ISI Impact Factor (2004): 1.096

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Prof. Yi-Fei WANG,

Acute scrotum due to arterial bleeding mimicking non-seminomatous germ cell tumor

F. Christoph¹, M. Schrader¹, A. Amirmaki², K. Miller¹

Asian J Androl  2004 Dec; 6: 379-381       

Keywords: acute scrotum; hemorrhage; testicular cancer

Abstract

Men with testicular tumors usually present with painless increase in testis size incidentally noticed by the patient. We report a case of a young patient presenting as an emergency with acute onset of massive right-sided testicular pain without previous injury. After physical examination testicular torsion could not be excluded. Ultrasound examination of the testis was suspicious for testicular tumor. Surgical exploration of the right testis by inguinal approach was performed revealing subcapsular arterial bleeding due to a small nonseminomatous germ cell tumor non-palpable on clinical examination.

1 Introduction

The most common symptom of nonseminomatous germ cell tumor (NSGCT) is a painless increase in testicular size rarely accompanied by testicular inflammation or hydrocele due to tumor necrosis. As large tumors can be diagnosed easily during physical examination, non palpable small tumors may be missed easily and are usually detected as incidental findings during testicular ultrasound performed for other reasons. Herein we describe an unusual case of a NSGCT presenting as acute scrotum.

2 Case presentation and management

A 27-year-old male was referred to the emergency department with an acute severe right side scrotal pain and testicular swelling. Pain onset was immediately after voiding and a slight testicular swelling occurred within few seconds afterwards. The patient denied any previous injury or trauma, neither any palpable testicular mass nor testicular pain. A coagulation disorder could be excluded. Physical examination revealed an enlarged, firm right testis with epididymis and spermatic cord in the normal position. Ultrasound demonstrated normal echogenicity of the epididymis but a small inhomogenous echo texture in the middle of the right testis as well as a small hematoma in the upper testicular pole (Figure 1). Color doppler sonography displayed normal arterial flow in the epididymis with a decreased flow in the right testis. All findings were normal for the left testis. A possible inflammatory process of the epididymis or testis could be excluded. As a malignant tumor could not be excluded, surgical exploration was done using an inguinal approach. Exploration of the testis revealed a subcapsular hematoma. After its removal, a small (1 × 1 cm) testicular mass was palpable following tumor excision. Histopathology proved a nonseminomatous germ cell tumor 8 mm in diameter. High orchiectomy and biopsy from the contralateral testis was performed subsequently. Tumor classification was pT1 of a testicular choriocarcinoma without vascular invasion (Figure 2). Alpha-fetoprotein and beta-human chorionic gonadotropin from preoperative plasma were 2.19 ng/mL and 1 129 U/L, respectively. CT tumor staging did not reveal distant metastasis or lymphadenopathy in thorax or abdomen and the patient was discharged from hospital in good general condition on third postoperative day. Elevated beta-human chorionic gonadotropin was normalized three weeks after surgery.

Figure 1. Ultrasound of the right testis with hematoma at the upper pole (A) and tumor mass (B) at the lower pole.

Figure 2. Histology of non seminomatous germ cell tumor and hemorrhage.

3 Discussion

This is an unusual presentation of a testicular tumor presenting as acute scrotum. As common diagnosis for acute scrotum is testicular torsion, this typical urological emergency requires immediate surgery within 6 hours to prevent testicular atrophy. Usually the operation is easy with a small scrotal incision for exploration, surgical detorsion and fixation of the testis to preclude subsequent torsion; the procedure should be done on the contralateral testis as well. In the present case the testicular pain and swelling was most likely caused by a small tumor vessel that ruptured when the intraabdominal pressure was increased during voiding. According to the clinical and histopathological criteria this tumor was staged as a pT1 choriocarcinoma without vascular invasion and parent presenting clinical stage I disease. The presence of vascular invasion increases the possibility to develop retroperitoneal lymph node metastasis up to approximately 50 percent and nerve-sparing retroperitoneal lymph node dissection or two cycles of adjuvant PEB chemotherapy is recommended [1, 2]. Risk to develop tumor recurrence is low after adjuvant therapy with 3 percent compared to 48 percent without chemotherapy [3].

Amongst the few publications that report acute scrotum mimicking testicular tumor only one case has been published describing subcapsular hematoma secondary to a pT1 mature teratoma [4]. Other rare clinical presentations of acute scrotum mimicking testicular tumor include inflammation due to tumor necrosis from seminoma [5], testicular torsion of the contralateral testis [6] and testicular infarction [7].

Choriocarcinomas are well known for their tendency to bleed. Recent studies by Hatakeyama et al suspected that Trophinin, a beta-HCG mediated membrane protein, to be functionally correlated with higher malignancy of germ cell tumors, as Trophinin mediates homphilic cell adhesion [8]. Zygmunt et al mentioned in their study, that human beta-hCG secreting tumors promoted cellular motility and in vitro neovascularization and underlined the importance of beta-HCG as an unrecognized angiogenic factor [9]. We therefore suggest that testicular tumor cells expressing beta-hCG and identified as choriocarcinoma have the potential of either early vascular cell invasion or building of fragile vascular structures, which might explain their higher tendency for bleeding.

Initial ultrasonography in the acute scrotum may help to distinguish hemorrhage, inflammation and testicular mass, given the fact that 50 percent of pathologic findings are infectious diseases and only 9 percent classify as tumors [10].

This case presentation underlines the major role of ultrasound of the testis when patients are referred with acute scrotum. However, ultrasound does not provide reliable information to differentiate between benign and malign lesion but plays a decisive role to decide which therapeutic treatment has to follow. It also demonstrates the clinical variety malignancies of the testis can display, be it a painless scrotal swelling or an acute onset of severe pain.

References

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[7] Flanagan JJ, Fowler RC. Testicular infarction mimicking tumour on scrotal ultrasound - a potential pitfall. Clin Radiol 1995; 50: 49-50.
[8] Hatakeyama S, Ohyama C, Minagawa S, Inoue T, Kakinuma H, Kyan A, et al. Functional correlation of trophinin expression with the malignancy of testicular germ cell tumor. Cancer Res 2004; 64: 4257-62.
[9] Zygmunt M, Herr F, Keller-Schoenwetter S, Kunzi-Rapp K, Munstedt K, Rao CV, et al. Characterization of human chorionic gonadotropin as a novel angiogenic factor. J Clin Endocrinol Metab 2002; 87: 5290-6.
[10] Martin B, Conte J. Ultrasonography of the acute scrotum. J Clin Ultrasound 1987; 15: 37-44.

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Correspondence to: F. Christoph, M.D., Department of Urology, Charit? Universit鋞smedizin Berlin Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany.
E-mail: frank.christoph@charite.de
Received 2004-04-02    Accepted 2004-10-08