Metachronous Testicular Seminoma-16 Years Later: Early Detection and Management /Case Report/

Abstract

ABSTRACT:A 28-year-old male presented at a regional hospital with a pulling sensation and feeling of unusual heaviness in the right scrotum. Pain and discomfort appeared two weeks ago.The patient had no previous medical history. Physical examination, US and CT confirmed 26 mm mass, localized centrally in the right testis without metastatic process and patient was treated with right inguinal orchiectomy, followed by 25 Gy radiotherapy. After 16 years and 3 months the same symptomatology started in the left side and US discovered two masses: 15 and 21 mm in left testis. Investigation included tumor marker assessment, scrotal US, CT and biopsy. Diagnosis metachronous testicular seminoma, stage T1N1M0.Biopsy, radical orchiectomy, androgen substitution and follow-up were performed.Key words: seminoma, bilateral, metachronous, germcell tumor. THE CASE:A 28-year-old male presented at a regional hospital with a sensation and feeling of unusual heaviness in the right scrotum. Pain and discomfort appeared two weeks ago. The patient had no previous medical history. US imaging showed a right side mass, measuring 28x20 mm and normal left testis. A CT scan revealed no evidence of infiltration of spermatic cord or the inguinal and paraaortic lymph nodes. Blood serum tumor markers of human chorionicgonadotropin (HCG), á-fetoprotein (AFP), and lactate dehydrogenase (LDH) were in referent levels. After consultation with anesthesiologist, right inguinal height orchectomy was made. Histology demonstrated a seminoma, without infiltrating tunica albuginea-stage pT1N0M0 tumor according UICC (Union International Against Cancer).One month after operation, the patient was presented to the hospital multidisciplinary oncology group and started radiotherapy in dose of 25Gy to the periaortic lymph nodes. Patient was accepted as disease free and according the protocol was followed up every 4 months the first two years with chest X-ray, CT, physical examination and tumor marker assessment.In May 2009, 16 years and 3 months after the first orchectomy, the patient complained in a medical office of enlarged left testis, firm in consistency and with a sensation for heaviness. Scrotal ultrasonography revealed two hypoechoic left-testicular masses measuring 19x12 mm and 13x7 mm (Fig. 1).Patient was referred to a specialized urologic clinic, where repeated physical and imaging study revealed no evidence of metastases, and serum concentrations of testosterone, â-HCG, LDH, and AFP were all within normal ranges. No suspicions for spread on CT of chest and abdomen.In elective plan left inguinal exploration and frozen section biopsy with confirmation of germ cell tumor-pure seminoma was made (Fig. 2).The tumors measured 12 mm and 10 cm in greatest dimension, respectively, and were confined to the testis. One lymph node was detected 2 cm in the spermatic cord but negative for neoplastic invasion. Second pT1N0M0 was found. Daily topical testosterone replacement therapy was administered, beginning on the first postoperative day-in the form of a hydroalcoholi...

Tumor testicular metacrónico 19 años después

“…El intervalo mayor de tiempo reportando entre tumores metacrónicos en la literatura médica ha sido en una serie (Schreiber et al, 1987) de hasta 32 años 6 .…”

“…La incidencia de un segundo tumor testicular contralateral en pacientes con antecedente de tumor germinal es del 1% al 5% publicada en las grandes series (Bokemeyer et al, 1993;Dieckmann et al, 1993Dieckmann et al, , 1999Dieckmann et al, , 2002Heidenreich et al, 1995Heidenreich et al, , 1997Heidenreich et al, , 2000 No existe un consenso del tiempo trascurrido para de nir la metacronicidad, se habla en diversos estudios prospectivos y retrospectivos de periodos de uno a 3 años posterior a la remisión completa del cáncer. Aproximadamente el 50% de las lesiones metacrónicas aparecen en un periodo de 5 años, se ha reportado que hasta el 23% de los pacientes presenta tumor metacrónico más de 10 años después 6 . La incidencia de cáncer testicular bilateral varía dependiendo de los reportes publicados, se encontró hasta el 1% en la serie del MD Anderson, 1.2% en el Memorial Sloan Kettering Cancer Center y 1.9% en el Institute Gustave Roussy [7][8][9] .…”