Baez Perea

Jose Antonio Contreras Ibañez

Jose María

Pedro Muriel Cueto

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Case Reports
Arch. Esp. Urol. 2009; 62 (3): 223-226
TESTICULAR METASTASIS AS FIRST CLINICAL 
EXPRESSION OF UNKNOWN ORIGIN 
MALIGNANT MELANOMA.
Jose Antonio Contreras Ibañez, Pedro Muriel Cueto1 
and  Jose María Baez Perea1. 
Medical Oncology Department and Pathologic Antomy 
Department1. Puerta del Mar Universitary Hospital. Cádiz. 
Spain.
Resumen.- OBJETIVO: Aportar información sobre un raro 
proceso y alentar a clínicos y patólogos para que tengan 
presente en sus diagnósticos esa posibilidad.
MÉTODOS: Presentamos el caso de un varón adulto con 
dolor y tumefacción en región inguinal izquierda y aumen-
to de volumen del testículo homolateral.
CONCLUSIONES: Es conveniente en varones adultos tener 
presente la posibilidad de metástasis testicular de un tumor 
primario oculto ya que la afectación metastásica puede 
constituir la primera manifestación de la enfermedad.
Palabras clave:  Testículo. Metástasis. Melanoma 
maligno.
Summary.- OBJECTIVE: To report a rare process and to 
stimulate clinicians and pathologists to have this possibility 
present in their diagnoses.
METHODS: We report the case of an adult male with pain 
and swelling in the left inguinal region and increased volume 
of the homolateral testicle.
CONCLUSION: It is appropriate to bear in mind the possi-
bility of testicular metastasis of a primary unknown tumor in 
adult males since metastatic affectation can constitute the first 
manifestation of the disease.
Keywords: Testicle. Metastases. Malignant melanoma.
INTRODUCTION
Testicular metastases of malignant melanoma are relati-
vely common in autopsy series, but are very rarely diag-
nosed in living patients (1). It is even more rare to find 
them as the first manifestation of disease and even more 
so to fail to discover the primary malignant melanoma.
There are cases in which the history of melanoma is 
remote and unrelated to the current testicular process. 
Furthermore, if this is added to the varied histological 
appearance of metastatic melanoma, it is not difficult to 
understand that the pathological diagnosis is underesti-
mated in the orchiectomy specimen, diagnosing primary 
testicular tumor. In other cases, testicular metastasis is the 
first manifestation of the disease, with no further eviden-
ce of spread, making diagnosis even more difficult.
The objective of this paper is to encourage clinicians 
and pathologists to consider this possibility when a tes-
ticular mass is found in an older man, even when the 
presence of a primary tumor is unknown.
CASE REPORT
61-year old patient, smoker of 20 cigarettes/day, diag-
nosed several years earlier with chronic atrial fibrillation, 
HBP and chronic airway obstruction, with a right knee 
replacement and receiving treatment with dicumarinic, 
antihypertensive and bronchodilator agents.
He visited the emergency room of the Centre at the end 
of November 2006 with pain and swelling in the left 
inguinal region, 12 days of evolution, together with 
increased volume of the homolateral testicle. He was 
assessed by the urologist on duty who, in the physical 
examination and ultrasound scan (27/11/06), detected 
@ CORRESPONDENCEJosé Antonio Contreras Ibañez
Hospital Universitario Puerta del Mar
Servicio Oncologia Médica (9ª planta)
Avda. Ana de Viya 21.
11009 Cádiz. (Spain).
joseantonio.contrerasibaez@gmail.com
Accepted for publication: February, 25th 2008.
224
J. A. Contreras Ibañez, P. Muriel Cueto and  J. M. Baez Perea.
a large solid 60 x 58 mm mass with necrotic areas, 
located in the left testis; there was another large 71 x 
55 mm mass in the left inguinal region, heterogeneous, 
well delimited and hypoecogenic, compatible with ade-
nopathy. Suspecting a primitive testicular tumor, alpha-
fetoprotein and B-HCG were requested (normal) and an 
inguinal orchiectomy was scheduled, being performed 
on 21/12/2006.
Anatomical pathology reported: adenopathy sections 
and testicle with tumor with abundant ochre pigment 
and nodule-forming theca-like cells with irregular nuclei, 
gross nucleolus and increased mitotic index. The tumor 
respects the periphery of the testis and albuginea and 
massively infiltrates the adenopathy. The immunohisto-
chemical study is positive for S-100 and HMB-45 and 
negative for alpha-inhibin (Figure 1)
He was referred to Dermatology to search for the prima-
ry melanoma, without success, so he was referred to our 
department for an evaluation of systemic treatment.
His examination in our department was anodyne.
We requested a TAC scan of the chest and abdomen 
with oral and intravenous contrast: non-calcified, 6 mm 
nodule on left segment I and 12 mm nodule on right 
segment 6 with pleural tail. In the upper lumbar region, 
a 3.1 cm nodule with soft tissue density was found with 
peripheral uptake and increased attenuation of local fat. 
17 mm left inguinal adenopathy with uptake. 
After obtaining his informed consent, we were about 
to apply the first cycle of systemic treatment with Da-
carbazine (DTIC), but a few days before the scheduled 
date, he was admitted with convulsions, with the cranial 
TAC scan (Figure 2) revealing multiple parenchymatous, 
hyper-uptake bilateral nodules, with digitiform edemas, 
predominantly located in the frontoparietal and right pa-
rietal regions, the largest measuring 2 cm.
He received three sessions of palliative holocranial irra-
diation, with the symptoms improving.
