Unilateral testicular seminoma with simultaneous contralateral torsion: a case report
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Testicular germ cell tumors are the most common malignancies in men. Testicular torsion is also a scrotal phenomenon seen in adolescence and adulthood. The co-occurrence of these two scrotal disorders is extremely rare.
A 28-year-old East Asian man presented at our hospital with painless bilateral scrotal swelling. Both scrotal ultrasonography and computed tomography findings showed bilateral testicular tumors, and magnetic resonance imaging demonstrated a lack of enhancement in his right testis, indicating a hemorrhagic infarction and a left testicular tumor. After a bilateral orchiectomy, the intraoperative and histopathological findings revealed a left seminoma with a complicating contralateral testicular torsion that had developed with hemorrhagic infarction.
Testicular germ cell tumor with contralateral torsion is extremely rare. We could differentiate this case from bilateral testicular tumors appropriately using magnetic resonance imaging, and suggest that magnetic resonance imaging examination may be necessary to diagnose bilateral testicular masses.
KeywordsSeminoma Testicular Tumor Testicular Germ Cell Tumor Testicular Torsion Left Testis
Testicular germ cell tumors (TGCTs) are the most common malignancies in men, including young adults, and their incidence has been increasing in almost all developed countries [1, 2]. Testicular torsion is also a scrotal phenomenon seen not only in adolescence, but also in adulthood . These two scrotal disorders can complicate each other, but cases in which each testis has each scrotal disease independently are extremely rare . In this report, we encountered a 28-year-old man presenting with a simultaneous seminoma and contralateral torsion. The scrotal disorders seemed to suggest bilateral TGCTs as a differential diagnosis, but corrective treatment was possible with the aid of magnetic resonance imaging (MRI).
Based on the preoperative diagnosis, a transverse scrotal incision was made to allow right scrotal exploration. Since inspection of his right testis revealed a necrotic testis with 270° intravaginal torsion of the spermatic cord, his right testis was removed. Left radical orchiectomy was then carried out.
The estimated incidence of testicular torsion in men is 4.5 per 100,000 , and the incidence of TGCT in men during their lifetime is 5.1 per 100,000 . TGCT with contralateral testicular torsion is still extremely rare. There have been some case reports of TGCT with ipsilateral testicular torsion, most detected after presenting with acute scrotal pain as a symptom of torsion. The causes of TGCT with developed torsion remain unclear, but there is a report that 96% of patients with testicular torsion have anatomical variations, such as bell clapper deformity and a long mesorchium . Srinivasan et al. reported that hyperactivity of the cremasteric reflex, stimulated by cold weather, has been postulated as the physiopathology of acute testicular torsion .
In general, the differential diagnosis to distinguish from bilateral TGCT is important because the intraoperative approaches, such as ligation of the spermatic cord and the site of incision, are significantly different depending on whether the testis is cancerous. In fact, the incidence of bilateral TGCT in patients with a TGCT has been reported as 1 to 3% , and patients with seminoma were especially at significantly higher risk for bilateral disease than those with a nonseminomatous germ cell tumor. In our patient, his right testis was diagnosed with hemorrhagic infarction with torsion by MRI, intraoperative and histopathological findings. Microscopic examination revealed markedly dilated vessels caused by torsion. These findings proved the diagnosis as a testicular infarction, not a tumor.
Most solid intratesticular masses should be considered malignant, and radical orchiectomy is the treatment of choice. To avoid unnecessary orchiectomy, however, it is extremely important to recognize the imaging features of various benign intratesticular mass lesions, including orchitis, hemorrhage, ischemia and infarction, fibrosis, and dilatation of the rete testis. Cohen et al. reported the first case of a testicular mixed germ cell tumor with contralateral testicular torsion . Although they mainly used a radionuclide scrotal scan to diagnose the torsion, it would not be useful for other scrotal disorders. Although Doppler ultrasonography and contrast-enhanced CT imaging are often used as diagnostic tools for acute scrotal disease, including torsion, inconclusive results may often be observed and their efficacy depends on the operator’s skill . Dynamic contrast-enhanced subtraction MRI could provide information about testicular perfusion and is useful to diagnose scrotal disorders . Diffusion-weighted MRI can also enable the detection of testicular torsion . Tsili et al. indicated that the sensitivity, specificity and accuracy of MRI in the diagnosis of malignant testicular tumors were 100%, 87.5% and 96.4%, respectively . The advantages of this technique include the acquisition of precise anatomic information, satisfactory tissue contrast, and imaging in various planes. MRI is an efficient diagnostic tool for the evaluation of testicular masses, especially in preoperative differentiation, as in our case. In addition, it is important to preserve postoperative fertility in patients with both unilateral and bilateral TGCTs. The most effective means of preserving fertility in these patients is sperm cryopreservation before the initiation of cancer-directed therapy . In this case, we could preserve his sperm before orchiectomy and avoid a hasty operation with useful findings from MRI.
This is an extremely rare report of a patient presenting with simultaneous right testicular torsion and left seminoma, which could be differentiated from bilateral TGCT by MRI. We believe that accurate examination using MRI is necessary to diagnose bilateral scrotal masses and evaluate the perioperative conditions to ensure the postoperative quality of life of patients.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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