INTRODUCTION

Testicular tumours are the commonest malignancy in males between 20 and 40 years of age and account for approx 1% of cancers in male. They most commonly present as painless scrotal mass or dull ache and sensation of heaviness in the testis. It may present with widespread pulmonary or abdominal metastasis. In our case patient presented with DVT, which is an unusual presentation for testicular tumours. Although there was no clinical evidence of testicular involvement, however para aortic lymphadenopathy on CT scan and ultrasound abdomen raised the suspicion for testicular involvement.

CASE REPORT

A patient 25 years old male presented with complaints of pain abdomen off and on for the last 2 months. Then he noticed that his left leg was swollen and it was gradually increasing until he had severe pain and limitation of movements of left leg. On General physical and Systemic examination there was no positive findings except swelling of left leg. Clinically tests were normal. His ultrasound left leg was requested to rule out DVT, which showed deep vein thrombosis of left femoral vein. Right leg deep veins were normal. Because of the persistence of his symptoms CT scan was done after 2 weeks. His CT scan abdomen showed paraortic and paracaval lymphadenopathy (fig. 1). There was thrombosis of both femoral and iliac veins as well as inferior vena cava upto renal hilum. Slices of lower chest showed bilateral nodular soft tissue shadows suggesting evidence of metastasis. Ultrasound testes were performed to look for the cause of lymphadenopathy although there were no testicular complaints and clinical examination revealed no testicular mass. Ultrasound right testes showed illdefined hypoechoic area with a blob of calcification (fig. 2). His alpha-fetoproteins and beta HCG levels were raised. LDH, Protein C, Protein S and Antithrombin-III levels were within normal limits. His X-ray chest showed innumerable, well defined, rounded soft tissue density nodules scattered in whole chest due to metastasis (fig. 3). Right Orchiectomy was done and long spermatic cord was excised and tissue sent for histopathological examination which showed Embryonal cell carcinoma of right testes. He is being treated by Chemotherapy. Two courses have been given. There is marked regression of pulmonary metastasis (fig. 4).

DISCUSSION

95% of testicular neoplasms are germ cell in origin, 4% lymphomas and 1% includes metastasis, Leydig cell & Sertoli cell tumours. 50% of Germ cell tumours are pure Seminomas, which are less aggressive and present at 30-45 years of age. Remaining 50% are Non Seminomatous Germ Cell Tumours (NSGCT) [1]. They present in younger age group (peak 15-30 years); majority produce biochemical tumour markers like Beta HCG or Alpha Fetoproteins.

Risk factors include undescended testis, microlithiasis [2,3] testicular atrophy, previous testicular malignancy or low birth weight.

Sonography is the standard imaging technique used to identify testicular carcinoma. It has a high sensitivity, but it must be combined with physical examination to achieve the best specificity. Tumours are predominantly hypoechoic; occasionally there is associated hydrocele. Seminomas are well defined and uniformly hypoechoic. NSGCT show significant echogenic areas of fibrosis or calcification and echofree cystic areas.