Seminoma in atrophic testis (report of 3 cases with review of literature).
Testicular tumours are common in day-to-day practice. The incidence of malignancy in the imperfectly descended testis as compared to the normal testis varies from 9 to 30%. But in all such, cases, the presentation is in the form of a tumour mass or its secondary manifestations. We report below 3 cases of seminoma of the testis in which the affected testis was atrophic but produced clinically detectable secondary metastasic deposits.
A 35 year old Hindu male was admitted with pain in the lower abdomen of 6 months' duration and a lump at the same site for the past 15 days. On examination, the patient was found to have bilateral undescended testes with a rudimentary scrotum [Fig. 1]. This patient had a 2 year old female child. Patients abdominal examination revealed a fixed intra-abdominal mass, 6" x 6" in size, in the hypogastrium. It was smooth with rounded margins, firm to hard in consistency and slightly mobile from side to side. No other lymph nodes were palpable in the abdomen.
In the inguinal canal, no testes could be felt on per rectal examination but the growth could by bimanually felt outside the rectum.
His investigations revealed the haemoglobin to be 10 gm%, ESR 32 mm in the first hour (Westergren), blood urea 28 mg% and serum creatinine 8 mg%. Urine and stool analysis was normal. His X-ray chest did not reveal any secondaries. His semen analysis revealed azoospermia.
On exploratory laparotomy, the left-sided testis was found to be intra-abdominal and measured 11 x 8 x 4.5 cm. It was adherent to the surrounding structures. It was dissected out by blunt dissection in toto. On the right side, a small nodule was seen deeper to the deep inguinal ring which was also removed (supposed to be the right atrophic testis). The histopathological examination revealed a seminoma of the testis of the left side and tumour cellularity of seminoma without any normal testicular tissue on the right side [Fig. 2].
Post-operatively, the patient was given a course of radiotherapy. He is recurrence-free till date even after about a year.
A 40 year old Hindu male presented with complaints of pain in the chest and upper abdomen of 2 months' duration. There was no history of fever or hemoptysis but the patient had some weight loss. The patent had 4 children, the youngest being 6 years old. The patient has been vasectomised 4 years earlier.
Routine investigations of blood, urine and stool were within normal limits with blood urea of 47 mg%., blood sugar 87 mg% and serum creatinine of 3.7 mg%. His X-ray chest revealed canon ball secondaries in both the lung fields.
The patient was found to be anemic and was of average built. His general examination showed palpable Virchow's glands. No other lymph nodes were palpable. Oedema of feet was absent. The chest examination showed presence of bilateral, coarse crepitations. The abdominal examination indicated fixed para aortic glands which were hard and nodular. The liver and spleen were not palpable and there was no ascitic fluid. Scrotal examination revealed the presence of atrophic but hard testis in the right hemiscrotum with loss of testicular sensation. The left-sided testis was normal except for its larger size. Per rectal examination was normal.
With a provisional diagnosis of a testicular tumour on the right side, a retrograde orchidectomy was done. A biopsy was also taken from the left testis.
On gross examination, the right-sided testis was about 1 x 1 cm in size, smooth and firm to hard in consistency. Its cut section showed a greyish white area with a homogenous surface. Its histopathology proved the presence of a seminoma and nodular Leydig cell hyperplasia in the right-sided atrophic testis and hypospermatogenesis in the left testis.
Post-operatively, the patient received a full course of chemotherapeutic drugs but was later lost to follow-up.
A 40 year old Hindu male presented with constipation and a lump in the upper abdomen of about a year's duration. Previously, the patient was treated for chronic cough in a distric T.B. hospital and then referred to the surgical specialist to exclude secondaries in the lungs.
On examination, the patient was found to be of average built and anemic. He was not jaundiced and had no oedema of the feet. The vital parameters were within normal limits. Examination of the abdomen revealed a fixed hard, nodular mass in the epigastrium with ill-defined margins. The liver and spleen were not palpable. There was no ascitic fluid. The hernial sites were normal. The right hemiscrotum was poorly developed. In the lower part of the inguinal canal, a small nodule was felt which was firm to hard in consistency with well-defined margins and measured about 0.5 x 0.5 cm. The left hemiscrotum contained normal testis with hydrocele.
Routine blood, urine and stool examination was normal. Blood urea was 35 mg%, serum creatinine, 0.9 mg% and the fasting blood sugar, 95 mg%. The liver function tests were within normal limits. The X-ray chest in the PA view revealed prominent broncho-vascular markings with a few, small, discrete, rounded shadows.
With a provisional diagnosis of a testicular tumour in the undescended atrophic testis on the right side, a retrograde orchidectomy was performed. On the left side also, the testis was explored but it was found normal with vaginal hydrocele. A biopsy was taken from the testis. Exploratory laparotomy was also done and a biopsy of the para-aortic lymph nodes was taken.
On gross examination, the right-sided testis was 1 x 1 cm in size, hard, and elongated; its cut surface revealed greyish white streaks. Histopathology of the specimen showed presence of a seminoma in the right atrophic testis and its deposits in the para-aortic lymph glands. The left-sided testis showed normal spermatogenesis.
Post-operatively, the patient had normal recovery; he was then subjected to radiotherapy. The para-aortic secondaries subsided significantly. The patient had no recurrence and has been symptom-free for the past 2 years.
A varying incidence of malignant change from 9 to 30% in an imperfectly descended testis has been reported by many workers.,,,, Bilateral testicular neoplasms are also sometimes encountered, the incidence of which is increased in cryptorchids and intersexuals. In A series of 7000 cases of testicular tumours, Hamilton and Gilbert found 142 cases of bilateral testicular neoplasms. Of these, 23 had bilateral ectopic testes. Similarly, Goel and Samuel reported bilateral seminoma in a male pseudohermaphrodite. In the present series also, one patient (Case 1) with bilateral, undescended testes had bilateral testicular seminoma. On the left side, the seminoma was intra-abdominal and of a big size but the right-sided atrophic testis in the inguinal canal revealed tumour cellularity of seminoma. Remaining two cases also had seminoma in an atrophic testis.
This phenomenon of a malignant change in an atrophic testis is rare and its relationship is controversial. The incidence of tumour is as high in the descended atrophic testis as in the cryptorchid testis. Dean and Melicow stated that seminoma is particularly prone to develop in the atrophic testis. In the present series, one atrophic testis was normally descended and two were undescended but all had pure seminoma.
Gilbert reported 0.5% incidence of malignancy following atrophy of testes due to mumps; in the present series, none had any history of mumps. One of our patients (Case 2) was vasectomised 4 years earlier but its role in the development of malignancy is not predictable.
Contrary to the atrophic testes, abdominal metastasis due to seminomatous deposits in a patient with bilateral normal testes has been reported by Azzopardi and Hoffbrand, with the explanation that either the metastsases began from a small tumour in the testis which then healed or the metastases were due to remnants of a testicular blastoma remaining at the site of primitive gonadal ridge.