PMC9807905_01
The results of preoperative examination. (A) The physical examination showed right scrotal painless and rubbery swelling. (B) The results of perineal color Doppler ultrasonography showed that the size of right testis was 29 mm x 22 mm x 20 mm, the PSV was 15.4 cm/s, and RI was 0.65. (C) CT showed the right testis with space-occupying lesions. (D-H) MRI showed slightly equal SI on T1WI (D), high SI (E) and homogenized enhancement of enlarged multiple lymph nodes in bilateral inguinal region (F) on T2WI, insignificant diffusion restriction on DWI (G), and high SI on ADC (H) in the lesion of right testis. PSV, peak systolic velocity; RI, resistive index; SI, signal intensity; T1WI, T1-weighted imaging; T2WI, T2-weighted imaging; DWI, diffusion-weighted imaging; ADC, apparent diffusion coefficient.
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F1
Physical examination showed a rubbery swelling of the right scrotum with rejective touch (Figure 1A). These results supported orchitis of the right testis (Figure 1B). Computed tomography (CT) found an occupying lesion in the right testis (Figure 1C). Magnetic resonance imaging (MRI) showed slightly equal signal intensity (SI) on T1-weighted imaging (T1WI), high SI on T2WI, insignificant diffusion restriction on diffusion-weighted imaging (DWI), and high SI on apparent diffusion coefficient (ADC) (26 mm x 21 mm x 29.6 mm) in the lesion of right testis, and homogenized enhancement of multiple lymph nodes with bilateral enlargement in the inguinal region (Figures 1D-H). The results of immunohistochemistry (IHC) staining were positive for AFP, spalt like transcription factor 4 (SALL4), cytokeratin (CK), CD117, and placental alkaline phosphatase (PLAP), and negative for Vimentin, CEA, Oct3/4, and CD30 (Figures 2C,D and Supplementary Figures S1A-G).
The postoperative pathology results. (A) Right testicular malignancy without capsular invasion. The results of postoperative pathology with HE staining (B) and AFP (+) (C), and SALL4 (+) (D) in IHC staining of testicular YST. AFP, alpha-fetoprotein; SALL4, spalt like transcription factor 4; IHC, immunohistochemistry; YST, yolk sac tumor.
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F2
The postoperative pathology report confirmed that the right testicular YST did not invade the testicular capsule, spermatic cord, epididymis, and vascular system (Figures 2A,B). The results of immunohistochemistry (IHC) staining were positive for AFP, spalt like transcription factor 4 (SALL4), cytokeratin (CK), CD117, and placental alkaline phosphatase (PLAP), and negative for Vimentin, CEA, Oct3/4, and CD30 (Figures 2C,D and Supplementary Figures S1A-G).
The results of postoperative reexamination. (A) The line graph of serum AFP, LDH, and HCG levels changes in the perioperative and chemotherapeutic period. (B) The results of reexamination of color Doppler ultrasonography showed hypoechoic and bloodless legion in right inguinal legion. POD, postoperative day. AFP, alpha-fetoprotein; LDH, lactate dehydrogenase; HCG, chorionic gonadotropin.
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F3
The HCG level was consistently below 2.39 mIU/ml within the normal range (Figure 3A). Within all the cycles of chemotherapy, the AFP levels remained within the normal range of 9.99 ng/ml on postoperative day 20 and 2.55 ng/ml on postoperative day 35 (Figure 3A). On postoperative day 84, the AFP levels still remained within the normal range of 3.81 ng/ml (Figure 3A). The results of reexamination of color Doppler ultrasonography showed normal imaging of the perineal legion and the hypoechoic and bloodless legion of the right inguinal legion, with a left testis size of 10.6 mm x 8.0 mm x 6.3 mm (Figure 3B).
The flowchart of timeline for diagnosis and treatment process. POD, postoperative day.
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F4
The flowchart of the timeline for the diagnosis and treatment process schedule is shown in Figure 4.