Presentation
Right scrotal mass for 6 months. Associated with scrotal discomfort and 6 kg weight loss in last 4 months.
Patient Data
relatively enlarged right testis. A sizable heterogeneous echogenicity mass lesion containing both solid and cystic components, measuring approximately 6.0 x 4.0 x 5.0 cm is seen within the right testis. Multiple hyperechoic foci, likely calcifications, are also seen within it. Increased vascularity is seen within the mass on color Doppler ultrasound examination.
left testis is normal in size, shape and parenchymal echogenicity. No suspicious focal solid or cystic lesion is seen in the left testis. Color Doppler ultrasound examination demonstrates normal intratesticular vascularity.
small turbid bilateral hydroceles.
morphology of the left epididymis is within normal limits. The right epididymis is not confidently identified.
Heterogeneous right testicular mass containing both solid and cystic components and multiple tiny calcifications. Mild right hydrocele. No evidence of loco-regional or distant metastases in the chest, abdomen and pelvis.
Magnified CT scan images of the scrotum.
Histopathology shows a mixed germ cell tumor with teratoma making > 95% of the tumor. Somatic-type malignancy (SM) rhabdomyosarcoma is also identified.
Case Discussion
The development of a somatic-type malignancy (SM) in a testicular germ cell tumor (TGCT) is an exceptional abnormality, challenging the diagnosis and management of testicular malignancy. The majority of these somatic-type malignancies originate from a teratoma and the remaining from the yolk sac tumor and are seen more commonly in the metastases than in the primary testicular tumors. Sarcoma, carcinoma, embryonic-type neuroectodermal tumor, nephroblastoma-like tumor and hematologic malignancy are the different histologic types of somatic-type malignancies derived from TGCTs. Sarcoma (especially rhabdomyosarcoma) is the commonest somatic-type malignancy in the primary testicular tumors, whereas carcinoma (especially adenocarcinoma), is the commonest in the metastases. Somatic-type malignancies usually develop in the metastasis after a long time interval from the initial diagnosis and this time interval is significantly longer in the carcinomatous SM than that for the sarcomatous SM. Somatic-type malignancies in metastases are associated with a worse outcome, though in primary testicular tumors, they may not affect the prognosis. Carcinomatous somatic-type malignancy is likely associated with a worse prognosis than somatic-type sarcoma. For most patients, prompt complete surgical resection of the SM is an effective treatment option as it generally does not respond well to cisplatin-based chemotherapy for conventional germ cell tumors 1.
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