MATURE TESTICULAR TERATOMA IN PEDIATRIC PATIENT: A CASE REPORT

Objective: To report our experience on management of testicular teratoma in pediatric patient. Case(s) presentation: A 2-years-old boy presented with progressive mass in his left testis. The mass was found 3 months ago but became larger in a few days. The patient had no other genitourinary complaint. Vital signs were within normal limits. A hard and tender mass in the left scrotum sized 5x4x2.5 cm was palpated from the physical examination. An imaging study with Computed Tomography (CT) Scan revealed an enhancement in the left scrotum mass area. There was no ring enhancement in pelvic and paraaortic lymph nodes. The laboratory examination within normal limit. Inguinal radical orchiectomy was performed, and histopathological examination revealed a mature testicular teratoma of the left testis. Discussion: Testicular teratoma in children is usually benign. Testicular germ cell tumors generally have a good prognosis with current therapy. Post-orchiectomy management depends on the histology type, staging, and tumor markers. Conclusion: Testicular teratoma is a rare case and can cause minimal symptoms until it grows significantly. Testicular teratoma should be considered in the differential diagnosis of non-traumatic painless progressive scrotal mass. Inguinal radical orchiectomy may be considered as the primary management.

Extramedullary Acute Myeloid Leukemia: Testicular Myeloid Leukemia, Leukemia Cutis with Leptomeningeal Involvement

Extramedullary Acute Myeloid Leukemia: Testicular myeloid leukemia, leukemia cutis with leptomeningeal involvement Z Saeed, H Aslam, A Weil, M Muzaffar Myeloid sarcoma also called granulocytic sarcoma, myeloblastoma, or chloroma is an extramedullary tumor of immature granulocytic cells. Extramedullary soft tissue manifestations are relatively rare in hematological malignancies. One of the rarest manifestations is myeloid sarcoma (MS). MS develops as part of acute myeloid leukemia, myeloproliferative neoplasm, or myelodysplastic syndrome or at relapse, especially following allogeneic hematopoietic stem cell transplant. Demographically, it has a slight male predominance with a male to female ratio of 1.2: 1. It may occur at any age and any site in the body leading to varied clinical presentations. The most reported sites are lymph nodes, skin and soft tissues, bone, testes, gastrointestinal tract, and peritoneum. 44 year old male with past medical history of diabetes mellitus type 2 and morbid obesity presented with right testicular pain and swelling and underwent radical orchiectomy. Pathology reported seminoma and received adjuvant Carboplatin for pT3 disease. He developed left testicular pain and swelling 2 months later and underwent left radical orchiectomy. Pathology reported CD4+, CD56+ high grade hematopoietic neoplasm. It was sent for second opinion to NIH and was consistent with myeloid sarcoma with monoblastic features. Repeat evaluation of right testicular specimen was CD45+. Bone marrow biopsy showed normocellular marrow with multilineage hematopoiesis. PET scan showed hyper metabolic activity in the right hemi scrotum, widespread osseous areas of increased uptake and 3 soft tissue nodules within the subcutaneous tissues of the left abdominal wall. FNA of the subcutaneous nodule showed CD56 positive monocytoid cells. Induction chemotherapy with 7+3 (cytarabine 200 mg/m2, daunorubicin 60mg/m2) with gemtuzumab 3mg/m2 on day 1, 4, 7 was completed. Cerebrospinal fluid studies (CSF) showed monoblastic/monocytic proliferation and received intrathecal (IT) chemotherapy alternating between methotrexate and cytarabine every week. CSF studies were cleared after 2 IT chemotherapy. Patient remained in the hospital for 87 days due to poor count recovery and development of pulmonary embolism. Myeloid mutation screening identified a mutation in NRASG13D. Repeat PET scan showed 7 areas of hypermetabolic foci involving nodular densities of bilateral lower anterior abdominal wall. One of the lesion was biopsied that was negative. He completed 2 cycles of high dose cytarabine for consolidation but had repeated hospital admissions and therapy was switched to azacytidine and venetoclax. Patient was evaluated by bone marrow transplant team. He had disease progression at tenth month when he presented with severe back pain and lower extremity weakness. MRI brain and spine showed new patchy T2 hyperintense signal in the right frontal white matter, increased number and size of marrow replacing lesions throughout the visualized skeleton. Patient underwent bone biopsy that showed >90% marrow involvement (sheets of infiltrative cells with identical phenotype. Positive for CD56 (>90% of marrow cellularity), CD4 and lysozyme. Hospital course was complicated with renal failure, electrolytes imbalance and hemodynamically instability requiring vasopressor support. Discussions were held for re-induction with CLAG (cladribine 5mg/m2, and cytarabine 2gm/m2) vs best supportive care. Patient decided to pursue comfort care and passed away peacefully. The uniqueness of this case is the myeloid sarcoma of testes as initial presentation with normal bone marrow. Misdiagnosis is not uncommon and can delay the appropriate treatment. Extra medullary involvement from leukemia is very aggressive and needs high suspicious and prompt treatment. Systemic chemotherapy using AML-like regimens should be commenced early, even in non leukemic disease. Allogeneic hematopoietic stem cell transplantation has demonstrated promising results, particularly in patients who achieved complete remission with AML-induction protocols, and recent advances in genetic profiling may enable the development of novel targeted therapies. Prospective multicenter controlled trials are required to further refine management decisions and investigate the role of novel targeted therapies. Disclosures No relevant conflicts of interest to declare.

