Case Report- Radiology
LOWER BACK PAIN - UNUSUAL MANIFESTATION OF TESTICULAR MALIGNANCY.
Dr.Ravindra B.N1 , Dr.Anushree2 1Assistant professor, 2Senior resident, department of radiology, MIMS Mandya, Karnataka. India.
Corresponding Author :- Dr.Ravindra B.N
Date Of Submission : 01/08/2020
Date Of Publication : 10/09/2020
Testicular germ cell tumors are one of the common types of malignancy seen in young age group. It usually presents as painless swelling. In many instances patients present late and the diagnosis is made due to manifestations caused by metastatic disease. Lower back pain due to metastatic disease is one of the uncommon presentations of testicular malignancies but must be kept in mind particularly in young males. An early diagnosis of testicular malignancy is essential as delayed diagnosis is associated with the risk of presenting with metastatic disease which is associated with uniformly poor prognosis.
Keywords:- Testicular Germ Cell Tumors, Imaging, Computerized tomography, lymphadenopathy.
Testicular germ cell tumors are the most common malignancy among young men. These are highly chemo-sensitive tumors with high cure rates. More than 95% of patients with testicular cancer present with a painless testicular mass.1
An eighteen-year-old boy presented with constant progressive lower back pain for 3 months which has aggravated for 1 week. There was a history of 6 kg weight loss over past 3 months. General examination of the patient revealed pallor. There was a 5x4cm lymph node over the Left anterior lower cervical group. Tinea corporis over anterior aspect of both legs was also seen. Neurological examination of the patient revealed Weakness in hip flexors and adductors along with brisk knee and ankle jerk bilateral plantar flexor with normal sensations. Patient was negative for HIV. Chest X-ray revealed multiple coin lesions in bilateral lung fields. CT thorax and abdomen revealed multiple metastasis in lung with pre aortic, paraaortic area and renal hilar lymphadenopathy. MRI Spine was normal. FNAC of cervical lymph node revealed metastatic seminoma. Scrotal examination was found to be normal, however USG scrotum showed well defined heterogenous lesion with areas of calcification in right testis.
Figure 1: Ultrasound examination of testis showed heterogenous lesion with areas of calcification in right testis (Left), Enlarged cervical Lymph nodes also seen on ultrasound (Right).
Figure 2: Multiple Coin Like lesion on X-Rays (Left) and Resolution Computed Tomography (Right).
Figure 3: – Enlarged para-aortic lymph node displacing Aorta (Left) and enlarged cervical lymph node (Right) as seen on Computerized tomography.
Testicular germ cell tumors are the most frequent cause of malignancy in young males.2 Clinical features include painless scrotal swelling and symptoms of secondary metastasis.3 Retroperitoneal lymph nodes metastasis is common and many patients first present with abdominal pain due to retroperitoneal lymphadenopathy.3 In many instances non-specific symptomatology may cause delay in seeking medical care which may lead to metastatic spread of the disease by the time of presentation, thus affecting prognosis.4
A careful physical examination with high index of suspicion is of prime importance in pointing towards the correct diagnosis. Radiological features such as multiple lung nodules giving cannon ball appearance indicates disseminated malignancy to the lungs and is sociated with poor prognosis.5,6 Scrotal ultrasound is highly sensitive for detecting testicular masses and is the imaging of choice for confirming the presence of testicular tumors.7 Blood concentrations of tumor markers including alpha fetoprotein and beta-human chorionic gonadotropin are often elevated.8,9 They are chemosensitive tumors respond well to platinum based drugs.10
Lower back pain in young boys with red flag signs should be cautiously screened for possibility of testicular malignancy as it is very sensitive to chemotherapy and 5 ear survival is 95% if the diagnosis is made early. Delay in the diagnosis may cause distant metastasis and adversely affect the outcome.
- Horwich A, Nicol D, Huddart R. Testicular germ cell tumours. BMJ. 2013;347:f5526.
- Anmugalingam T, Soultati A, Chowdhury S, Rudman S, Van Hemelrijck M. Global incidence and outcome of testicular cancer. Clin Epidemiol. 2013;5:417-427. Published 2013 Oct 17.
- Kreydin EI, Barrisford GW, Feldman AS, Preston MA. Testicular cancer: what the adiologist needs to know. AJR Am J Roentgenol. 2013;200(6):1215-1225.
- Huyghe E, Muller A, Mieusset R, et al. Impact of diagnostic delay in testis cancer: results of a large population-based study. Eur Urol. 2007;52(6):1710-1716.
- Agarwal R, Mukhopadhyay J, Lahiri D, Biswas A, Maity P. Cannon-ball pulmonary metastases as a presenting feature of stomach cancer. Lung India. 2015;32(3):300-302.
- Nabi G, Sadiq M. Multiple bilateral cannon-ball lung metastases from carcinoma of the prostate: orchiedectomy induced remission. Med J Malaysia. 2002;57(1):111-113.
- Dogra VS, Gottlieb RH, Oka M, Rubens DJ. Sonography of the scrotum. Radiology. 2003;227(1):18-36.
- Light PA. Tumour markers in testicular cancer. J R Soc Med. 1985;78 Suppl 6(Suppl 6):19-24.
- Milose JC, Filson CP, Weizer AZ, Hafez KS, Montgomery JS. Role of biochemical markers in testicular cancer: diagnosis, staging, and surveillance. Open Access J Urol. 2011;4:1-8. Published 2011 Dec 30.
- Javadpour N. Current status of tumor markers in testicular cancer. A practical review. Eur Urol. 1992;21 Suppl 1:34-36.
Cite this article: Dr.Ravindra B.N , Dr.Anushree Lower Back Pain – Unusual Manifestation Of Testicular Malignancy .Int J Med Case Reports. 2020 Jul 3 (3) 13-15