Burned Out Seminomatous Testicular Tumor with Retroperitoneal Lymph Node Metastasis: A Case Report

Abstract

Germ cell tumor is the most common malignancy in men aged 15-35 years. About five percent of the malignant germ cell tumors are extragonadal in origin. However metastatic deposit of seminoma in retroperitoneal lymph node without presence of any tumor in the testes is uncommon. We present a case of metastatic retroperitoneal seminoma as the initial presentation of a burned out testicular primary. The patient presented with pain in abdomen and back. Ultrasonography of the testis showed a lesion, which after high inguinal ochidectomy was reported as fibrosis only, without any tumor, i.e. burned out phenomenon. A laparotomy biopsy of the retroperitoneal lymph node mass was taken and reported as metastatic seminoma after immunohistochemistry. After 14 months of chemotherapy there is a residual lymph node of less than 3cm, serum tumor markers are normal and the patient is under observation.Keywords Seminoma . Burned out phenomenon . Testis . Extragonadal germ cell tumor Case ReportA 33 year old Indian male presented to our Institute with pain in abdomen and back intermittently, for 3 months duration. Patient is a tobacco chewer and hypothyroid under treatment. There was no significant history, physical examination was normal.Ultrasonography (USG) of abdomen revealed a heterogeneous mass in the retroperitoneum. Contrast enhanced computed tomography (CECT) of abdomen showed a rim enhancing lesion 6.1×5.0 cm at aortic bifurcation [ Fig. 1a]. Trucut biopsy was done and histopathological examination (HPE) reported as poorly differentiated carcinoma or NonHodgkin's lymphoma. Immunohistochemistry (IHC) showed CD117 positivity in the tumor cells, suggestive of seminoma. The tumor cells were negative for pancytokeratin, CD30 and CD45.To find out the primary, USG of bilateral testes was done, which showed a heterogenous lesion of 1.5×1.2 cm in the left testicle [ Fig. 1b]. Testicular tumor serum markers human chorionic gonadotropin (hCG), alphafetoprotein (AFP) and lactate dehydrogenase (LDH) were normal.Left high inguinal orchidectomy was done. On gross, a whitish scar like lesion was noted [Fig. 1c]; microscopically no tumor was found; only fibrosis was seen. Re-grossing and re-examination of the specimen was reported as same.Laparotomy and biopsy from the retroperitoneal lymph nodal mass was done. HPE showed neoplastic cells in sheets and nests with intervening thin fibrous septae and scattered lymphocytes. The cells had vesicular nuclei, prominent nucleoli and pale cytoplasm [ Fig. 1d], suggestive of (1) metastatic/ primary seminoma, (2) metastatic/primary poorly differentiated carcinoma. No definite lymph nodal architecture could be

Burned-Out Testis Tumors in Asymptomatic Infertile Men: Multiparametric Sonography and MRI Findings

“…Testis tumor markers that are within the normal range could not be relied on to establish the diagnosis. To our knowledge, this is the largest series of this rare entity, as the literature only contains 25 instances that have been reported either as case reports or as small cohorts . Only one of these cases involved nonmetastatic disease .…”

“…To our knowledge, this is the largest series of this rare entity, as the literature only contains 25 instances that have been reported either as case reports or as small cohorts. [16][17][18][19][20][21] Only one of these cases involved nonmetastatic disease. 22 A recent case report illustrated a similar situation to what we report here.…”

Tumor extragonadal de células germinales con fenómeno de burned-out testicular

“…Los germinomas extragonadales representan el 1-5% de los tumores de células germinales. Una de las causas atribuibles a la aparición de estos tumores podría ser una migración aberrante de células primordiales germinativas en la línea media y su consecuente transformación maligna de estas células 4,5 , las cuales se originan del epiblasto proximal 6 . Uno de los sitios más frecuentemente afectados por estos tumores es el retroperitoneo 7,8 .…”

“…Cuando el germinoma se encuentra en una región extragonadal, se debe considerar la presencia de un tumor testicular oculto o el fenómeno de burned-out. Este último se refiere a la existencia de un tumor germinativo extragonadal con un tumor intragonadal en regresión 9,10 . Esta situación fue la presentada en nuestro caso reportado, ya que la biopsia del tumor testicular reveló atrofia y fibrosis.…”

Extragonadal germ cell tumor with testicular "burned-out" phenomenon

“…Extragonadal germinomas account for 1-5% of germ cell tumors. One of the causes the occurrence of these tumors can be attributed to might be an aberrant migration of primordial germ cells in the midline and a consequent malignant transformation of these cells 4,5 , which stem from the proximal epiblast 6 . One of the sites most commonly compromised by this tumors is the retroperitoneum 7,8 .…”