We present the case of a 41-year-old male with repeated visits to outside emergency\ndepartments over a 3-month period with a waxing and waning pattern of worsening\ncognitive dysfunction as well as intermittent fevers. He also complained of\ngeneralized weakness and fatigue. His initial diagnosis was viral meningitis. He had\na negative workup for infectious etiologies, including negative CSF cultures,\nnegative Lyme titers, normal ACE level. Previous lumbar puncture was notable for\nelevated white blood cells, elevated protein, and glucose below 50g/dL. CT scan of\nthe abdomen at an outside hospital revealed a right pericaval lymph node measuring\n3.8 x 3.7 cm with central necrosis ().\nExternal genitalia were incompletely visualized on this scan. After transfer to our\ninstitution, the condition continued to worsen and after being admitted, the patient\nwas unable to speak and reported weakness in all four extremities that progressed to\nalteration of awareness, disorientation, and difficulty speaking. Labs at this time\nwere significant for phosphorous less than 2 mg/dL, which is known to precipitate\nseizures and altered mental status, however it was felt that the lower extremity\nshaking was not consistent with a seizure. He was placed on Keppra prior to arrival\nat our hospital. Based on this presentation, a CT of the head was obtained to rule\nout a primary central nervous system etiology. This imaging showed no acute process.\nFurther work up with MRI could not be obtained due to a non-compatible internal\npacemaker. Pacemaker analysis showed no abnormalities. Due to the para-aortic\nlocation of the mass, a 24-hour urine metanephrine was also performed to rule out a\nneuroendocrine tumor.\nAfter the negative initial workup, concern for distant metastasis led to the belief\ncurrent symptomatology was due to secondary to a paraneoplastic process.\nSpecifically, the presence of retroperitoneal lymphadenopathy with necrosis raised\nconcern for testicular origin. Sonographic evaluation of the testicles showed a\nright sided, ill-defined, multi-cystic 2.4 x 2.1 x 2.2cm mass (). Further laboratory evaluation revealed an\nelevated B-hCG of 49.9 mIU/mL, alpha fetoprotein level of 1.67 ng/mL and normal LDH\nlevel. A right radical orchiectomy was performed.\nGross pathology obtained from the right radical orchiectomy showed a 2.1 x 1.8 x 1.6\ncm tan-white, ill defined, soft, multicystic lesion in the medial and inferior pole\nof the testis, without hemorrhage or necrosis. Histologic evaluation revealed mixed\nrespiratory epithelium, gastrointestinal glands, and squamous epithelium with\nkeratinization consistent with a post-pubertal testicular teratoma with associated\ngerm cell neoplasia in situ (Figures , ).\nRepeat CT scan of the abdomen and pelvis showed continuous enlargement of the right\nperi-aortic lymph node, now measuring 5.6 cm in greatest dimension, as well as a new\nleft peri-aortic node measuring 2.2 cm in the largest dimension. After\nmultidisciplinary discussion, given the likelihood of a paraneoplastic syndrome that\nwould likely worsen with up front chemotherapy, the decision was made to proceed\nwith a primary retroperitoneal lymph node dissection. The large aortocaval mass was\nadherent to the inferior vena cava (IVC), but no invasion was noted. Measurement of\nthe extirpated mass was noted to be 7 x 6 x 4.5 cm in size cm in the largest\ndiameter. A complete bilateral template retroperitoneal lymph node dissection was\nperformed extending inferiorly from the renal veins to the bifurcation of the common\niliac arteries and to the ureters bilaterally.\nOn gross pathology, the aortocaval mass was well encapsulated with hemorrhagic and\nnecrotic cut surfaces. Microscopic evaluation displayed large anaplastic cells with\nepithelioid features, nuclear pleomorphism and frequent mitoses. Giant cells with\ngranular cytoplasm were also present. One node measuring 1.5 x 1.0 x 1.0 cm was\npositive for malignancy. Immunostaining of the mass and positive lymph node\ndisplayed positive staining for Pan-Keratin and OCT4, and negative staining for\nCD30, S-100, Desmin, pan-melanoma, and SOX2. The microscopic evaluation and\nimmunostaining combination led to the diagnosis of poorly differentiated embryonal\ncarcinoma ().\nThe patient’s neurological symptoms were managed with methylprednisolone, and Keppra\nwas continued for seizure prophylaxis. Following resection of the aortocaval mass,\nthe patient recovered well, and the diplopia and paralysis resolved. He was managed\npost-operatively with Bleomycin-Etoposide-Cisplatin (BEP) therapy. At the time of\npublication, he had received three cycles of BEP and has shown no evidence of tumor\nrecurrence.
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.