PMC5797537_01
(A) Sagittal T1 image shows vermian atrophy (arrow) and (B) axial FLAIR image shows right hippocampal hyperintensity (arrow). (C) Right testicular US showing a 9 mm x 7 mm hypoechoic lesion (arrow) with microcalcifications. (D) F18-FDG positron emission tomography/computerized tomography showing an FDG-avid 1.4-cm x 0.9-cm lymph node in the periaortic chain (arrow).
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F1
Initial brain magnetic resonance imaging scan (MRI) showed cerebellar vermian atrophy (Figure 1A). Brain MRI showed non-enhancing hyperintensity and swelling of right amygdala as well as hyperintensity in the periaqueductal gray area (Figure 1B). A testicular ultrasound done in hospital showed a worrisome mass measuring 9 mm x 7 mm in the right testicle (Figure 1C). Although a previous CT of the body was normal, given the concern for occult malignancy, an F18-FDG PET/CT scan was pursued which revealed a 1.4-cm x 0.9-cm solitary hypermetabolic lymph node in the interaortocaval distribution, worrisome for metastatic disease but not amenable to percutaneous biopsy (Figure 1D).
(A,B) Testis, hematoxylin and eosin stain: scarred area with hyalinized tubular Ghosts (lack arrow), increased vascularity and coarse calcifications (red arrow) within tubular profiles. No viable tumor was identified. (C) Lymph node, hematoxylin and eosin stain: small foci of metastatic GCT with seminomatous component (black arrows) with associated granulomas (red arrow head). (D) Immunohistochemical reactivity in tumor cells for CD117 support the diagnosis. CD30 (not shown) is negative.
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F2
A right inguinal radical orchiectomy was performed, with pathological findings showing a 1.3 cm scar tissue with fibrosis and microcalcifications without sign of viable tumor or intratubular germ cell neoplasia in situ (Figure 2A). A robotic retroperitoneal lymph node dissection was performed and pathology revealed a CD117 positive metastatic seminoma:stage IIA (Figures 2B-D) most probably secondary to a primary testicular "burned out" tumor.