History and Presentation: Testicular tumour
A 72-year-old man from Japan presented with right scrotum enlargement, for which the doctors gave a provisional diagnosis of testicular tumour. He had a history of appendectomy and inguinal hernia surgery. Moreover, he was a known case of diabetes, hypertension and benign prostatic hyperplasia for which he was taking medications. However, he did not have a family history of any disease and was vitally stable.
Examination and Investigations
On examination, the right testicle was hard to touch, with a size of 50 × 50 mm. However, the remaining examination was unremarkable. Additionally, neurological examination was also normal. The doctors sent baselines, which turned out to be normal. Moreover, his ultrasound revealed a mosaic shadow in the right testis, whereas the left testis showed no abnormal findings.
Chest CT scan demonstrated no signs of effusion. However, a CT scan of the testis revealed an enlarged para-aortic lymph node with evidence of contents in the right testis. There was no evidence of distant metastasis.
The TNM classification of the right testicular tumour was cT1, N1, M0, and S0. The clinical stage of the right testicular tumour was IIA. The size of the tumour was 55 × 45 × 40 mm3 and 63 g in weight. The surface was yellowish-white with bleeding.
Management: Testicular Tumour
The doctors performed an inguinal orchiectomy. They sent the removed tumour for histopathology, revealing a solid tumour confined to the testis, with distinct nucleoli and large nuclei, which was proliferating in a nest-like manner with some necrosis. The tumour was poorly differentiated with vascular infiltration of tumour cells. Immunohistochemistry of the tumour revealed that the cells were diffusely positive for SF-1 and Ki-67, partially positive for inhibin, and calretinin, and negative for CAM5.2, CK7, CK20, C-KIT, CD30, LCA, GATA-3, TTF-1, and PAX8. It did not extend into the tunica albuginea. The final diagnosis made on histopathology was a malignant unclassified sex cord-stromal testicular tumour.
After the removal of the tumour, the patient received four courses of postoperative chemotherapy with etoposide and cisplatin.
Moreover, after the chemotherapy regimen, the doctors ordered a CT scan again, which demonstrated the progression of the disease. Furthermore, there was an increase in the size of the pancreatic and lymph node metastasis. The doctors also noticed a new lesion in the lung. Therefore, they tested the genes for a new mutation so they could administer the drugs accordingly. However, no new mutation was found.
Due to the progression of the disease, the doctors offered the patient second-line chemotherapy with paclitaxel, ifosfamide, and cisplatin. The patient declined this new regimen, and therefore, was shifted to another nearby hospital. The patient passed away at this hospital due to the progression of cancer.
Testicular tumours are classified into germ cell tumours and sex cord-stromal tumours. Germ cell tumours account for the majority of these tumours. 10% of the sex cord-stromal tumours (SCST) are malignant.
Testicular tumours usually present with a lump, heaviness, pain and discomfort and back pain.
The risk factors for developing testicular cancer include family history and cryptorchidism. It is diagnosed based on history and clinical examination. Ultrasound, CT scan and X-rays can be used to determine the extent of the disease. However, the definitive diagnosis is based on a biopsy.
The management of SCSTs includes inguinal orchiectomy and it is diagnosed on histopathology. At the initial diagnosis of SCSTs, 20% of the cases are metastatic. In the rest of the cases, 40% become metastatic over the years.
The prognosis of SCSTs is poor as the tumour progresses rapidly. Therefore, it is essential to administer post-operative chemotherapy and radiotherapy.
Unclassified sex cord-stromal tumours are extremely rare. If the tumour is metastatic, it is essential to commence immediate intervention to prevent worsening the prognosis of the disease. Due to the scarce data for these tumours, the treatment regimen is often incorrectly administered with an incorrect diagnosis.