title: Nonpalpable testicular pure seminoma with elevated serum alpha-fetoprotein presenting with retroperitoneal metastasis: a case report.
abstract: BACKGROUND
  Patients with a primary pure seminoma in the testis who have elevated serum alpha-fetoprotein are rare and should be treated as patients with nonseminomatous germ cell tumors. However, nonpalpable testicular tumors in this condition have never been reported. We describe a case of nonpalpable pure testicular seminoma with elevated serum alpha-fetoprotein presenting retroperitoneal metastasis.
  
  
  METHODS
  A 29-year-old Asian man was referred to our hospital with right flank pain. Computed tomography showed a mass located between his aorta and inferior vena cava, but a testicular tumor was not detected. His serum levels of lactate dehydrogenase, alpha-fetoprotein, and DUPAN-2 were high. Although no tumor or nodule was palpable in his testis, ultrasonography revealed multiple low echoic lesions in his right testicular parenchyma. He was diagnosed with right testicular cancer with retroperitoneal lymph node metastasis and underwent right high orchiectomy. A pathological examination revealed pure seminoma and no nonseminomatous components were found in the specimen. Three courses of induction systemic chemotherapy (cisplatin, etoposide, and bleomycin) normalized his serum alpha-fetoprotein and DUPAN-2 levels. Three additional courses of chemotherapy (etoposide and bleomycin) were performed, and treatment was completed with laparoscopic retroperitoneal lymph node dissection. Pathology of the dissected specimen showed fibrous and necrotic tissue with no viable cells. He is alive without recurrence 54 months after orchiectomy.
  
  
  CONCLUSIONS
  We report a case of pure testicular seminoma with elevated serum alpha-fetoprotein and DUPAN-2 presenting retroperitoneal metastasis. We recommend an ultrasound examination of bilateral testes when large retroperitoneal tumors are detected in young men, even if a mass is not palpable in the scrotum.
authors.affiliation: Department of Nephro-urology, Graduate School of Medical Sciences, Nagoya City University, 1, Kawasumi, Mizuho-cho, Mizuho-ku, 467-8601, Nagoya, Japan.
authors.forename: Shoichiro
authors.initials: S
authors.lastname: Iwatsuki
authors.affiliation: Department of Nephro-urology, Graduate School of Medical Sciences, Nagoya City University, 1, Kawasumi, Mizuho-cho, Mizuho-ku, 467-8601, Nagoya, Japan. naiki@med.nagoya-cu.ac.jp.
authors.forename: Taku
authors.initials: T
authors.lastname: Naiki
authors.affiliation: Department of Nephro-urology, Graduate School of Medical Sciences, Nagoya City University, 1, Kawasumi, Mizuho-cho, Mizuho-ku, 467-8601, Nagoya, Japan.
authors.forename: Noriyasu
authors.initials: N
authors.lastname: Kawai
authors.affiliation: Department of Nephro-urology, Graduate School of Medical Sciences, Nagoya City University, 1, Kawasumi, Mizuho-cho, Mizuho-ku, 467-8601, Nagoya, Japan.
authors.forename: Toshiki
authors.initials: T
authors.lastname: Etani
authors.affiliation: Department of Nephro-urology, Graduate School of Medical Sciences, Nagoya City University, 1, Kawasumi, Mizuho-cho, Mizuho-ku, 467-8601, Nagoya, Japan.
authors.forename: Keitaro
authors.initials: K
authors.lastname: Iida
authors.affiliation: Department of Nephro-urology, Graduate School of Medical Sciences, Nagoya City University, 1, Kawasumi, Mizuho-cho, Mizuho-ku, 467-8601, Nagoya, Japan.
authors.forename: Ryosuke
authors.initials: R
authors.lastname: Ando
authors.affiliation: Department of Nephro-urology, Graduate School of Medical Sciences, Nagoya City University, 1, Kawasumi, Mizuho-cho, Mizuho-ku, 467-8601, Nagoya, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Nagai
authors.affiliation: Department of Nephro-urology, Graduate School of Medical Sciences, Nagoya City University, 1, Kawasumi, Mizuho-cho, Mizuho-ku, 467-8601, Nagoya, Japan.
authors.forename: Atsushi
authors.initials: A
authors.lastname: Okada
authors.affiliation: Department of Nephro-urology, Graduate School of Medical Sciences, Nagoya City University, 1, Kawasumi, Mizuho-cho, Mizuho-ku, 467-8601, Nagoya, Japan.
authors.forename: Keiichi
authors.initials: K
authors.lastname: Tozawa
authors.affiliation: Department of Pharmacy, Nagoya City University Hospital, Nagoya, Japan.
authors.forename: Yosuke
authors.initials: Y
authors.lastname: Sugiyama
authors.affiliation: Department of Nephro-urology, Graduate School of Medical Sciences, Nagoya City University, 1, Kawasumi, Mizuho-cho, Mizuho-ku, 467-8601, Nagoya, Japan.
authors.forename: Takahiro
authors.initials: T
authors.lastname: Yasui
mesh_terms: D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D006801:Humans; D060828:Induction Chemotherapy; D008197:Lymph Node Excision; D008297:Male; D009919:Orchiectomy; D012186:Retroperitoneal Neoplasms / Q000000981:diagnostic imaging* / Q000378:metabolism / Q000556:secondary / Q000628:therapy; D018239:Seminoma / Q000097:blood / Q000000981:diagnostic imaging* / Q000556:secondary / Q000628:therapy; D013736:Testicular Neoplasms / Q000000981:diagnostic imaging* / Q000378:metabolism / Q000628:therapy; D014057:Tomography, X-Ray Computed; D014463:Ultrasonography; D000509:alpha-Fetoproteins / Q000378:metabolism
chemical_list: D000509:alpha-Fetoproteins
keywords: Alpha-fetoprotein; Burned-out tumor; Case report; DUPAN-2; Retroperitoneal lymph node dissection; Seminoma; Testicular tumor