CASE REPORT
TESTICULAR METASTASIS FROM GASTRIC CARCINOMA HASAN A. R. QAZI, RAMASWAMY MANIKANDAN, CHRISTOPHER S. FOSTER, AND MARK V. FORDHAM
ABSTRACT Secondary neoplasms of the testis have been reported with an incidence of 0.02% to 2.5% on autopsy. Other than leukemias and lymphomas, the most common sites from which metastases occur are the lung and prostate gland. We report the case of a 58-year-old patient, recently diagnosed with gastric carcinoma, who presented with swelling and discomfort of the left testis. An ultrasound scan of the scrotum suggested a malignant mass. Orchiectomy was performed, and the subsequent pathologic examination revealed the mass to be a gastric carcinoma metastasis that appeared to mimic a testicular primary clinically. UROLOGY 68: 890.e7–890.e8, 2006. © 2006 Elsevier Inc.
G
astric carcinoma is the second most common cause of cancer-related death worldwide. It metastasizes principally by way of the lymphatics, along the celiac axis and to a minor degree along the splenic, suprapancreatic, porta hepatis, and gastroduodenal nodal groups. The testis is a rare site of metastasis from a gastric carcinoma. A testicular secondary may present as a lump, mimicking a primary tumor of the testis. We report a man diagnosed with gastric carcinoma 2 months previously who presented with a testicular lump found to be a metastasis from the gastric primary. CASE REPORT A 58-year-old man diagnosed with gastric adenocarcinoma presented with a sensation of heaviness and swelling of the left testis. Examination revealed a moderate hydrocele on the left side, with the testis impalpable. Ultrasonography revealed a 9-cm mass in the left testis, with numerous fronds surrounded by the hydrocele (Fig. 1). The scrotal wall contained nodular deposits. These appearances were consistent with a testicular tumor. The beta-human chorionic gonadotropin and alphafetoprotein levels were within normal limits. Two months earlier, the patient had undergone investigation for anorexia and vomiting. Gastroscopy had From the Departments of Urology and Pathology, Royal Liverpool University Hospital, Liverpool, United Kingdom Address for correspondence: Ramaswamy Manikandan, M.R.C.S., 15 Langtree Close, Ellenbrook, Manchester M28 7XT, United Kingdom. E-mail:
[email protected] Submitted: January 20, 2006, accepted (with revisions): April 25, 2006 © 2006 ELSEVIER INC. ALL RIGHTS RESERVED
FIGURE 1. Ultrasound scan of left testis showing tumor, hydrocele, and small testis. N ⫽ tumor nodule.
revealed an extensive gastric carcinoma. Histologic examination had confirmed this to be an adenocarcinoma, and computed tomography had revealed ascites and paraaortic lymphadenopathy. After consultation with the patient, radical orchiectomy was performed to establish the origin of this neoplasm. Macroscopically, the right testis contained a large neoplasm, with frond-like growths projecting into a cystic area and multiple nodules involving the spermatic cord (Fig. 2). Microscopy revealed extensive infiltrates of a poorly differentiated adenocarcinoma involving the testicular interstitium, tunica albuginea, paratesticular tissue, and spermatic cord (Fig. 3). These features suggested a metastatic mucinous adenocarcinoma, in keeping with an origin from the patient’s gastric carcinoma. 0090-4295/06/$32.00 doi:10.1016/j.urology.2006.04.025 890.e7
FIGURE 2. Gross specimen of testis showing multiple metastatic tumor nodules involving testis and spermatic cord.
COMMENT The incidence on biopsy of secondary neoplasms of the genitourinary tract is low at 2.3% for bladder neoplasms, 3% for renal neoplasms, and 0.02% to 2.5% for testicular neoplasms.1 Only about 200 cases of testicular metastases have been reported. Testicular secondaries most commonly arise from the prostate, lungs, and the colon, and rarely from the stomach, kidneys, ureters, and malignant melanoma.2 In addition to the lymphatic and vascular routes, several routes of metastasis to the testis have been postulated. These include retrograde extension through the vas deferens, through its lumen, the lymphatic channels in its wall, or as transperitoneal seeding along a patent tunica vaginalis.3 Differentiating between primary and secondary neoplasms is important but may be difficult clinically. Ultrasonography is the imaging modality of choice and may help clinch the diagnosis of a secondary tumor, especially in the presence of nodules and a recent diagnosis of another primary cancer. Orchiectomy followed by histopathologic examination
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FIGURE 3. Histopathologic examination revealed signet ring cancer cells typical of gastric carcinoma origin. Mitotic figures are plentiful. Hematoxylin-eosin, original magnification ⫻440.
remains the definitive method of diagnosis. The prognosis eventually depends on the primary malignancy and is often worse with secondary neoplasms, because testicular primary neoplasms are frequently chemosensitive and may be cured, even at an advanced stage. The differential diagnosis for nodules in the tunica with a hydrocele includes malignant mesothelioma, adenocarcinoma of the rete testis, and serous carcinoma. REFERENCES 1. Dutt N, Bates AW, and Baithun SI: Secondary neoplasms of the male genital tract with different patterns of involvement in adults and children. Histopathology 37: 323–331, 2000. 2. Patel SR, Richardson RL, and Kvols L: Metastatic cancer to the testes: a report of 20 cases and a review of the literature. J Urol 142: 1003–1005, 1989. 3. Jesus Carlos MN, Goldberg J, Camargo JLV: Single testicular metastasis mimicking primary testicular neoplasm: a rare manifestation of prostate cancer. Int Braz J Urol 35: 54 – 56, 2005.
UROLOGY 68 (4), 2006
