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.
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.