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.
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.