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Bilateral testicular metastases from adenocarcinoma prostate: A rare case report with review of literature

1 Department of Surgical Oncology, Sri Venkateshwaraa Medical College Hospital and Research Centre, Puducherry, India
2 Department of Radiation Oncology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
3 Department of Pathology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India

Date of Submission29-Mar-2021
Date of Decision10-Sep-2021
Date of Acceptance18-Sep-2021

Correspondence Address:
Jayanthi Chandran,
No: 24, Assistant Professor Quarters, Sri Manakula Vinayagar Medical College and Hospital, Madagadipet, Puducherry
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_228_21


The incidence of secondary neoplasms of the testis has been reported at 0.02%–2.5%. The testis is a rare metastasis site for prostatic adenocarcinoma. A 62-year-old gentleman presented with neck swelling and testicular swelling. On evaluation, he was found to have metastatic carcinoma of prostate on 68-Gallium prostate-specific membrane antigen study with disseminated metastasis along with right testicular metastases. The patient underwent bilateral orchidectomy as part of the hormonal treatment, and the histopathological examination revealed the metastatic deposits on both the testis with the left testis showing only micrometastasis. Only few cases of bilateral testes metastases from the prostatic carcinoma are reported in the literature.

Keywords: Bilateral testis, metastatis, prostatic adenocarcinoma

How to cite this URL:
Palaniappan R, Purushotaman D, Chandran J. Bilateral testicular metastases from adenocarcinoma prostate: A rare case report with review of literature. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Nov 30]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=337701

  Introduction Top

In the genitourinary tract, the proportion of secondary neoplasm is relatively low. The incidence of secondary neoplasms of the testis has been reported at 0.02%–2.5%.[1],[2],[3] Most of the metastatic tumors to the testes are of leukemia origin.[4] Prostatic adenocarcinoma is one of the common malignancies affecting the adult male population. The favored sites of metastasis of prostatic cancer are the bone, liver, and lungs. Prostatic adenocarcinoma rarely metastasizes to testis and is incidentally detected in orchidectomy specimens as part of the antiandrogen therapy.[5] Unilateral metastases have been documented in the literature, whereas only few cases with bilateral testes metastases are documented in the literature so far.[6],[7]

  Case Report Top

A 62-year-old gentleman presented to our institution with the complaints of left lower neck swelling of 1-month duration which is progressively increasing in size. On evaluation, he was found to large left supraclavicular fixed nodal mass of size 6 cm × 6 cm and hard nodular prostate. Serum prostate-specific antigen (PSA) was found to be 2136 ng/ml. The biopsy from the prostate revealed prostatic adenocarcinoma with Gleason's score of 5 + 4 in 80% of the cores. The biopsy of the neck nodal mass also confirmed the origin of the tumor to be of prostate.

68 Gallium prostate-specific membrane antigen (PSMA) – magnetic resonance imaging fusion study revealed ill-defined 68Ga PSMA-avid T2 heterointense lesion involving entire left lobe of prostate and with focal extracapsular invasion, neurovascular bundle involvement on the left side, and infiltration of the bladder base. Furthermore, there were PSMA-avid multiple inguinal, iliac, retroperitoneal, mediastinal and cervical lymph nodal metastases, multiple osteolytic/sclerotic lesions in left parietal bone, left humerus, lumbar and thoracic vertebra, left 6th rib and bilateral iliac bones, and left acetabulum and right testes [Figure 1]a, [Figure 1]b, [Figure 1]c. After the multidisciplinary board discussion, in view of the extensive metastatic prostatic cancer, the patient was counseled for hormonal management and palliative chemotherapy.
Figure 1: (a) Computed tomography axial section showing metastases in the right testis. (b) 68-Gallium prostate-specific membrane antigen PET imaging showing uptake in the right testis. (c) 68 Gallium prostate-specific membrane antigen positron emission tomography imaging with coronal image revealing disseminated metastasis along with the right testis uptake of the isotope

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The patient underwent surgical hormonal management with bilateral orchidectomy. The right testis was grossly enlarged and the left testis was normal on gross examination. The postoperative histopathology examination of the testis revealed the presence of tumor cells arranged in sheets with abundant eosinophilic to vacuolated cytoplasm with a centrally placed vesicular to hyperchromatic nucleus. Left testis showed similar kind of metastatic deposits ranging in size from 0.4 to 0.6 cm microscopically. Immunohistochemical marker analysis using PSA showed a strong cytoplasmic and membranous positivity confirming the diagnosis of metastatic prostatic adenocarcinoma to the testis [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d.
Figure 2: (a) Photomicrograph showing tumor cells arranged in sheets infiltrating the testicular parenchyma (H and E, ×100). (b and c): Photomicrograph showing tumor cells with abundant eosinophilic to vacuolated cytoplasm (H and E, ×400). (d) Photomicrograph showing strong cytoplasmic positivity for prostate-specific antigen (immunohistochemistry, ×400)

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The patient was further treated with combined androgen blockade and palliative chemotherapy. This case is reported for its rarity of the bilateral testicular metastases in carcinoma prostate.

