'Burned-out' syndrome of testicular teratoma: A case report

Abstract

The majority of testicular tumors are germ cell tumors (GCTs) which, although rare, frequently present in young adults. In exceptional circumstances, spontaneous regression of the primary tumor occurs. The appellation 'burned-out' is applied to situations in which a metastatic GCT is found to be present, accompanied by histological regression of the primary testicular lesion. It is of crucial importance that a clinical examination of the testis is performed, and scrotal sonography is essential in the preliminary diagnosis of such neoplasms. In the present case report, a burned-out, non-seminomatous testicular GCT case is described. A CT scan revealed that a 29-year-old male patient who was experiencing loss of weight and appetite had retroperitoneal and mediastinal masses. A testicular examination did not reveal the presence of any palpable lesion, and an ultrasound examination of the scrotum disclosed a normal left testis and an atrophic right testicle with heterogeneous architecture, but with no evidence of a tumor. Chemotherapy was administered to the patient following surgical intervention into the retroperitoneal and mediastinal mass. It is evident that it remains problematic to accurately differentiate between a primary retroperitoneal tumor and a metastatic testicular tumor with an occult testicular primary or a 'burned-out' testicular cancer. The burned-out phenomenon is a rare occurrence, and further research into its pathogenesis is required. Both the rarity of this phenomenon and the difficulties encountered in diagnosis prompted the writing of the present case report, especially considering that teratomas are categorized as belonging to the histology group that shows the least likelihood of regressing.

Keywords: burned-out syndrome; punctuate echogenic foci; testicular teratoma.

Figure 1

Pre-operative evaluation of the patient with imaging techniques. This CT, also performed with contrast medium, showed the lymphadenopathies of the retroperitoneum. (A) Arterial phase of the CT scan in which the voluminous lymph node mass is indicated by the red arrow while the blue arrow indicates the aorta. (B) The blue arrow shows the left common iliac artery while the red arrow indicates lymphadenopathy. (C) The blue arrow indicates the bifurcation of the left iliac arterial axis in the left internal and external iliac artery while the red arrow indicates the lymph node mass. (D) Voluminous lymphadenopathy (indicated by the red arrow) incorporates the left external iliac artery (indicated by the blue arrow).

Figure 2

Follow-up performed with imaging techniques after the first surgery. This control CT scan revealed tumor recurrence of the retroperitoneum: (A) In the lumbar aortic left region (where a mass occupying space is visible between the aorta and the vascular peduncle of the left kidney), (B) long and close to the common iliac and external left vascular axis (since the mass extends to the bifurcation of the aorta into the iliac arteries).

Figure 3

Access to the retroperitoneal space using an open surgical approach with a median incision. (A) Isolation, upstream and downstream between two blue ribbon-like wires, of the caval vein from the lymph node mass. (B) Isolation of the left iliac artery (with red vessel loop) and ureter (with yellow vessel loop).