Hepatocellular Carcinoma Presenting as Testicular Mass：A Case Report

Correspondence and requests for reprints : Dr. Shee-Chan Lin Address : No 92 Sec 2 Chung-Shan N Road, Taipei City, 104 Taiwan

Hepatocellular Carcinoma Presenting as Testicular Mass A Case Report

An-Ming Yang

, Shou-Chuan Shih

, Wen-Shiung Chang

, Be-Fong Chen

, and Shee-Chan Lin

Abstract

An 84-year-old man presented with an enlarged scrotum. He had no gastrointestinal complaints.

Scrotal ultrasonography showed a 2-cm left testicular mass and a 1-cm mass on the right. The serum PSA and -HCG were in the normal range, but his AFP level was very high. Abdominal ultrasono- graphy revealed a huge tumor in the left lobe of liver. A bilateral orchiectomy was performed, and patho- logy examination demonstrated hepatocellular carcinoma metastatic to the left testis. Adenocarcinoma from any source very rarely metastasizes to the testis. We found only two reports of hepatocellular car- cinoma with testicular metastases in the English literature. ( J Intern Med Taiwan 2005; 16: 274-278 ) Key Words Metastatic hepatocellular carcinoma, Testicular tumor

Division of Gastroenterology,

Department of Internal Medicine;

2

Health Evaluation Center;

Department of Pathology, Mackay Memorial Hospital, Taipei, Taiwan.

Introduction

A scrotal mass is a fairly commonly encountered clinical problem. The differential diagnosis includes such entities as testicular torsion, epididymitis, acute orchitis, strangulated hernia, and testicular cancer.

Other benign causes of scrotal mass include hydro- cele, varicocele, and spermatocele

. Rarely, non-tes- ticular malignancy may be found in the testis, such as primary lymphoma or metastases from other can-

cers. These malignancies behave very differently from primary testicular tumors, so an accurate diag- nosis is essential.

Case Report

An 84-year-old man was admitted because of

progressive scrotal enlargement for six months. The

patient was otherwise well except for peptic ulcer dis-

ease diagnosed 7 years prior to admission. At the same

time, he had noted a small caliber urinary stream, but

a prostate ultrasound was normal. The patient had no history of viral hepatitis, and his family history was not contributory.

Two weeks before admission, the patient was seen in the urology clinic for evaluation of his scro- tal enlargement, which was more pronounced on the left than on the right. Scrotal ultrasound revealed a 2.4 x 1.9-cm mass in the left testis and a 1.1-cm mass in the right testis. (Fig. 1) The PSA (0.07 ng/mL) and -HCG (<5 mIU/mL) levels were within the normal range, but the AFP level was markedly elevated at 19617 ng/mL. A scrotal scan performed one week pri- or to admission demonstrated a highly vascular left testicular mass that was thought to be due to left epi- didymo-orchitis or, less likely, a vascular testicular tumor. Abdominal ultrasonography revealed a huge mosaic mass in the left lobe of liver. Subphrenic lym- phadenopathy and left portal vein invasion were al- so suspected on that exam. (Fig. 2) The most likely diagnosis was hepatocellular carcinoma or possible liver metastases from another primary.

On physical examination, the patient's left testis was enlarged. There was a 5-cm palpable mass in the epigastric area, but the rest of the examination was unremarkable.

The patient underwent bilateral orchiectomy. In the left testis, there were multiple well-defined, rub- bery-firm, tan tumors with purple, gray, or yellow tinges, measuring up to 1.4 cm in left testis. These tu- mors were all confined within the tunica albicans.

Histologically, the tumor cells had vesicular nuclei with prominent nucleoli arranged in a solid pattern or in cords. There was marked necrosis. (Fig. 3) The left testicular tumor cells had focal immunoreactivity for AFP and strong immunoreactivity for cytokeratin and EMA but none for CD30 or placenta-like alkaline phos- phatase. (Fig. 4) The results of immunostaining were thus consistent with a diagnosis of metastatic hepato- cellular carcinoma. The epididymis and spermatic cord were free of tumor involvement. The right testicular mass was fibrotic with no evidence of tumor.

Fig.1.Scrotal ultrasonography showing a 2.4 cm x 1.9 cm mosaic mass in the left testis (left panel) and a 1.1 cm x 1.1 cm hypoechoic mass in the right testis (right panel).

