CASE REPORTS
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Orchiopexy by Torek leading to bilateral inguinal lymph node dissemination of seminoma
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After orchiopexy, collateral lymphatic channels form towards the superficial inguinal lymph nodes by violating the tunica alba. We describe bilateral inguinal lymphadenopathy from seminoma testis.
Keywords: seminoma
Corresponding Author: De Vos, Filip
Additional Authors:
Kirkels , Wim; de Wit, Ronald; Sleijfer, Stefan
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Orchiopexy by Torek leading to bilateral inguinal lymph node dissemination of seminoma
Filip Y.F.L. De Vosa, Wim J. Kirkelsb, Ronald de Wita, Stefan Sleijfera
a. Department of Medical Oncology, Erasmus Medical Center, Rotterdam, The Netherlands; b. Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
Corresponding author: Filip Y.F.L. De Vos, mailing address: Department of Medical Oncology, Erasmus Medical Center, Groene Hilledijk 301, 3075 EA Rotterdam, The Netherlands, Telephone: 0031-10-7041906, fax: 0031-10-7041003, e-mail address: f.devos@erasmusmc.nl
Introduction: Even in cases with overt metastatic disease of testicular germ-cell cancer, excellent prognosis can be achieved because of the availability of effective chemotherapy. As prognosis is adversely associated with more advanced disease, it is important to establish diagnosis as early as possible. Therefore, knowledge on dissemination patterns of this disease and knowledge on possible accompanying presenting symptoms is required.
The normal dissemination pattern of testicular germ-cell cancer follows the ipsilateral lymphatic vessels. Right-sided tumours have primary landing zones in the interaortacaval, precaval and paraaortic zone, while left-sided tumours disseminate in the paraaortic and preaortic zones, with the interaortocaval zone involved in higher stage disease. In addition, invasion of the epididymis and spermatic cord can lead to iliac lymph node involvement, while invasion of the tunica albuginea is associated with inguinal metastases. Haematogenous dissemination may occur in later stages of the disease.
Changed anatomy of lymphatics after surgery involving the scrotum and groin can lead to altered patterns of dissemination, in particular to the ipsilateral groin. This case-report describes a patient with seminoma of the right testis with bilateral inguinal lymphadenopathy.
Case report: A 56-year-old Caucasian male presented with asymptomatic, gradually enlarging masses in both groins of 5-6 cm in diameter. At 12 years old, he underwent an unsuccessful right-sided orchiopexy to position the undescended testis in the scrotum. Since then, he had a small testicle in his right groin and an empty right-sided scrotum. At admission, physical examination revealed no abnormalities. Laboratory results showed slightly elevated beta-human choriogonadotrophine (beta-HCG 2.5 IU/L (normal values 0.0-1.9 IU/L)) and lactate dehydrogenase (LD 518 U/L (normal values 0-449 U/L)) with normal alpha-fetoprotein. Ultrasonography revealed a small testicle in the right groin with a volume of 4 mL, normal left testicle and lymphadenopathy in both groins. Histopathological examination of tissue obtained from the left groin revealed pure seminoma. Computed tomography (CT) of chest and abdomen showed bilateral inguinal lymphadenopathy without retroperitoneal metastases. (Figure 1). Seminoma, clinical stage IIC, of good prognosis according to the International Germ Cell Cancer Collaborative Group (IGCCCG) was diagnosed. Given his age rendering an increased risk for bleomycin-induced pneumonitis (BIP), etoposide 100 mg/m2 and cisplatin 20 mg/m2 (EP) was administrated intravenously on days 1 to 5 every 3 weeks for four cycles. Chemotherapy proceeded uneventfully and initially elevated tumour markers beta-HCG and LD normalized already after first course. CT after completing chemotherapy showed a partial response; the left groin mass was reduced in diameter from 51 x 46 to 36 x 26 mm and right groin mass from 48 x 41 to 18 x 14 mm. (Figure 2) Four weeks later, surgical removal of the right testis located in the groin was performed, while no further masses in the right groin could be identified anymore. Simultaneously, a left groin lymph node dissection was conducted. Histopathological examination of residual mass from the left groin revealed no trace of viable tumour tissue. In the right testicle, a small necrotic lesion was found without viable tumour cells. To this date, no evidence of disease is reported with 12 months follow-up.
Figure 1 (above): CT scan of bilateral inguinal lymphadenopathy before start of chemotherapy.
