Case Report
Seminoma in Retroperitoneal Undescended Testis
Doğan Öztürk*, Hakan Bulus and Alper Yavuz
Department of General Surgery, Kecioren Training and Research Hospital, Ankara, Turkey
*Corresponding author: Doğan Öztürk, Department of General Surgery, Kecioren Training and Research Hospital, Ankara, Turkey
Published: 20 Aug, 2018
Cite this article as: Öztürk D, Bulus H, Yavuz A. Seminoma
in Retroperitoneal Undescended Testis.
Clin Surg. 2018; 3: 2083.
Abstract
A testicular carcinoma in retroperitoneal undescended testis can mimic other mesenteric or
retroperitoneal mass. The role of cryptorchidism in testicular carcinogenesis has been of concern
for many physicians for quite a long time. The probability of a malignant neoplasm developing
in an undescended testicle is about 20 to 48 times greater than a normally descended testicle. The
identification of pampiniform plexus draining the mass can play an important role in diagnosis
of testicular carcinoma in undescended testis. The pathological diagnosis of the tumor was pure
seminoma as showed. We report a case of seminoma in retroperitoneal undescended testis,
draining into pampiniform plexus and thrombus within it. 44 years old male, admitted to the
emergency department for left lower quadrant pain who was diagnosed seminoma originating in
an undescended testis.
Keywords: Undescended testis; Seminoma; Carcinoma
Introduction
Retroperitoneal undescended testis carcinoma can be misdiagnosed as mesenteric or retroperitoneal masses. Furthermore, undescended testicles are risk factors for testicular cancer, especially for development of seminoma. While seminoma comprises 30% to 40% of testicular cancer in normal testicles, this rate is 60% in undescended testicles [1]. Undescended testicles are usually located in the distal part of the external inguinal ring and are usually palpable. Non-palpable undescended testicles are typically located in the inguinal canal, but in some cases they can be located intra-abdominally. The relative risk of tumor development in undescended testicles is 4 -7,5 fold higher than normal according to the literature [2,3]. The risk of cancer development is closely related to the position of the testis and intra-abdominally located testicles have the highest potential for malignancy [4]. Non-seminomatous germ cell tumors are less frequently seen. Demonstration of the mass being drained by the pampiniform plexus plays an important role in diagnosing testicular cancer for undescended testis. Unilateral dilation of the pampiniform plexus and development of venous thrombosis is important in the diagnosis of testicular cancer in undescended testis. This is defined as the vascular pedicle sign. We have hereby reported a 44-year-old male patient who had a wide, solid, retroperitoneal undescended testis seminoma displacing the neighbouring tissues, which was demonstrated on Computed Tomography (CT).
Case Presentation
A 44-year- old male patient presented to the emergency department with right and left lower quadrant pain. It was learnt that he had dysuria along with consistent pain. On physical examination, he had tenderness in the left lower quadrant but no rebound. An intra-abdominal mass was not detected on palpation. On scrotal examination, it was found that his left testis was not in the scrotum, but the right testis was in its normal location. The mass was considered to be a tumor originating from the left testis. On ultrasonographic evaluation, a smooth and heterogenous solid mass lesion of 74 mm x 70 mm size was detected in the superior contiguity of the bladder and compressing the bladder from the superior. On Doppler ultrasonographic evaluation, a significant vascularity was detected in the lesion. A smooth, hypodense mass lesion with intense homogenous content and 67 mm x 75 mm x 50 mm size located between the mesenteric layers neighbouring the superior part of the bladder was detected on abdominal Computed Tomography (CT) (Figure 1). No pathological finding was detected on chest X-ray. Laboratory findings were normal except for mild leucocytosis. Considering a tumor originating from his left undescended testis, an operation was planned for the mass. The abdomen was explored through an infraumbilical midline incision. A space occupying lesion with thick walls was detected, which was approximately 9 cm in diameter, located in the left of midline in the entrance of the pelvis, and pushing the sigmoid towards the right and anterior (Figure 2). Paraaortic, paracaval and mesenteric lymphadenopathies were not detected. The mass was excised by devascularizing from the neighbouring tissues. On pathological examination, a seminoma was seen, displaying a nodular growing pattern, including widespread areas with hemorrhage and necrosis (Figure 3).
Figure 1
Figure 2
Discussion
Retroperitoneal seminoma is a very rare disease of the testis [5].
