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Introduction

Metastatic tumors of the testis are rare entity. With the exception of leukaemia and lymphoma, the most common primary sites for testicular metastases are the lung and prostate. Generally, it is diagnosed during autopsy or incidentally, following therapeutic orchiectomies in more advanced stages of the disease.

We report a patient who was diagnosed with metastatic carcinoma of the giant prostate. He was then subjected to right-sided inguinal and left-sided scrotal orchiectomy. Afterwards, maximal androgen blockade was initiated.

Case report

A 76-year-old man was referred to our clinic with complaints of lower urinary tract symptoms. His complaints were increasing continuously for three years. Clinical examination of the testis and scrotum were normal. Digital rectal examination of the prostate revealed a markedly nodular, hard, bulgy, very large and fixed prostate tissue. Seminal vesicles could not be palpated. Examination of the other systems was normal. Serum prostate-specific antigen (PSA) was elevated with total 153 ng /ml. Urine microscopy showed sterile pyuria. Serum glucose, creatinine and blood urea nitrogen were within normal limits. Upper and lower urinary tract system ultrasound revealed bilaterally normal kidneys and prostatic enlargement (400 gr prostate). The prostatic mass was irregular in limits and invaded seminal vesicles. An increased postvoid residual urine volume was noted (180 cc). Transrectal ultrasound and biopsy were suggested to the patient. The patient did not accept the biopsy. After two months he came back to our clinic and ultrasound guided prostate biopsy was performed. Histological examination of the cores revealed presence of prostate adenocarcinoma, Gleason score 9 (4+5). Then abdominal Magnetic Resonance Imaging (MRI) was performed. The MRI demonstrated a 9 x 8 x 7 cm. significantly irregular mass arising from prostate and invading the rectum, bladder and ischiorectal fossa, there was no lymph node enlargement (Figure 1). The pelvic MRI demonstrated 2.5 x 2 cm. mass in the posterior aspect of the left testicle. Right testicle was found in the inguinal region (Figure 2). Because of MRI features scrotal sonogram was not carried out. After these findings Transurethral Resection of Prostate (TUR-P) and bilateral orchiectomy were suggested to the patient. Because of the testicular mass, serum levels of the beta-human chorionic gonadotropin (ß-hCG), alpha-fetoprotein (AFP) and lactate dehydrogenase (LDH) were investigated. These enzymes and hormones levels were within normal limits. He underwent left-sided radical orchiectomy and right-sided scrotal orchiectomy, and TUR-P. Histopathology showed the testis to be extensively infiltrated by metastatic adenocarcinoma that had a similar histological pattern to the original histology (Gleason 4+5) (Figure 3). There was no involvement of the vas or spermatic cord structures. Then androgen blockade with bicalutamide (Casodex®, 50 mg/d) was initiated after surgery. Afterwards, total PSA decreased to 10.8 ng/ml within three months. Bone scintigraphy revealed increased osteoblastic activity in the third lumbar vertebrae.

Discussion

Metastasis of prostate cancer to the testis are asymptomatic in most cases. About 4% of them are detected incidentally after bilateral orchiectomy done due to advanced prostate cancer as androgen deprivation therapy [1]. Pienkos and Jablockow found the incidence of testicular metastasis to be 0.06% in the study of 24.000 autopsies [2].

Metastatic tumor of the testis occurs later in life, during the fifth and sixth decades [3]. The most common primary sites for testicular metastases are the lung, prostate, melanoma and kidney. Testicular metastases are rarely derived from stomach, pancreas, bladder, rectum or penis [4].

There were several mechanisms of metastasis formation within testicular tissues proposed. Among them retrograde venous extension or embolism, arterial embolism, lymphatic extension and endocanalicular spread were emphasized [2,5].

The histological nature of the testicular metastasis is the same as primary prostate cancer. Although testicular metastasis of the prostate are rare, it should be considered when a patient presents with a bulge in the testis, especially in a patient known to have prostate cancer.

1. Manikandan R, Nathaniel C, Reeve N, Brough RJ: Bilateral testicular metastases
2. from prostatic carcinoma. Int J Urol 2006, 13, 476-477.
3. Pienkos EJ, Jablokow VR: Secondary testicular tumors. Cancer 1972, 30, 481-485.
4. Johansson JE, Lannes P: Metastases to the spermatic cord, epididymis and testicles from carcinoma of the prostate-five cases. Scand J Urol Nephrol 1983, 17, 249- 251.
5. Patel SR, Richardson RL, Kvols L: Metastatic cancer to the testes: a report of 20 cases and review of the literature. J Urol 1989, 142, 1003-1005.
6. Richie JP, Steele GS: Neoplasms of the testis. In Walsh PC, Retik AB, Vaughan ED Jr, Wein AJ [eds]. Campbell’s Urology, 8th edn. W.B. Saunders, Philadelphia, 2002: 2876-919.

Sahin Kabay
Dumlupinar University Faculty of Medicine
Department of Urology
43100 Kutahya Turkey
phone: +90 274 265 2031
skabay@yahoo.com