Abstract | April 4, 2022

Stage IIIb Seminoma Presenting as Hydronephrosis in a 73-year-old Man

Presenting Author: Jordan Michael Sexe, DO, Internal Medicine Resident PGY2, University of Texas Health Science Center at Tyler, Tyler, TX

Coauthors: Es-Haq Hassanin, Internal Medicine, PGY2, University of Texas Health Science Center at Tyler, Tyler, TX; Robert Droder, MD, Attending Physician, Medical Oncology, Hope Cancer Center of East Texas,Tyler, TX.

Learning Objectives

  1. Discuss the differential diagnosis of obstructive hydronephrosis in an elderly male.��

Introduction: A seminoma is a germ cell tumor that typically affects men aged 15-35 years. Fewer than 4% of germ cell tumors present over the age of 65 years. Additionally, only 5% of seminomas will present at Stage III. We present a 73-year-old man who presented with a retroperitoneal seminoma in the context of hydronephrosis and a normal testicular examination.

Case Presentation: A 73-year-old man presented to the ED due to worsening left flank pain for three weeks. He described the pain as excruciating and sharp. There was no relief despite over-the-counter pain medications. He denied previous episodes, aggravating factors, and pain radiation. Past medical history included panniculitis treated with chronic hydroxychloroquine, BPH, type 2 diabetes mellitus, and atrial fibrillation. The physical exam was negative for CVA tenderness, spinal tenderness, or testicular abnormality. A CT abdomen/pelvis revealed mild left hydronephrosis secondary to mass effect from a 17.8 x 13.3 x 11.7 cm paraaortic mass (Figure 1). Further review of a CT abdomen/pelvis 16 years prior showed this mass measuring 2 x 2 cm. The differential included neoplastic disease and infection. A CT-guided biopsy was obtained revealing a poorly differentiated carcinoma. Immunostains for GI, prostate, lung, and kidney were negative. Tumor markers were obtained showing AFP 2 (ref range 0-9), beta hCG 1 (ref range 0-3), and LDH 497 (ref range 100-190). Due to unknown site of primary, testicular origin was considered given the paraaortic location. Immunostains for testicular origin showed positive OCT3/4, CD 117, D2-40, and SALL4 with negative glypican 3, CD30, consistent with a pure seminoma.

Final Diagnosis: The final diagnosis is stage IIIb (TxN3M0S2) seminoma versus extragonadal retroperitoneal seminoma.

Outcome: The patient is currently undergoing four cycles of cisplatin and etoposide chemotherapy with curative intent. Pending the clinical course, surgical removal of large residual disease and left orchiectomy may be considered.

References and Resources:

  1. Steele, Graeme S., Jerome P. Richie, William K. Oh, and D. Michaelson. Clinical manifestations, diagnosis, and staging of testicular germ cell tumors. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on November 08, 2021.)
  2. Downes M. Seminoma. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/testisseminomas.html. (Accessed November 11th, 2021.)