Diagnosis of Seminoma With Metastasis to the Brain and Kidneys in a Moluccan Eclectus (Eclectus roratus) Using Advanced Contrast Based Imaging.

A 20-year-old male Moluccan eclectus (Eclectus roratus) was presented with a history of falling off the perch, ataxia, unilateral blindness, hyporexia, and progressive lethargy. The eclectus was found to have a leukocytosis (52 × 103 cells/µL), characterized by an absolute and relative heterophilia (42.6 × 103 cells/µL and 82%, respectively), relative lymphopenia (18%), elevated bile acids (88 µmol/L), and elevated triglycerides (236 mg/dL). Radiographic images revealed a mass effect within the caudal coelom. After 13 days of outpatient supportive care, the patient was rechecked and had normalized bile acids (<35 µmol/L), static triglycerides (232 mg/ dL), and hyperuricemia (18.6 mg/dL). Computed tomography was performed antemortem with and without iodinated contrast agent, 4 mL/kg IV over 2 minutes, and a mass was found associated with the left kidney. Due to worsening neurologic signs and involvement with surrounding structures, the owner elected euthanasia. Before the postmortem examination, a postmortem intravascular contrast agent was used to provide a more thorough visualization of internal anatomical structures, including left renal vasculature disruption, mass vasculature, caudal coelomic organ displacement, and increased irregular optic chiasm radiodensity. Postmortem, a 4 × 4.1 × 5.1-cm white to tan mass was identified. Histopathology confirmed a seminoma with metastasis to the kidneys and optic chiasm. Seminomas have been described in avian species; however, seminoma metastasis in an eclectus parrot confirmed by histopathology has not been reported, and optic chiasm metastasis of a seminoma has not been described in any avian species. This report describes postmortem computed tomographic angiography of metastatic seminoma in a Moluccan eclectus with metastasis to the optic chiasm.

Contrast-enhanced ultrasound in the diagnosis of a solitary neck mass: a case report of metastatic seminoma.

Seminoma accounting for approximately 98% of malignant testicular tumours and it typically presents as a painless, palpable solid mass in the testis. Seminomas presenting only as a solitary neck mass are very rare. This case report describes a previously healthy 35-year-old male that presented with a 3-month history of the incidental discovery of a mass in his right neck. He had no testicular symptoms. He underwent neck ultrasound, contrast-enhanced ultrasound, computed tomography and positron emission tomography. Serum human chorionic gonadotropin (3.90 mIU/ml) was raised and alpha-fetoprotein (3.79 ng/ml) was within normal limits. Clinical examination and imaging examinations did not find any suspicious signs of testicular cancer. Biopsy from the neck mass confirmed the diagnosis of metastatic seminoma. The case report presents the ultrasound and contrast-enhanced ultrasound characteristics of seminoma and provides an update of the literature regarding this very rare metastatic site for seminomas.

Two decades of FDG-PET/CT in seminoma: exploring its role in diagnosis, surveillance and follow-up.

BACKGROUND: Survivors of testicular cancer may experience long-term morbidity following treatment. There is an unmet need to investigate techniques that can differentiate individuals who need additional therapy from those who do not. 2-18fluoro-deoxy-D-glucose (FDG) positron emission tomography (PET) with computerised tomography (CT) may be helpful in select settings and may be used outside of current evidence-based recommendations in real-world practice. METHODS: A institutional FDG-PET/CT database of scans performed between 2000 and 2020 for adults with testicular seminoma was interrogated. Endpoints of interest included the positive (PPV) and negative (NPV) predictive value of FDG-PET/CT for identifying active seminoma (defined by progressive radiology, response to treatment or biopsy); or no active seminoma within 24-months for patients with stage 1 and advanced seminoma. An exploratory analysis examining predictive role of SUVmax was also performed. RESULTS: 249 patients met eligibility criteria for the analysis, including 184 patients with stage 1 and 77 patients with advanced testicular seminoma. Of 193 FDG-PET/CT performed in stage 1 seminoma with available follow-up data, 79 were performed during active surveillance. 18 (23%) of these were positive, all of which had confirmed recurrent seminoma (PPV 100%). Of 45 negative FDG-PET/CT during active surveillance, 4 recurrences developed corresponding to a NPV 91%. When clinical suspicion precipitated FDG-PET/CT (n = 36): PPV 100%, NPV 86%. Of 145 FDG-PET/CT in advanced seminoma with available follow-up data, 25 (17%) were performed at baseline (within 2 months of diagnosis), 70 (48%) post-treatment for evaluation of treatment response and 50 (34%) during follow-up following prior curative treatment. 10 (14%) post-treatment FDG-PET/CT were positive corresponding to a PPV 60%. Of 46 negative FDG-PET/CT, 5 recurrences occurred (NPV 89%). During follow-up after prior curative treatment, 24 (50%) FDG-PET/CT were positive corresponding to a PPV 83%; of 20 negative FDG-PET/CT, 1 recurrence occurred, NPV 95%. When clinical suspicion indicated FDG-PET/CT (n = 36): PPV 100%, NPV 94%. CONCLUSION: FDG-PET/CT offers high PPV for identifying seminoma and accurately predicts non-recurrence across a clinically relevant 24-months. Notably, FDG-PET/CT may prevent unnecessary treatment in 45% of patients undergoing investigation for clinical suspicion of recurrence during follow-up of advanced seminoma. The use of FDG-PET/CT in selected patients now, may help prevent unnecessary treatment of people with testicular seminoma.