  Discussion Top

Testicular metastasis of prostatic adenocarcinoma is an uncommon phenomenon with the lungs and kidneys being the most common primary sites of metastasis. One of the factors hypothesized for this low incidence is the relatively low temperature of the scrotum.[8] The metastatic spread to the testicles can occur in several ways. First, it can be through retrograde migration into the lumen of the vas deferens. Second, it can spread through vascular or lymphatic routes. Third, it may occur as a direct, local extension of the prostate tumor.[9] Most of prostatic cancer patients with testicular metastases have widespread metastases, although isolated testicular metastases also have been defined.[10] The involvement of the prostatic urethra in prostatic carcinoma increases the risk of testicular metastases.[11]

The testicular metastases can occur as synchronous lesions or metachronous lesions after the treatment for the primary tumor.[12] The entire testicular tissue should be sectioned and subjected meticulously to microscopic examination not to miss out any micrometastatic deposits.[13] In our case, the left testis did not show any macroscopic spread of the tumor. On detailed microscopic examination, the presence of tumor microdeposit was established, stressing the important of comprehensive histopathological analysis for a definitive diagnosis. Since prostatic adenocarcinoma has variable morphology, the diagnosis of testicular metastasis could be challenging on histopathology. The treatment of the prostatic carcinoma with the testicular metastases is not changed. The clinical implication of testicular metastasis in prostatic adenocarcinoma is though not well established although some of the reports have shown it as a poor prognostic factor.[14]

  Conclusion Top

The metastasis of the prostate carcinoma into a testis as a rare localization of the metastatic dissemination particularly in the bilateral testes might have both prognostic and therapeutic implications. The detailed examination of the specimen by the pathologists plays a vital role in the diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Dutt N, Bates AW, Baithun SI. Secondary neoplasms of the male genital tract with different patterns of involvement in adults and children. Histopathology 2000;37:323-31.  Back to cited text no. 1
Hanash KA, Carney JA, Kelalis PP. Metastatic tumors to testicles: Routes of metastasis. J Urol 1969;102:465-8.  Back to cited text no. 2
Tiltman AJ. Metastatic tumours in the testis. Histopathology 1979;3:31-7.  Back to cited text no. 3
Grigron DJ, Shum DT, Hayman WP. Metastatic cancer of testis. Can J Surg 1986;29:359-61.  Back to cited text no. 4
Saitoh H, Hida M, Shimbo T, Nakamura K, Yamagata J, Satoh T. Metastatic patterns of prostatic cancer. Correlation between sites and number of organs involved. Cancer 1984;54:3078-84.  Back to cited text no. 5
Ho CR, Ng KF, Chen JF, Wu CT, Chuang CK, Pang ST. Metastasis of prostate cancer in a single testis presented as a hydrocele: Report of a case. Curr Urol 2007;1:55-6.  Back to cited text no. 6
Giannakopoulos X, Bai M, Grammeniatis E, Stefanou D, Agnanti N. Bilateral testicular metastasis of an adenocarcinoma of the prostate. Ann Urol (Paris) 1994;28:274-6.  Back to cited text no. 7
Ulbright TM, Young RH. Metastatic carcinoma to the testis: A clinicopathologic analysis of 26 non incidental cases with emphasis on deceptive features. Am J Surg Pathol 2008;32:1683-93.  Back to cited text no. 8
DiGregorio M, Nollevaux MC, Hondt LD, Lorge F. Testicular metastasis of prostatic adenocarcinoma after ablatherm® treatment. Med Sur Urol 2017;6:178.  Back to cited text no. 9
Inaba Y, Okamoto M, Harada M, Sakaue M, Maeda S. Prostatic carcinoma with bilateral testicular metastasis: A case report. Hinyokika Kiyo 1994;40:249-52.  Back to cited text no. 10
Kusaka A, Koie T, Yamamoto H, Hamano I, Yoneyama T, Hashimoto Y, et al. Testicular metastasis of prostate cancer: A case report. Case Rep Oncol 2014;7:643-7.  Back to cited text no. 11
Janssen S, Bernhards J, Anastasiadis AG, Bruns F. Solitary testicular metastasis from prostate cancer: A rare case of isolated recurrence after radical prostatectomy. Anticancer Res 2010;30:1747-50.  Back to cited text no. 12
Sampathrajan S, Garg G, Gupta S, Sahay SC, De S. Incidentally detected testicular metastasis in a case of prostatic adenocarcinoma. J Clin Diagn Res 2015;9:D03-4.  Back to cited text no. 13
Korkes F, Gasperini R, Korkes KL, Silva Neto DC, Castro MG. Testicular metastases: A poor prognostic factor in patients with advanced prostate cancer. World J Urol 2009;27:113-5.  Back to cited text no. 14


  [Figure 1], [Figure 2]


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