Health & Medical Kidney & Urinary System

A Case of Spermatic Cord Teratoma in Low-Stage Testicular Cancer

A Case of Spermatic Cord Teratoma in Low-Stage Testicular Cancer
Background: A 25-year-old male presented to his local urologist with new-onset right testicular pain and swelling detected on self examination. A scrotal ultrasound scan showed a right testicular mass, suspicious for neoplasm. Serum levels of α-fetoprotein and human chorionic gonadotropin were found to be elevated at 920.2µg/l and 637.4 U/l, respectively. The patient underwent right inguinal orchiectomy and was diagnosed with nonseminomatous germ cell tumor of the right testis, composed of yolk sac tumor, teratoma, and embryonal carcinoma with no evidence of metastatic disease. He opted to remain under surveillance rather than undergo primary chemotherapy or retroperitoneal lymph node dissection for his clinical stage I disease. Serologic relapse at 4 months after orchiectomy was successfully treated with bleomycin, etoposide and cisplatin (BEP) chemotherapy.
Investigations: Surveillance comprised regular clinic visits, measurement of serum levels of α-fetoprotein, human chorionic gonadotropin and lactate dehydrogenase, chest X-ray and CT of the abdomen and pelvis. Pathology of the testicular mass was reviewed.
Diagnosis: A 1.7 cm nodule anterior to the right psoas muscle suspicious for metastatic disease that was seen on CT 16 months after orchiectomy was pathologically confirmed as recurrent mature teratoma in the spermatic cord. Additionally, one of eleven interaortocaval lymph nodes showed evidence of teratoma.
Management: Bilateral nerve-sparing retroperitoneal lymph node dissection with complete excision of the right spermatic cord was performed. The patient has since remained disease-free, with normal levels of serum tumor markers and no evidence of metastasis on chest X-ray and abdominal CT.

A 25-year-old white male presented to his local urologist with new-onset testicular pain of 2 weeks' duration, and was noted on examination to have an enlarged right testicle. The remainder of his physical examination, medical history and surgical history were unremarkable. He had no history of cryptorchidism or genital trauma, and no family history of testicular cancer. A scrotal ultrasound scan performed on the day of presentation showed a solid intratesticular mass, which raised suspicion for testicular neoplasm. At presentation, levels of serum tumor markers were elevated: human chorionic gonadotrophin (hCG) level was 637.4 U/l (normal range < 5U/l) and α-fetoprotein (AFP) level was 920.2 µg/l (normal range 1–10 µg/l). The referring urologist opted not to measure serum lactate dehydrogenase (LDH) level at this time. As testicular neoplasm was suspected, right inguinal orchiectomy with high ligation of the spermatic cord was performed 2 weeks after the onset of symptoms. Histopathology showed a 7 cm mixed germ cell tumor comprising 60% yolk sac tumor, 30% teratoma and 10% embryonal carcinoma. The tumor was confined to the testis, without vascular invasion, and all margins (including the spermatic cord) were negative. CT of the chest, abdomen and pelvis showed no sign of metastatic disease. The patient was diagnosed with stage T1N0M0S1 nonseminomatous germ cell tumor (NSGCT) of the right testis.

At 6 weeks after orchiectomy, the patient's serum tumor marker levels had normalized to hCG <0.5 U/l, AFP 8.7 µg/l, and LDH 121 U/l (normal range 100–220 U/l). The patient opted to remain under surveillance with monthly measurement of serum tumor marker levels and chest X-rays, rather than undergo retroperitoneal lymph node dissection (RPLND) or primary chemotherapy. Four months after orchiectomy, his serum AFP level had increased to 24.8 µg/l; hCG and LDH levels had remained normal. He underwent three cycles of bleomycin, etoposide and cisplatin (BEP) chemotherapy for serologic relapse of low-risk disease. On completion of chemotherapy, the patient's serum tumor marker levels had normalized and CT of the abdomen and pelvis and chest X-ray remained negative for metastatic disease. He had one episode of febrile neutropenia, but otherwise experienced no adverse effects of chemotherapy.

The patient continued to do well; monthly measurements showed normal serum tumor marker levels, and quarterly imaging indicated remission. At 16 months after orchiectomy, a CT scan of the abdomen and pelvis revealed a 1.7 cm nodule anterior to the right psoas muscle (Figure 1). A bilateral nerve-sparing RPLND was performed 1 month later (Figure 2), which included complete excision of the spermatic cord from the origin of the testicular vein at the inferior vena cava to its distal extent in the proximal inguinal canal. Following an uncomplicated operative and postoperative course, the patient was discharged on the fourth day after surgery. His final pathology revealed a 2.2 cm mass in the right spermatic cord, consistent with mature teratoma, with negative margins and one of eleven interaortocaval lymph nodes positive for mature teratoma. The remainder of the para-aortic and paracaval nodes were negative for cancer. Seven months after RPLND, the patient was doing well with normal serum tumor marker levels. He has continued to receive follow-up with quarterly measurement of serum tumor marker levels and chest X-rays, as well as twice-yearly abdominal CT scans.


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CT scan of the patient's abdomen 16 months after orchiectomy. A 1.7 cm mass (arrow) superior to the right psoas muscle can be seen.


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Intraoperative view of the retroperitoneal lymph node dissection. The image shows spermatic cord metastasis (white arrow) and interaortocaval metastasis (black arrow)

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