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.
A 27 year old single male presented to our patient department with complaint of one month testicular swelling with left side preference. He has no complaints of pain in the testicles and abdomen. No problem in erectile function. He had no problems during puberty. He had no history of smoking and use of opioid in social habits. There is no family history and no evidence of risk factor for testicular cancer such as cryptorchidism or congenital abnormalities in the patient. Physical examination specified the left side testis with twice the normal volume swelling and without tenderness. The size of right side testis has increased slightly. Laboratory workup revealed azoospermia and an elevated a-FP (258.4IU/mL), and b-hcG (3.12mIU/mL) within normal levels. On ultrasound study the testes have 50mm×30mm in right side and 72mm×50mm in left side dimensions. No hydrocele was seen. Images of the right testis demonstrated 38mm×27mm hypoecho mass that accounting for (occupying) three-quarters of the volume of the parenchyma. Images of the left testis demonstrated approximately 70mm×47mm mixed echogenic mass, comprises almost the entire volume of the testis. Epididymis have normal parenchymal dimensions and echoes.\nThe ultrasound study of abdomen and pelvis showed no abnormality. The abdomen CT scan was not indicative of enlargement of the lymph nodes of retroperitoneum. The chest x-ray did not show evidence of metastasis. The patient underwent bilateral radical orchiectomy. Right testicular mass, excisional biopsy, for frozen section and intra-operative diagnosis, consists of a piece of creamy colored soft tissue specimen, with homogenous appearance, measured 45×35×22 mm in the largest diameters. Cryo and permanent sections of right testis mass, confirmed invasive, classic type seminoma that limited to the testis with intratubular and invasion to lympho-vascular tissues (tumor stage: at-least PT2) ().\nIn the left testis, in cut sections, almost all testicular volume replaced by tumoral tissue with heterogeneous appearance, containing solid and cystic, hemorrhagic and necrotic areas, measured 80×50×40 mm. the left side tumor was a malignant GCT with component of invasive, classic type seminoma (50-60%), yolk sac tumor (40-50%) and embryonal carcinoma (about 10%) (). Tumor extended to rete testis, tunica albuginea and tunica vaginalis. Epididymis was not involved. Intratubular and lympho-vascular invasion was present (tumor stage: PT2). Immunocytochemical study with AE1/AE3, CD30 and CD117 markers demonstrated a positive reaction (). The patient was discharged without problems and complications one day after surgery. The elevated a-FP on the postoperative measurement decreased to lower values (6,05mIU/mL). The patient was advised to go to an oncologist and was submitted to one cycle of adjuvant chemotherapy with bleomycin, etoposide, and cisplatin (BEP). As the follow-up physical examination, serum markers, chest X ray, and CT of the abdomen, were checked. Six months after the orchiectomy there was no residual tumor or recurrence, neither local nor systematic. Finally the patient is under a follow-up by an endocrinologist for the long-term management regarding the testosterone replacement therapy and he has been started on topical testrogel for life.