Teratocarcinoma is one type of testis cancer that can be represented in the youth population and usually shows itself with swelling of the testis and edema and a rise of BHCG and alpha-fetoprotein, but spontaneous rupture is a rare manifestation. A 23-year-old man was referred to the Sina Hospital with complaints of testis pain and swelling. Laboratory findings were alpha f.p more than 2,000, BHCG titer 255.21, and LDH 504. Sonography findings showed the right testis had been detected with a heterogeneous mass with vascularity and cystic area with microcalcification, measuring 76*69 mm. During surgery, we faced rupture tumor that was unusual and rare. The radical orchidectomy was done successfully without any complications. After the surgery, pathology showed teratocarcinoma of the right testis, and a 6-month observation and follow-up were done without any complication.

© 2023 The Author(s). Published by S. Karger AG, Basel

Testis cancer is one of the most common cancers in men aged 15–45 years and is one of the most curable cancers. It shows itself as one hundred percent men’s cancer and five hundred percent urological cancer [1]. One type of testis cancer is teratocarcinoma, a germ cell-derived tumor [[2], [3]]. Men with symptoms should receive a complete history and physical examination. Scrotal ultrasonography is the preferred initial imaging study. If a solid intratesticular mass is discovered, orchiectomy is both diagnostic and therapeutic. Staging through chest radiography, chemistry panel, liver function tests, and tumor markers guides treatment [4].

Spontaneous rupture of testis cancers like teratocarcinoma, according to papers, is very rare. In this report, we introduce a case that underwent radical orchidectomy with the pathology of teratocarcinoma; the tumor tissue was torn during the operation, and the patient had no history of trauma.

A 23-year-old man was referred to the ED of Sina Hospital with swelling and engorgement of the testis and dull pain for 4 weeks. This case is reported based on the CARE checklist, and the patient agreed to report his case by signing the written informed consent [5] (online supplementary file 1; for all online suppl. material, see www.karger.com/doi/10.1159/000530502). The patient informed us that his involved testis expansion began 10 days ago. In our examination, we found that the left hemiscrotum was intact. However, the right hemiscrotum was seen with extensive swelling and slight redness, and the right testis was very engorged with tenderness but correct coordination. There was not any evidence of trauma or any other systematic symptom like fever. The positive point of the present illness was the history of bilateral cryptorchidism. In sonography, the right testis had been detected with heterogeneous mass with vascularity and cystic area with microcalcification measuring 76*69 mm. On laboratory date, alpha f.p was more than 2,000, BHCG titer 255.21, and LDH 504. The surgery was done with a routine cut for radical orchiectomy and an inguinal incision (Fig. 1).

We found a ruptured testis after radical orchidectomy in the common incision.

During the surgery, we faced giant tumors in the testis with ruptured tunica albuginea and some necrotic and bloody tissues that were spilled out like the picture above. The testis tumor was excised and had a size of about 11*10*8 cm.

Teratocarcinoma was reported in a pathologic study: the appearance of the tumor cut surface was homogenous tan elastic with necrosis and extensive invasion to the tunica albuginea, a malignant mixed germ cell tumor with 65% polyembryoma, 25% teratoma, and 10% embryonal carcinoma (Fig. 2). The patient was referred to a radio-oncology clinic for the following management. In addition, there was any metastatic lesion in the follow-up chest and abdominopelvic CT scan with contrast.

The pathology pictures after radical orchidectomy that show teratocarcinoma.

Mixed germ cell tumors are a group of testis tumors that include more than one type of tumor, and for this reason, they can have differences in appearance, growth rate, metastasis, and the level of tumor markers [6]. Some kinds of testis tumors are found in pure form, and most of them are part of M-GCTs [[6], [7]].

Considering that teratomas can form a part of M-GCTs, the evidence can support the origin of rare tumors such as choriocarcinomas and sarcomas as part of M-GCTs being teratomas because teratoma has a potential for exchanging with the other tissues. However, certain combined kinds of tumors such as (embryonal carcinoma teratoma) seem to be more prevalent in M-GCTs which is almost close to the pathology report of our case [8].

Here we introduce the tumor kinds reported in the pathology of our case; polyembryoma itself is a combination of embryonal carcinoma and yolk sac tumor, which in the microscopic view has cavity-like sections called embryoid bodies in a myxoid stoma [9]. Also, teratomas are another category of M-GCTs, which are divided into pubertal and prepubertal groups; they are found in fifty percent of M-GCT cases, including in our case. Contrary to the pubertal type, the prepubertal type is not associated with germinal cell neoplasia and has less metastasis and mortality rate than the pubertal. Teratomas usually have a firm texture and definite borders. This case had a vascularized and heterogeneous mass with cystic and necrotic areas, which was similar to previous studies [[10]–[12]]. However, without any history of previous trauma or comorbidities, there was invasion and rupture of the tunica albuginea layer and extensive hematoma around the right testis, which was a rare finding. Currently, there is no specific strategy for managing such conditions during radical orchiectomy, and in a previous study, the number of cases of testicular rupture due to the tumor was only 5 cases in 60 years. In these cases, pathology like seminoma teratoma had been reported. Mature cystic teratoma yolk sac tumor and mixed GCT [13]. In this case, every one of three tumor markers was elevated as mentioned above. Radical orchiectomy and chemoradiotherapy can lead to the treatment of M-GCTs, despite the difference between the components and subsequently the level of tumor markers. Measuring these markers, especially AFP and hCG at the beginning of treatment, can play an important role in helping patient with treatment and follow-up [[6], [14]].

In this study, we report a mixed germ cell tumor of the testis that grew rapidly and caused the rupture of the tunica albuginea with rising levels of every three tumor markers, especially AFP. It is still not possible to provide detailed information on the management of such cases, but at least shorter follow-ups may be more useful for patients.

The authors would like to thank the patient and the Urology Research Center at Sina Hospital.

Written informed consent was obtained from the patient for publication of the details of their medical care and any accompanying images. This is a case report, and no ethics code and committee are applicable, and ethical approval is not required for this study. This retrospective review of patient data did not require ethical approval in accordance with local/national guidelines. This case is reported based on the CARE checklist, and the patient agreed to report his case by signing the written informed consent.

The authors declare that they have no competing interests.

There was no funding.

Fardin Asgari wrote the manuscript, Pedram Golmohammadi revised the manuscript, Diana Taheri ran pathology tests, and Seyed Mohammad Kazem Aghamir undertook surgery.

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.

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