Forgotten abdominal pain.

A 25-year-old man presented with abdominal pain. The patient was in his usual state of health until three months prior to admission, when diffuse abdominal pain developed, most severe in the epigastria. He reported a sharp, constant pain usually unrelated to eating. Upper endoscopy was performed several times and revealed no significant finding. Abdominal pain was progressive and fever, night sweating and weight loss was added since one month before admission. The abdomen was soft and a bulging mass was palpated in mid-abdomen. There was no peripheral lymphadenopathy. The all remainder of the examination was normal. Abdominopelvic CT scan performed ( Figuer 1 , 2 ).

Fig. 1

Fig. 2

A huge lobulated retroperitoneal mass with left hydronephrosis.

Mass is heterogenous and include some area of necrosis.

Hb=12 gr/dl, WBC=5700 /mm3, PLT=278000/ mm3, Cr = 0.8 mg/dl, LDH=6144 IU/L, AST=18 IU/L, ALT=10 IU/L, ALP=2390 IU/L (100-270), ESR=50 mm/h, β-HCG=218 IU/L (normal: ≤ 25 IU/L), AFP=0.94 IU/mL (normal: ≤ 5.5 IU/ml) and Gamma GT was normal.

Answer:

CT scan revealed a huge lobulated and heterogeneous enhanced soft tissue mass, 155×133 mm in diameter in the retroperitoneum. There was encasement of large abdominal vessels by mass, without invasion and mild hydronephrosis in left side.

In according to elevated β-HCG in a young male, despite normal testicular examination, we decided to perform scrotal ultrasound. Ultrasound showed three well-defined hypoechoic lesions 3, 5 and 9 mm in diameter in the left testicle. CT-guided needle biopsy from retroperitoneal mass confirmed metastatic germ cell tumor, seminoma. Other evidence such as normal αFP [1] and character of lesion in scrotal ultrasound [2] was in favor of seminoma. Primary site was located in the gonad. Further evaluation revealed elevated alkaline phosphatase was heat-stable isoform of alkaline phosphatase which has named as placental-like alkaline phosphatase (PLAP).

Chemotherapy with bleomycin, etoposide and cisplatin was started and followed by radical inguinal orchiectomy.

Testicular tumors usually present as a nodule or painless swelling of one testicle, which may be noted incidentally by the patient.[3] Approximately 30 to 40 percent of patients complain of a dull ache or heavy sensation in the lower abdomen, perianal area, or scrotum, while acute pain is the presenting symptom in 10 percent. The presenting manifestations of testicular cancer are attributable to metastatic disease in approximately 10 percent of patients. Symptoms vary with the site of metastasis such as anorexia, nausea, vomiting, or abdominal pain due to retroperitoneal metastasis. Gynecomastia is a systemic endocrine manifestation of these neoplasms.[4] Also patients with marked overproduction of hCG can develop another endocrine complication, paraneoplastic hyperthyroidism.[5] Elevated PLAP concentrations can be seen with germ cell tumors as well as tumors of the lung, pancreas, stomach, colon, and ovaries.[6]

CONFLICT OF INTEREST

The author declares no conflict of interest related to this work.