Abstract

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Testicular cancer is the most common cancer in men 15 TO 35 years old. Cryptorchidism is a major factor of testicular cancer.

We report a case of a young men having a giant abdominal mass secondary to an ectopic right testicle.

We decided to do debulking surgery ;in order to reduce the size of the tumor ;we could remove approximatly 90% of the tumor volume ; then we sent the patient to the oncological department for further chemotherapy.

Introduction

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Testicular cancer is the most common cancer in men 15 to 35 years old. Histological subtypes are seminoma, non-seminoma and mixed tumours (partly seminoma and partly non-seminoma).

Cryptorchidism is a major factor of testicular cancer.

We report  in this article an interesting clinical case of a young men having a giant abdominal mass  secondary to a seminomatous testicular cancer;

We review also the epidemiological and historical data of the classic association between undescendent testes and testes cancer.

Case Report

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A18 year old patient consulted our department for chronic abdominal pain  with  the appearance of an abdominal mass increasing progressively in volume for 8 months.

According to the patient  there are no associated abdominal or urinary complaints.

Clinical examination revealed an enormous fix and tough  abdominal mass ; measuring 30 cm in diameter and taking the whole abdomen .

Genital examination revealed an epispadias and both scrotums were empty ;we couldn t palpate the left testicle ;however we found a small right undescended testicle over the superficial inguinal pouch.

An abdominal CT SCAN(fig1-2) was done demonstrating a tissular abdominal mass measuring 62 cm ;taking lightly the contrast and countaining some fine calcifications.

Biological analyses ;mainly Tumor markers(fig:3)  has revealed a too high levels of alpha feto protein (39310ng/ml ) ;LDH(605U/l);and a normal rate of betaHCG(55MUI/ml). Testosterone level was low and spermogram analysis revealed an AZOOSPERMIA.

Before starting adjuvant chemotherapy we voted for a primary debulking surgery. The inspection of the abdomen was enabled by xyphopubien laparotomy. We found an enormous mass wich is sticked to the rectal muscle ;to the large gastric curbature ;to the 3rd duodenal segment ;to the sigmoid and even to the anterior wall of the urinary bladder.

We have removed nearly more than 90% of the initial tumor volume (fig 4) and lastly through the same incision we have done a right orchidectomy. The histological examination of the operative specimen was in favour of a pur seminoma. The right testicle was atrophique and contains some fibroinflammatory remnants. Then the patient was sent to the oncological department to start chemotherapy treatment.

Discussion

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Testicular germ cell tumors represent only about 1% - 2% of all human malignant tumors ; however they are the most common malignancies in young adult men.

The vast majority of patients with disseminated germ cell tumors are curable .

Likely to according to a meta –analysis of the risk of boys with isolated cryptorchidism developing testicular cancer in later life done by lip and al ; boys with isolated cryptorchidism are three times more to develop testicular cancer.[2]

Another study done by Hadley m and all showed that secondary  to the higher risk of malignancy in cryptorchid testes  Orchiectomy may be considered in healthy patients with cryptorchidism who are between ages 12 and 50 years.[3]

All this facts defend our thinking in removing for our patient his right undescendent testes. Debulking of tumors is a procedure whereby a surgically incurable malignant neoplasm is partially removed without curative intent in order to make subsequent therapy with drugs, radiation or other adjunctive measures more effective and, thereby, improve the length of survival.

Debulking has been advocated for carcinoma of the testis and ovary, a subtype of lymphoma, sarcoma, renal cell carcinoma, adrenal and other endocrine-related tumors, neoplasms of the central nervous system and other miscellaneous tumors.

Nonrandomized data indicate that surgical debulking is rarely indicated; however, complete resection of all gross disease following intensive chemotherapy is indicated for advanced carcinoma of the testis.

Complete or nearly complete resection of all gross disease prior to chemotherapy is indicated for advanced carcinoma of the ovary and possibly for Burkitt's lymphoma. Prospective randomized studies of all three of these malignant conditions would be appropriate, and an evaluation of preoperative intensive chemotherapy [1]

For our patient we removed 90% of the mass ;and we sent him to the oncological institute for adjuvant induction therapy in order to remove the remaining pathological tissu.

The role of cytoreductive surgery in testicular cancer has shifted from one of primary therapy to one of an adjunct to chemotherapy. In this setting, surgery restages the disease. It provides therapeutic benefit to many and determines the need for additional chemotherapy. Because of the heterogeneity of the tissue in the retroperitoneum, a thorough dissection is needed to reassess the patient adequately. Thoroughness is especially important in the case of teratoma. If active carcinoma is found in it, additional salvage chemotherapy is usually required. If teratoma without carcinoma is present, careful observation is required because of the propensity for local or distent later recurrence.[4]

The role of further chemotherapy in this group is not well defined. If neither carcinoma nor teratoma is present, the patient can be observed, because there is only a small likelihood of recurrence.

For our patient the histological type of the disease was seminoma ;and according to litterature they are more common in UDT in the addomen than those in inguinal region and chemotherapy is considered as  the primary treatment for such histological type of germ cell tumors [5] ; that s why our patient was sent to oncological department for further  therapy in order to destroy the remaining mass.

Conclusion

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Debulking surgery associated to intensive chemotherapy for testicular cancer helps the patient to obtain all his chances to get cured from his disease.During debulking surgery we shouldn t remove the whole mass when impossible ;but we should remove the majority of the tumor in order to enable chemotherapy to attack the remaining carcinological tissue.

References

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1. A meta –analysis of the risk of boys with isolated cryptorchidism developping testicular cancer in later life by [ lip sz ;murchison le ;cullis ps]
2. Cryptorchidism and testicular cancer :separating fact from fiction by [hadley m ;wood and jack s
3. Accelerated growth of testicular cancer after cytoreductive surgery by [paul h ;lange md ;kiumars hekmat md]
4. Cytoreductive surgery in testicular cancer by randullg ;rowland and john p ;donohue [journal of urology]
5. Chemotherapy for seminoma by [h.dumez and a.van oosteron]

Authors Contributions

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All Authors have Contributed in Writing This case Report

Source(s) of Funding

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This Case Report have been done during my studies in the Department of Urology B At Avicenne University Hospital. Rabat. Morocco

Competing Interests

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Authors Declare No Competing Interest