Presentation
Right inguinal pain and fullness.
Patient Data
Enlarged right testis, exhibiting heterogeneous echogenicity, with loss of normal echotexture. Spermatic cord appears thickened.
Small amount of septated fluid in right hemiscrotum.
Left testis normal in size, echogenicity and echotexture. Normal arterial and venous pattern elicited. 5 mm cyst in head of epididymis.
There are 2 sets of images because the ultrasound examination was repeated for the urologist.
No axillary, mediastinal or hilar lymphadenopathy.
Patchy, coalescing alveolar infiltrates with thickened intralobular septa ("crazy paving") in all lung lobes.
Subpleural right middle lobe (RML) node measuring 10 mm in length, rounded right upper lobe (LUL) node measuring 12 mm in diameter.
Several para-aortic lymph nodes up to 25 mm in thickness.
Innumerable hepatic cysts, unchanged cf. previous CT from 3 years prior.
In summary:
Metastatic spread of testicular tumor to lungs and retroperitoneum, most probably.
"Crazy paving" pattern in all lung lobes, significance unknown - atypical pneumonia?
Case Discussion
Complained of right inguinal pain and bulging. No fever, nausea, vomiting, diarrhea or dysuria.
History notable for smoking 1-2 packs a day for 16 years and drinking 2 vodka bottles a week. He had an appendectomy 3 years prior.
Physical examination ruled out an inguinal hernia.
Ultrasound interrogation showed a large right testicular mass. CT chest-abdomen-pelvis showed several lung nodes and retroperitoneal lymphadenopathy.
Beta-HCG 0.57 mIU/ml (normal 0-3 mIU/ml), alpha fetoprotein 43.46 ng/ml (normal 0-15 ng/ml).
Histopathology report:
Embryonal carcinoma, 7 cm in greatest diameter. The tumor focally involves the rete testis and invades the tunica albuginea. Vascular invasion also present.
Immunostains:
Positive: CD30, OCT 3/4, patchy PLAP, pankeratin. Focally positive alpha fetoprotein.
Negative: CD117, EMA, vimentin.
Intratubular embryonal carcinoma. Surgical margins and spermatic cord free of tumor.
Underwent right orchiectomy and received chemotherapy, recovered fully.
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