This is a case report of a 72-year-old male patient who presented to his General Practitioner (GP) with a painless right sided scrotal swelling for few weeks.
The patient had a history of G2Ta transitional cell carcinoma (TCC) of the bladder since 2016 and was on regular surveillance with cystoscopy and Mitomycin-C (MMC) intravesical treatment. The patient had a history of stage A CLL since 2015 and was under surveillance by hematology team.
After examining the patient, the GP requested a Doppler ultrasound (Philips Epiq 7®) (US) scan testes which showed that right testis appeared diffusely enlarged and diffusely hypoechoic with marked hyper vascularity, no calcification and no obvious discrete masses. The report suggested the diagnosis of epididymo-orchitis (Fig. 1). The GP started the patient on a course of an antibiotic (Ciprofloxacin) but given the concern about the ‘painless’ testicular mass, GP decided to refer the patient for urology consultation.
In January 2019, the patient attended in our urology outpatient clinic. Scrotal examination revealed about 10 X 10 cm hard non-tender right-sided scrotal mass with normal left testicle. There was no peripheral lymphadenopathy or organomegaly.
Peripheral blood counts showed WBC = 17.5 × 109/L with neutrophils of 4.39 × 109/L, lymphocytes of 11.16 × 109/L. Testicular tumor marker; B-HCG < 1 IU/L, AFP = 2.3 IU/ml and LDH = 169 IU/L. Computed tomography (Siemens Healthcare®) (CT) scan chest, abdomen and pelvis (CAP) reported some borderline enlarged left para-aortic and aorto-caval lymph nodes and Unremarkable abdominal viscera (Fig. 2).
Right inguinal orchidectomy was performed. Histopathology reported the entire right testicle was heavily infilterated with sheets of medium-sized and large lymphoid tissue associated with frequent mitotic figures. The infilteration was diffuse with no obvious nodular architecture. The atypical lymphoid cells were positive for CD20, CD79a, BCL-2, BCL-6, CD10 and MUM 1. There was negative staining for CD23, CD 5 but showed weak wide spread Lef-1 nuclear staining. The morphology and immunohistochemistry profile were consistent with a high grade Richter’s transformation to diffuse large B cell lymphoma of germinal center type, which was confirmed by expert second opinion (Figs. 3, 4, 5).
Two weeks postoperatively the patient presented with a right-sided scrotal swelling for which USS testes showed an approximately 76 × 60 × 57 mm avascular, right-sided well-defined cystic structure with internal debris and septations was identified; possibly a collection (Fig. 6). Surgical drainage of 200 ml serosanguinous fluid was performed through a midline scrotal incision.
In view of development of RS, Hematology team planned the following treatment for the patient; first, to start on R-CHOP (Rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone).
Secondly, as testicular lymphomas are associated with late lymphoma relapses around the brain or spinal cord; therefore, in order to reduce this risk, we proposed to give him methotrexate intrathecal (as a lumbar puncture) and two methotrexate treatments intravenously.
Finally, as testicular lymphomas tend to spread to the other testicle, the hematologist also recommended that the patient should consider either surveillance, radiotherapy or the last option to be removal of the other testicle (a contralateral orchiectomy).
After full counseling, our patient opted to go for contralateral orchiectomy after completing the whole course of chemotherapy as he was not accepting any possibility of recurrence; however, minimal that risk is. Simple orchidectomy was done and histopathology confirmed normal testicle. Our patient has been referred for endocrinology follow-up to manage his testosterone level. At almost two years follow-up, the patient is in remission.