With the extensive use of scrotal ultrasound (US), incidental non-palpable testicular tumors have thus been unexpectedly discovered. This report documents the case of 24-year-old male with a non-palpable testicular tumor that contained non-seminomatous germ cell components detected by US. Radical orchiectomy was performed and histological examinations confirmed a diagnosis of a mixed tumor of seminoma and embryonal carcinoma. Serum alpha-fetoprotein (AFP) rose from 7.8 to 43 ng/ml and CT scan revealed multiple metastases only 1 month after the operation. Systemic chemotherapy was introduced immediately, and the serum level of AFP decreased to the normal range and the metastatic lesions had disappeared after three courses of the chemotherapy. No recurrence was observed at 18 months follow-up after the chemotherapy. This is the first case of non-palpable testicular embryonal carcinoma, which metastasized soon after the resection. The obscurity and implications of such a diagnosis are also discussed.

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IgG4-related disease (IgG4RD) is a novel clinical entity characterized by tissue infiltration of IgG4-positive plasma cells. We report here 3 cases of IgG4RD associated with urinary tract obstruction. Patient 1 was a 59-year-old male who complained of difficulty on urination. A CT scan showed bilateral ureteral wall thickness, hydronephrosis, and an enlarged prostate. His serum IgG4 was 817 mg/dl. We made a diagnosis of IgG4RD and performed bilateral ureteral stenting and steroid therapy. A significant reduction in the size of the lesion was detected, and IgG4 was decreased to 272 mg/dl. He was doing well after removal of the ureteral stent. Patient 2 was a 51-year-old female who complained of bilateral swelling of the submaxillary gland. A CT scan showed left ureteral wall thickness and hydronephrosis. Her serum IgG4 was 1,020 mg/dl. We made a diagnosis of IgG4RD and performed left ureteral stenting and steroid therapy. A significant reduction in the size of the lesion was detected, and IgG4 was decreased to 337 mg/dl. She was doing well after removal of the ureteral stent. Patient 3 was a 64-year-old male who underwent evaluation for autoimmune pancreatitis. He complained of back pain and bilateral hydronephrosis was detected. His serum IgG4 level was 649 mg/dl. Bilateral ureteral stenting was performed based on a diagnosis of IgG4RD. He did not receive steroid therapy because of poorly-controlled diabetes mellitus. After insertion of the ureteral stent, hydronephrosis and back pain were relieved. We could only find a few case reports in the literature on IgG4RD associated with urinary tract obstruction. It is important for clinicians to bear in mind that IgG4RD sometimes causes urinary tract obstruction.

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