Malignant Mixed Germ Cell Tumor of the Testis with Associated Nephroblastoma: A Rare Entity

Introduction/Objective While nephroblastoma is the most common primary childhood renal malignancy, it rarely occurs at extra-renal sites. Testicular nephroblastoma is exceedingly rare, with only 5 previously reported cases arising in association with primary testicular teratoma (4 of which arising in non-atrophic, and 1 arising in atrophic testis). We report a case of testicular nephroblastoma with multiple associated germ cell components. Methods/Case Report The case is that of a 28-year-old male presenting with an enlarging, painless right scrotal swelling. Laboratory results showed elevated serum AFP with normal LDH and beta-HCG, and imaging confirmed the presence of a heterogenous testicular mass. A radical orchiectomy was performed, revealing a tan-white, fleshy, nodular 5.5 cm mass almost entirely replacing the testicular parenchyma. Microscopically, the tumor consisted of multiple components. The nephroblastoma component was associated with teratoma with immature elements and consisted of epithelial tubular structures, small blue blastemal cells, and pale mesenchymal stroma which demonstrated pan-cytokeratin and patchy WT1 expression by immunohistochemistry. Additional components included yolk sac tumor and minor component of seminoma. Foci of germ cell neoplasia in-situ were also identified, supported by immunohistochemical stains for PLAP and OCT3/4. The patient’s post-resection tumor markers normalized, and further assessment for metastasis and chemotherapy is pending. Results (if a Case Study enter NA) NA Conclusion Malignant mixed germ cell tumors of the testis with associated nephroblastoma are exceedingly rare, further studies nand followup are required to determine prognostic values and achieve a more complete understanding of this combination of entities.

Primary Testicular Neuroendocrine Tumor Coexisting With Seminoma Sharing Germ Cell Origin

A 40-year-old, male, Japanese patient presented with the complaint of painless, right testicular swelling. Tumor markers for testicular cancer were normal. He underwent radical orchiectomy with the clinical diagnosis of stage I seminoma. Pathological examination revealed seminoma and coexisting neuroendocrine tumor (NET). Germ cell neoplasia in situ (GCNIS) was present in the vicinity of seminoma, but there was no continuity between NET and seminoma. Tumor cells of both lesions displayed amplification of 12p and isochromosome 12p on fluorescence in situ hybridization, suggesting that both tumors originated from GCNIS. The present report is the first to describe a case of primary testicular NET coexisting with seminoma in an ipsilateral testis.

Case Report: Paratesticular Rhabdomyosarcoma

Paratesticular rhabdomyosarcoma (RMS) accounts for only 7% of all the RMS cases. Due to the limited available data, there is no consensus on the diagnosis and management of the paratesticular tumors. Here, we interrogated two paratesticular RMS cases in 25 and 27-year-old men presenting with painless and rapidly growing mass in the scrotum. Whereas the data showed no upregulation of tumor markers such as β-human chorionic gonadotropin (β-HCG), alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH), scrotal ultrasonography and magnetic resonance imaging indicated the existence of paratesticular and inguinal lesions respectively. There was local recurrence in one patient who underwent radical orchiectomy for the sarcoma one year ago. In addition, the CT scans showed no occurrence of distant metastasis. The two patients underwent radical inguinal orchiectomy or resection of the recurrent tumors with nerve-sparing retroperitoneal lymph node dissection. Histologic examination revealed embryonal RMS (eRMS) without lymph node metastasis. We highlight the importance of multi-disciplinary participation for paratesticular RMS detection and preoperative ultrasound-guided needle biopsy (UNB) for rapid confirmatory diagnosis. Complete surgical resection coupled with chemotherapy and radiotherapy is the main treatment option for the paratesticular RMS. In addition, sperm cryopreservation treatment and endocrine follow-up could increase the overall survival and quality of life of the patients.

The prognostic importance of neutrophil-to-lymphocyte ratio in testicular cancer

Purpose: Testicular cancer is mostly seen in young men. We planned this study that neutrophil-lymphocyte ratio (NLR) would help us predict the prognosis of the patients, except known markers such as AFP, hCG, and LDH. Patients and Method: Between 2015 and 2020, we conducted our study on 152 patients undergoing radical orchiectomy in our clinic. We divided our patients into good, moderate, and poor prognostic groups. We also created a control group of healthy patients of similar ages. We evaluated the NLR results in preoperative peripheral blood statistically among these groups. Results: We found a significant difference between the control group and the patient group, and between the good and moderate/poor prognostic groups for preoperative NLR. Conclusion: This study created the opinion that preoperative NLR will help us predict the prognosis of patients.