Fig.2.(A) Abdominal ultrasonography showing an ill-de-

fined mosaic tumor, 10 cm in greatest diameter, in

the left lobe of the liver. There is thrombosis in the

left umbilical vein and the transverse portion of the

portal vein. (B) A 2-cm hypoechoic lesion (arrow)

in the left subphrenic area, thought to be lym-

phadenopathy.

A needle biopsy on the hepatic tumor was per- formed. The microscopic findings were consistent with hepatocellular carcinoma with features similar to those of the testicular tumor. (Fig. 3) The HBSAg and anti-HCV were negative.

The patient was treated with trans-arterial em- bolization of the left hepatic artery accompanied by oral thalidomide (100 mg twice per day). However, his response to the treatment was poor, and he died of massive variceal bleeding about 3 months after di- agnosis.

Discussion

Malignancies metastasizing to the testis are rare, particularly with the testicular mass as the presenting

sign of the disease

. Such metastases are usually in- cidental findings at autopsy or following orchiecto- my for prostate carcinoma. The incidence of testicu- lar metastasis is reportedly 0.02% to 0.06%

. There are only a few case reports of testicular metastases being the first clue to a previously undiagnosed pri- mary cancer

. Haupt et al

. reported that the com- monest primary malignancies that metastasiae to the testis are prostate, followed by lung, gastrointestinal tract, melanoma, and kidney cancer. We found only two case reports in the English literature of hepato- cellular carcinoma metastatic to the testis

. It's sur- prising this has not previously been reported in Taiwan, given the high incidence of liver cancer here.

The other main diagnostic consideration in our patient's case was a primary testicular tumor metastat- ic to the liver, particularly as he had no viral hepati- Fig.3.Tumor cells from the left testis having vesicular

nuclei with prominent nucleoli arranged in a solid or cord pattern (A. H&E x400). Similar histologic features are seen in the liver biopsy specimen (B.

H&E x250).

Fig.4.The testicular tumor is positive for endomysial an-

tibody (A. EMA x250, arrow) and negative for pla-

centa-like alkaline phosphatase (PLAP) (B. x100).

tis and so no obvious risk factors for a hepatoma. The possibility that merited the most serious considera- tion was embryonal carcinoma. The immunohisto- chemical staining was helpful in distinguishing be- tween these diagnoses. The fact that it was negative for CD30 and placenta-like alkaline phosphatase ex- cluded the diagnosis of embryonal carcinoma.

Another possibility was a hepatoid yolk sac tumor.

This has been described arising in the ovary

. In ad- dition, 19% of mixed germ cell tumors of the testis reportedly have hepatic-type cells within or adjacent to foci of yolk sac neoplasia

. However, a true hepa- toid yolk sac tumor has never been reported in the testis, and a germ cell tumor would be a very unlike- ly finding in an 84-year-old man

. Further histologic features that argue against this diagnosis were the multifocality of the tumor, the fact that all the lesions were confined within the tunica albicans, and the lack of involvement of the epididymis or spermatic cord.

By contrast, 80% of germ cell tumors invade beyond the tunica albicans

. Finally, the hepatic biopsy spe- cimen had features typical of primary hepatocellular carcinoma, which effectively excludes the possibili- ty of a primary testicular tumor metastatic to the li- ver. Given the huge, solitary large hepatic tumor, the patient's age, the histologic findings, and the im- munohistochemical results (Table 1), we are confi- dent that the correct diagnosis in this case is hepato- cellular carcinoma with testicular metastases.

Extrahepatic metastases reportedly occur in 14.0% to 36.7% of cases of hepatocellular carcino-

ma

, including to the lung in 18% to 55% of pa-

tients, lymph nodes in 26.7% to 53%, bone in 5.8%

to 38 %, and the adrenal gland in 8.4% to 15.4%

. We think the route of metastasis in our patient was most likely lymphatic spread. Natsuizaka et al. re- ported that the median survival in patients with metastatic hepatoma was 7 months (range: 1 to 59 months) and the 1-year survival a dismal 24.9%

. Our patient's death within three months of diagnosis is consistent with the very poor prognosis in such ca- ses.

In conclusion, patients with testicular mass may be primary testicular tumor or, in rare circumstance, metastasized from elsewhere. In this case, testicular mass and liver tumor were found concurrently which made the differentiation between primary and se- condary tumor difficult. We suggested that biopsy of the tumors with immunostaining in histological study is vital to the diagnosis. On the other hand, this pa- tient had high AFP level with testicular tumor which may mislead the diagnosis to germ-cell tumor once the liver tumor is not found. We cannot overempha- size the possibility of liver tumor in patients with high AFP whether he has testicular tumor or not.

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