Seminoma cases located in the retroperitoneum, mediastinum and
thymus have been reported in literature. Extratesticular seminoma
is considered to go through neoplastic formation during the
migration of primordial germ cells to the scrotum from the yolk sac
endoderm [6-8]. Undescended testis can be seen at any site during the
development of the testis beginning from the lower pole of the kidney
to the external ring. Approximately 66% of undescended testicles are
located in the distal of the external inguinal ring, 16% in the inguinal
canal, and 10% in the intra-abdominal location. Moreover, the
location cannot be found surgically in 3% of undescended testis cases
[9]. Development of malignancy in undescended testis is a commonly
discussed subject. In these patients, development of cancer is seen
in the 3 and 4 decades independently from the cancer location and
interventions, as in normal testicles. In our case, the patient was in
the 4 decade when he was diagnosed [10]. Prevalance of malignancy
varies between 3.5% and 14.5% in undescended testes [11]. The ages
in which the tumor is most prevalent, and the histological distribution
of the tumor are similar to those in scrotal testes. The most prevalent
tumor is seminoma. This is the type especially seen in cases located
intra-abdominally. The other histological types of the tumor are
embryonic cell carcinoma, teratocarcinoma and choriocarcinoma
[9]. In our case, the specimen was analysed histopathologically
and it was reported as seminoma. The reason for the increased risk
of malignancy is that orchioectomy is performed after puberty in
patients with undescended testes [12]. When our patient presented
to the emergency room with the complaint of abdominal pain, his left
testis was not found in scrotum on the urogenital examination and it
was seen that he had a retroperitoneal mass. Thus, his operation could
be performed after puberty. Clinical manifestations of seminoma
developing in undescended testes have significant variations. It can
present with abdominal pain or symptoms related to the mass effect,
while it can be asymptomatic. Furthermore, weight loss, constipation,
and edema of lower extremities can be seen. In the differential
diagnosis, it can be misdignosed as apppendicitis or other masses that
can form retroperitoneal masses [12]. In our case, an abdominal mass
was not found on the physical examination, despite the presence of
abdominal pain, weight loss and some non-specific findings.
Findings of metastases can be seen on chest X-ray in cases
with extracellular seminomas. Intravenous pyelography and
lymphangiography have been formerly used in the differential
diagnosis, but they are not currently used. Computed tomography,
which is used for determination of paraaortic lymph nodes, masses,
locations and relations to neighbouring tissues, is still used for the
diagnosis today. In our case, location of the mass and relationship
with paraaortic lymph nodes were visualised on CT performed
preoperatively [11,13]. The tumor size can be large when it is first
detected if the symptoms are obscure and if the patient does not state
that his testis is not in the scrotum. In our case, it was understood
on the physical examination that his left testis was not in the
scrotum, although he did not state that he had an undescended
testis. Furthermore, in the preoperative period, mesenteric or
retroperitoneal sarcoma, lymphoma or lymphadenopathies related
to metastases must be taken into consideration in the differential
diagnosis of this case [11,14]. Testicular vascular pedicle consists
of vessels feeding and draining the testis [13]. In its developmental
period, the testes pass through the inguinal canal with vascular, neural
and ductal contents in the course of descent [15]. If testicular descent
is interrupted in fetal life, the pampiniform plexus and the testicular
vein would drain the undescended testes. Testicular angiography has
been used as the most common study in the diagnosis of undescended
testis for years. The presence and location of the testis can be known
if the pampiniform plexus can be visualised by venography. Similarly,
the display of the pampiniform plexus consisting of many parallel
veins should be shown on CT in order to indicate the location of
the undescended testis, in addition to the pelvic mass caused by the
undescended testis. Radiologists can interpret the findings as dilated
vascular structures draining the mass on optimally contrasted thin
section CT [16]. Thrombosis can develop in the inferior vena cava,
renal vein or testicular vein due to the slow flow developing as
a result of pressure exerted by the tumor or direct invasion of the
testicular cancer [17]. No filling defect due to thrombus developed in
the pampiniform plexus in our patient. On pathological evaluation,
tumor emboli were reported in the vessels just beneath the tunica
albuginea and in the periphery.
Figure 3
Conclusion
In conclusion, showing the absence of the spermatic cord in the ipsilateral inguinal canal and presence of the pampiniform plexus draining the mass is helpful in the determination of intra-abdominal undescended testis tumor.
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