Answer for BIR CoW 19 Aug 2018
Non seminomatous germ cell tumour
Findings
UGS: Appearance :Large hetero echoic midline lesion with multiple cystic components Displacing bowel loops and iliac vessels Extent: from umbilicus level to just above bladder Measurement : 7 x 12 x 15 cms.
CT FINDINGS : LARGE MIDLINE HETERODENSE LESION SHOWING MILD CONTRAST ENHANCEMENT CAUSING MESENTRIC DEPOSITS DISPLACING BOWEL LOOPS BILATERAL ABSENT TESTIS IN SCROTUM
Discussion
Things to consider in this case: Organ of origin - (testis) – PHANTOM ORGAN SIGN Lesion from which side of organ . Seminoma / Non seminomatous Germ cell tumour . Metastasis +/- Tracking of spermatic cord: In the left side , spermatic cord ( oval echogenic structure , with anechoic vessel and vas deferens) is seen in inguinal canal ( tracing from femoral vessels to antero medially), on tracing it down, is seen ending in superior aspect of fluid filled left scrotal sac In the right side, cord is seen not seen in inguinal canal , hence traced along external iliac vessel. Spermatic cord is seen for a short distance , ending into the lesion at the level of right iliac fossa Interpretation : lesion appears originating from right testis. Differentiating seminoma from non seminoma : seminoma: homogenous, well defined, fibrovascula septa, increased LDH, PLAP non seminoma: heterogenous, ill defined, heterogrnous enhancement, increased AFP, HCG This patient has elevated AFP, HCG and normal LDH. Hence the final diagnosis was , Non Seminomatous germ cell tumour from right intra abdominal testis. Patient was started on chemotherapy , with BLEOMYCIN, ETOPOSIDE, CISPLATIN. Has Completed 2 cycles Reduction of abdomen discomfort now Lesson reinforced from this case: As senior professors say, Radiologist has to be a clinician first. To never miss an opportunity to interact with the patient, especially during an Ultrasonogram examination Undescended testis: 2-4% incidence 80 % of it will descend by 1 year of life. 25% of undescended testis are bilateral. Risk of developing germ cell tumour is much higher in bilateral and intra abdominal testis Seminoma is common in testicular germ cell tumour In extra gonadal germ cell tumour , non seminoma is common.
REFERENCES: GRAINGER &ALLISON’S DIAGNOSTIC RADIOLOGY ;A Textbook of Medical Imaging CT AND MRI OF THE WHOLE BODY , Sixth Edition ; John R. Haaga, Daniel T. Boll Testicular Cancer and Cryptorchidism ;Lydia Ferguson1 and Alexander I. Agoulnik1,* Tumors in undescended testis ;Kulkarni JN1, Kamat MR.
Findings
UGS: Appearance :Large hetero echoic midline lesion with multiple cystic components Displacing bowel loops and iliac vessels Extent: from umbilicus level to just above bladder Measurement : 7 x 12 x 15 cms.
CT FINDINGS : LARGE MIDLINE HETERODENSE LESION SHOWING MILD CONTRAST ENHANCEMENT CAUSING MESENTRIC DEPOSITS DISPLACING BOWEL LOOPS BILATERAL ABSENT TESTIS IN SCROTUM
Discussion
Things to consider in this case: Organ of origin - (testis) – PHANTOM ORGAN SIGN Lesion from which side of organ . Seminoma / Non seminomatous Germ cell tumour . Metastasis +/- Tracking of spermatic cord: In the left side , spermatic cord ( oval echogenic structure , with anechoic vessel and vas deferens) is seen in inguinal canal ( tracing from femoral vessels to antero medially), on tracing it down, is seen ending in superior aspect of fluid filled left scrotal sac In the right side, cord is seen not seen in inguinal canal , hence traced along external iliac vessel. Spermatic cord is seen for a short distance , ending into the lesion at the level of right iliac fossa Interpretation : lesion appears originating from right testis. Differentiating seminoma from non seminoma : seminoma: homogenous, well defined, fibrovascula septa, increased LDH, PLAP non seminoma: heterogenous, ill defined, heterogrnous enhancement, increased AFP, HCG This patient has elevated AFP, HCG and normal LDH. Hence the final diagnosis was , Non Seminomatous germ cell tumour from right intra abdominal testis. Patient was started on chemotherapy , with BLEOMYCIN, ETOPOSIDE, CISPLATIN. Has Completed 2 cycles Reduction of abdomen discomfort now Lesson reinforced from this case: As senior professors say, Radiologist has to be a clinician first. To never miss an opportunity to interact with the patient, especially during an Ultrasonogram examination Undescended testis: 2-4% incidence 80 % of it will descend by 1 year of life. 25% of undescended testis are bilateral. Risk of developing germ cell tumour is much higher in bilateral and intra abdominal testis Seminoma is common in testicular germ cell tumour In extra gonadal germ cell tumour , non seminoma is common.
REFERENCES: GRAINGER &ALLISON’S DIAGNOSTIC RADIOLOGY ;A Textbook of Medical Imaging CT AND MRI OF THE WHOLE BODY , Sixth Edition ; John R. Haaga, Daniel T. Boll Testicular Cancer and Cryptorchidism ;Lydia Ferguson1 and Alexander I. Agoulnik1,* Tumors in undescended testis ;Kulkarni JN1, Kamat MR.
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!