Journal of Surgical Oncology 31:44-47 (1986)

Seminoma Arising in Undescended Testis Clinically Presenting as Acute Appendicitis

DEBA P. SARMA, MD, T H O M A S G. WEILBAECHER, MD, AND ALI A. HATEM, MD From the Department of Pathology, Veterans Administration Medical Center, and the

Louisiana State University Medical Center, New Orleans

A 48-year-old man with a clinical diagnosis of acute appendicitis on exploration was found to have a seminoma in an undescended pelvic testis. The tumor had directly invaded the retrocecal appendix, causing acute appendicitis. Such a highly unusual occurrence has not been described in the English literature.

KEY WORDS: seminoma in undescended testis, unusual clinical presentation of seminoma, unusual cause of acute appendicitis, seminoma and acute appendicitis

INTRODUCTION Development of a malignant neoplasm is a well-known

complication of an undescended testis. Neoplastic intra- abdominal testis may present with signs and symptoms, such as a groin or abdominal mass or pain; or it may remain clinically silent until distant metastases occur as evidenced by lesions on chest roentgenograms or en- larged lymph nodes [Batata et al, 19801. Various primary benign and malignant tumors as well as metastatic tumors have been noted to have caused acute appendicitis [Col- lins, 19631. We did not find any report in the English literature describing seminoma invading vermiform ap- pendix and causing acute appendicitis.

CASE REPORT A 48-year-old white man was brought to the emer-

gency room with a 48-hour history of right lower quad- rant abdominal pain. He had a fever (temperature 100°F) but had no gastrointestinal complaints. Bowel sounds were faint. The right lower abdomen was markedly tender with rebound tenderness. The rest of the physical exam- ination was unremarkable except for the absence of the left testicle in the scrotal sac. The white blood cell count was 11,300/mm3 with 5% neutrophilic bands, 82% neu- trophils, 5 % lymphocytes, and 7% monocytes. Urinaly- sis yielded normal values. A clinical diagnosis of acute appendicitis was made.

On abdominal exploration, an enlarged edematous re- trocecal appendix (6X2.5 X2cm) was noted to be adher- ent and invaded by a gray-white tumor mass near its distal end. The large, lobulated pelvic tumor mass

0 1986 Alan R. Lm, Inc.

( 1 3 ~ 6 ~ 5 c m ) was adherent to the left anterior pelvic wall and the urinary bladder. It crossed the midline and extended to the periappendiceal adipose tissue and di- rectly invaded the distal portion of the appendix. The appendix and the pelvic tumor were removed. There was no gross enlargement of pelvic or aortic lymph nodes.

Microscopic examination of the pelvic mass revealed a typical seminoma arising in an atrophic undescended testis (Figs. 1, 2). The tumor extended into the fibroadi- pose tissue around the appendix and directly invaded the appendiceal wall up to the mucosa (Figs. 3, 4). There was acute fibrinopurulent appendicitis and periappendi- citis. Multiple sections of the pelvic tumor did not show any other germ cell component in the seminoma.

The patient made an uneventful postoperative recovery. Metastatic survey including CT scans did not reveal

any evidence of tumor in the lungs, mediastinurn, liver, pancreas, kidneys, or the abdominal lymph nodes. Serum alpha-fetoprotein was not detected. Serum human cho- rionic gonadotropin level was less than 1.0 MIU/ml (nor- mal < 10 MIU/ml).

The patient received radiation therapy with a total dose of 3,510 rads over a l%-month period that included 2,010 rads to whole abdomen and a boost of 1,500 rads over the pelvis and the para-aortic lymph nodes. Admin- istration of prophylactic irradiation to the mediastinum and the supraclavicular areas has been planned.

Accepted for publication August 27, 1984. Address reprint requests to D. Sarma, MD, V.A. Medical Center, 1601 Perdido Street, New Orleans, 70146.

Seminoma Presenting as Acute Appendicitis 45

Fig. 1. The pelvic tumor revealing typical seminoma (H&E X 120).

Fig. 2. One intact seminiferous tubule and hyalinized nodules suggesting atrophic testis (above) and seminoma (below) (H&E x60).

46 Sarma, Weilbaecher, and Hatem

Fig. 3. Cut section of the appendix showing tumor invading the wall and protruding into the lumen (H&E X 10).

Fig. 4. Seminoma invading the mucosa of the appendix (H&E ~ 8 0 ) .

Seminoma Presenting as Acute Appendicitis 47

The choice of treatment for seminoma is irradiation DISCUSSION after surgery to the regional lymph nodes [Jose et al, 19841. Five-year survival for the patients with seminoma arising in cryptorchid testis treated by external irradiation to the regional lymphatics after abdominal orchiectomy is about 78% [Batata et al, 19801.

The probability of a malignant neoplasm developing in an undescended testis is about 30-50 times greater than in a normally descended testis [Fonkalsrud, 19701. The various clinical presentations of testicular tumors arising in an abdominal testis include abdominal pain, lower abdominal mass, positive urinary or serum chorionic gonadotropin, ureteral displacement on intravenous py- elogram, regional lymphadenopathy on lymphangiogra- phy, enlarged inguinal or neck lymph nodes, and gynecomastia [Batata et al, 19801. One case of recurrent torsion of an intra-abdominal testis presenting clinically as acute appendicitis has been described [O’Riordan and Sherman, 19771. In several studies describing the various lesions in appendectomy specimens, several neoplasms including ovarian and uterine cancers [Stephenson and Snoddy, 19611 and stomach cancer [Dymock, 19771 have been noted to have metastasized to the appendix. Collins [ 19631 has studied 7 1 ,OOO human appendix specimens over a @year period but has not found a case of semi- noma causing appendicitis.

Our case is most unusual because the seminoma origi- nating in the left undescended testis had to cross the midline to invade the retrocecal appendix on the right side of the abdomen.

ACKNOWLEDGMENTS We thank Mrs. Roey Holliday for excellent secretarial

assistance.

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