Figure 2 (below): CT scan after completing chemotherapy
Discussion: Our patient is noteworthy because of the distinct presentation of lymphadenopathy in the groins. Normally, the lymphatic system drains the testis via the spermatic vein into retroperitoneal nodes situated near the lower thoracic and lumbar vertebrae. Inguinal lymph nodes are divided into two groups: superficial and deep nodes. The first group drains the lower abdomen, perineum, scrotal skin, the latter the lower extremities. Normal lymphatic drainage can be altered by surgery resulting in lymphatic spread to unusual sites. (1) Our patient, suffering from cryptorchidism, previously underwent a right-sided orchiopexy. Cryptochidism is a well-known risk factor for testicular cancer, even after orchiopexy. Orchiopexy at that time in the Netherlands was usually performed by Torek procedure. (2) This two-stage procedure combines surgical dissection of the spermatic cord with creation of a channel between the inguinal incision and scrotum. As a consequence of this approach, collateral lymphatic channels are formed towards superficial inguinal lymph nodes by violating the tunica alba and surgically changing anatomy. (3) Accordingly, in patients with a history of scrotal and inguinal surgery, ipsilateral inguinal lymphadenopathy from testicular cancer have been described in numerous reports. Although contralateral inguinal lymphadenopathy due to the formation of collateral lymphatic channels has been described in earlier reports (4,5), to the best of our knowledge, this report is the first presentation of bilateral inguinal lymphadenopathy from testicular cancer after a history of orchiopexy.
Radiotherapy is considered standard for seminoma clinical stage IIA and IIB, while chemotherapy is preferred for seminoma clinical stage IIC and higher. (6) The number of courses depends on the prognosis, according to IGCCCG. For patients with metastatic seminoma belonging to the good prognosis group, three cycles of chemotherapy consisting of bleomycin, etoposide, and cisplatin (BEP) is regarded standard treatment. In our patient, we choose to administer four cycles EP as a valid alternative for three cycles BEP, given patient’s age rendering him at risk to develop BIP. (7,8) The treatment resulted in partial remission with normalized tumour markers. A bilateral lymph node dissection with right-sided orchidectomy followed as residual seminoma masses with a diameter of >3 cm after chemotherapy have a relatively high risk for harbouring viable tumour. (9) The orchidectomy was conducted as viable tumour cells are frequently found in the primary tumour after chemotherapy, probably due to the presence of the blood-testis barrier hindering distribution of chemotherapy in the testis. (10) In our patient, there were no signs of vital tumour in the resected tissue. This case-report describing the first patient with bilateral inguinal lymphadenopathy from seminoma testis emphasises the importance of anatomical knowledge of the lymphatic drainage system.
References
[1] Palomar JM, Brothers J, Luer W, Evans BB. Lymphatic neovascularization after orchiopexy. Invest Urol 1980;17:491-4.
[2] Torek F. Orchiopexy for undescended testicle. Ann Surg 1931;94:794-8.
[3] Crawford ED, Cain DR, Black WC, Borden TA. Inguinal lymph node metastases following a Torek orchiopexy. Urol 1983;21:300-1.
[4] Nishimoto K, Ono H, Hirayama M, Kadomoto Y, Usui T. Inguinal lymph node metastases from contralateral testicular origin. Urol 1993;41:275-7.
[5] von Rottkay P. Spread of a testicular tumour to the contralateral groin: another case. Br J Radiol 1986;59:196.
[6] Krege S, Beyer J, Souchon R, et al. European consensus conference on diagnosis and treatment of germ cell cancer: areport of the second meeting of the European germ cell cancer consensus group (EGCCCG): Part II. Eur Urol 2008;53:497-513.
[7] Sleijfer S. Bleomycin-induced pneumonitis. Chest 2001;120:617-24.
[8] de Wit R. Optimal management of retroperitoneal metastatic nonseminomatous testicular cancer: toward a better selection between scalpel and needle. J Clin Oncol 2007;25:5550-2.
[9] Puc HS, Heelan R, Mazumdar M, et al. Management of residual mass in advanced seminoma: results and recommendations from the Memorial Sloan-Kettering Cancer Center. J Clin Oncol 1996;14:454-60.
[10] Bart J, Groen HJM, van der Graaf WTA, et al. An oncological view on the blood-testis barrier. Lancet Oncol 2002;3:357-63.
Date added to bjui.org: 24/10/2009 (publication information)
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