass of 2,4 × 1,5 cm in size on the left testis (). The computer tomography (CT) of the abdomen did not demonstrate any enlarged retroperitoneal lymph nodes. The chest X-ray showed no abnormality. The patient was scheduled for operation and he did not want to have frozen storage of sperm, although he was fully informed about the consequences, since he was a father of two children and also was informed about the occurrence of hypogonadism after the operation and that he will have to be under a strict endocrinologist follow-up and hormone replacement. He chose bilateral orchiectomy for oncological reasons. Finally, he underwent bilateral orchiectomy with high ligation of the spermatic cord. The postoperative period was uneventful and the patient exited the hospital the next day. The elevated b-hcG on the postoperative measurement (the 15th day) was within normal values (0,3 mIU/mL). Histopathological evaluation of the specimens revealed the following: (a) an embryonal cell carcinoma of the right testis limited to the testis with lymphovascular invasion of pathological stage pT2 (): staining with antibodies showed CD30(+) and a-FP(−); (b) a seminoma of the left testis, limited to the testis without invasion of the tunica albuginea or vascular invasion of pathological stage pT1 (): staining with antibodies showed CD117(+), CD30(−), and a-FP(−). On both testicles intratubular germ cell neoplasia of unclassified type (IGCNU) was present. The patient was referred to an oncologist and was submitted to two cycles of adjuvant combined chemotherapy with bleomycin, etoposide, and cisplatin (BEP). His follow-up consisted of physical examination, serum markers, chest X-ray, and CT of the abdomen, according to the EAU Guidelines recommended follow-up schedule. Six months after the operation no residual tumor or recurrence was observed, neither local nor systematic. Finally the patient is under a strict endocrinologist follow-up for the management of his hypogonadism state.