We have started palliative monochemotherapy with 
DTIC, having administered two cycles to date, which 
he has tolerated without remarkable incidents. He is 
FIGURE 1. Pigments cells tumors nodule-forming positive for S-100.
225
TESTICULAR METASTASIS AS FIRST CLINICAL EXPRESSION OF UNKNOWN ORIGIN MALIGNANT MELANOMA.
also receiving corticoid therapy and anticonvulsant 
treatment.
DISCUSSION
- Testicular metastases are uncommon and around 15% 
of all cases derive from a malignant melanoma (MM). 
Around 30 cases had been described by 2006, most 
of them as post mortem findings. Only in four cases did 
testicular metastasis represent the first manifestation of 
the disease (2). 
- Testicular metastases of any histological type without 
prior diagnosis of the primary tumor are rare and have 
been reported as isolated cases (3-7). Only exceptiona-
lly is the primary tumor a melanoma (8).
- In our case, the diagnosis was made while the patient 
was alive. It was the first clinical manifestation of the di-
sease and the most remarkable point is that the location 
of the primary melanoma was unknown. 
- Where most testicular metastases have been found in 
autopsy series have been at the Memorial Hospital and 
M. D. Anderson. The former identified 8 cases in 100 
autopsies performed on patients with metastatic melano-
ma, and they all formed part of a widespread disease 
(9). The latter found only 2 cases in 72 autopsies perfor-
med on patients with metastatic melanoma at genitouri-
nary locations, and none of them had been clinically 
recognised (10).
- Metastatic spread to the testicle can occur through se-
veral routes: retrograde venous extension, retrograde 
lymphatic extension and arterial embolism. On the other 
hand, on some occasions the primary tumor has regres-
sed and is only manifest in the metastasis, as in the case 
presented here.
- The primary locations most commonly giving rise to tes-
ticular metastases are carcinoma of the prostate, lung, 
kidney, colon and stomach.
- The important practical aspect under discussion is the 
differential diagnosis with primitive and metastatic tu-
mors of the testicle and even benign processes (hydroce-
le, varicocele), in order to establish a correct approach 
and therapeutic plan. Obviously, a microscopic evalua-
tion is essential for establishing a diagnosis of testicular 
metastasis of melanoma, especially considering that the 
clinical history of disease is often lacking and the prima-
ry melanoma could have regressed, which could have 
occurred in this case. 
- In our case, the anatomopathological characteristics 
were typical and there were no doubts over the diag-
nosis.
- In general lines, the specific prognosis of testicular me-
tastases is unclear. In our case, it was the first manifes-
tation of the disease, although it was soon followed by 
other visceral metastasis sites. We therefore believe that 
the testicular metastasis in this case does not represent a 
worse prognosis.
- The treatment of the testicular metastasis will largely de-
pend on the patient’s life expectancy. In this case, as the 
primary tumor was unknown, the surgeon decided on 
an inguinal orchiectomy. This procedure could also be 
applied in cases when the primary location is known, in 
order to eliminate potential local-regional complications 
derived from the neoplastic testicular involvement. The 
patient was also treated with holocranial irradiation and 
monochemotherapy with DTIC, in view of possibly com-
promised cerebral and systemic sites. Polychemotherapy 
does not improve survival relative to DTIC alone.
CONCLUSION
Testicular metastases are rare and largely discovered in-
cidentally in autopsies or therapeutic orchiectomies. They 
are derived from primary carcinomata of the prostate, 
lung, gastrointestinal tract, kidney or melanomas. Only 
exceptionally do they represent the first manifestation of 
the disease and their specific prognosis is unknown. His-
tologically, they present distinctive characteristics and 
should be considered in the differential diagnosis of tes-
ticular masses, especially in older men.
FIGURE 2. Cranial TAC (contrast): hiper-uptake bilateral 
nodules with digitiform edemas.
Tiltman AJ. Metastatic tumors in the testis. Histopa-
thology 1979; 3: 31-37.
Bothing R, Rogosch KU, Mach P et al. Aktuelle Urol 
2006; 37(2): 138-140.
Meacham RB, Mata JA, Espada R et al. Testicular 
metastases as first manifestation of colon carcinoma.
J Urol 1988; 140: 621-622.
Zur RJ, Trotter SE, Baithun SI. Krukemberg tumor 
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Muir GH, Fisher C. Gastric carcinoma presenting 
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Blasco de Villalonga M, Llarena RI, Acha MP et al. 
Testicular metastases of renal adenocarcinoma. Re-
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Lauro S, Lanceta G, Brisa E et al. Contralateral so-
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Gupta TD, Grabstaald H. Melanoma of the geni-
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REFERENCES AND RECOMENDED READINGS
(*of special interest, **of outstanding interest)
226
J. L. Mijan Ortiz, F. Valle Diaz de la Guardia, A. Jimenez Pacheco et al.


TESTICULAR METASTASIS AS FIRST CLINICAL EXPRESSION OF UNKNOWN ORIGIN MALIGNANT MELANOMA

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TESTICULAR METASTASIS AS FIRST CLINICAL EXPRESSION OF UNKNOWN ORIGIN MALIGNANT MELANOMA

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