The GETUG SEMITEP Trial: De-escalating Chemotherapy in Good-prognosis Seminoma Based on Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography.

BACKGROUND: In metastatic seminoma, a strategy is needed for selecting patients for less intensive chemotherapy, to limit toxicities. OBJECTIVE: To assess whether men with good-prognosis metastatic seminoma could be treated with two cycles of etoposide-cisplatin (EP) followed by only one cycle of carboplatin (CARBO) based on negative interim fluorodeoxyglucose positron emission tomography (FDG-PET)/computed tomography (CT). DESIGN, SETTING, AND PARTICIPANTS: A nonrandomised, multicentre, phase 2 trial was conducted (NCT01887340). INTERVENTION: All patients with baseline-positive FDG-PET/CT received EP for two cycles. After completing the first two cycles, the patients underwent a second FDG-PET/CT to assess the response. Patients with positive FDG-PET/CT proceeded directly to two additional EP cycles; those who achieved FDG-PET/CT negativity received one cycle of CARBO. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The proportion of patients with negative interim FDG-PET/CT who received carboplatin was determined. RESULTS AND LIMITATIONS: Between 2013 and 2017, 102 patients were enrolled. After the first two EP cycles, FDG-PET/CT was available in 98 patients. Overall, 67 patients (68.4%; 95% confidence interval [CI]: 58.2-77.4) had negative FDG-PET/CT and proceeded to a single CARBO cycle. Twenty-seven patients (27.6%; 95% CI: 19.0-37.5) had positive FDG-PET/CT after two EP cycles. The 3-yr progression-free survival rate was 90.0% (95% CI: 74.4-96.5) in the EP group and 90.8% (95% CI: 81.4-95.7) in the CARBO group. The cumulative incidences of peripheral neuropathy and ototoxicity were significantly higher in the EP group. CONCLUSIONS: Omission of two cycles of EP based on negative FDG-PET/CT after two cycles of chemotherapy appears to be feasible. However, the absence of consensus criteria for FDG-PET/CT interpretation and the short follow-up need additional studies. This strategy does not warrant routine integration yet. PATIENT SUMMARY: Men with good-prognosis metastatic seminoma were treated with fewer cycles of chemotherapy based on interim fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT). Omission of two cycles of chemotherapy based on negative FDG-PET/CT after two initial cycles appears to be feasible, thereby limiting the burden of treatment and toxicity.

18F-FDG PET/CT value in the detection of seminoma and correlation with CT and tumor marker levels - up to 8 years of follow-up.

OBJECTIVE: Positron emission tomography/computed tomography using fluorine-18 fluoro-deoxyglucose (18F-FDG PET/CT) is not routinely used for diagnosis of testicular carcinoma. Unlike CT which cannot confirm with certainty the nature of the lesions, especially in post-therapy setting, 18F-FDG PET/CT detects active disease by showing increased glucose metabolism within the lesions. AIM: Determination of 18F-FDG PET/CT usefulness in detection of seminoma, therapy response evaluation and comparison to CT findings and tumor marker levels. MATERIAL AND METHODS: Eighty-two men (age 39.8±10.1) after orchiectomy and histopathological confirmation of seminoma were included in this study. Indications for 18F-FDG PET/CT were initial staging, restaging after chemo/radiotherapy with positive/uncertain CT, suspected recurrence on CT, elevated tumor markers. All patients had clinical follow-up of up to 8 years (median 33.5) after the first 18F-FDG PET/CT examination. Degree of metabolic activity was analyzed visually and semi-quantitatively using maximum standardized uptake value(SUVmax). RESULTS: Fluorine-18-FDG PET/CT was true positive in 36 patients (43.9%) with average SUVmax of 7.9±4.8.Recurrence was mostly found in retroperitoneal lymph nodes and distant metastases in lungs, bones, liver. Six findings were false positive and 3 false negative. Sensitivity, specificity, accuracy of 18F-FDG PET/CT were 92.3%, 86.0%, 89.0% and of CT 60.8%, 66.6%, 63.4%. Pearson Chi-square test showed statistically significant difference between the results of 18F-FDG PET/CT and CT (P=0.016). Significant correlation was found between positive 18F-FDG PET/CT findings and levels of LDH (P=0.043), while non-significant between AFP, ß-hCG (P>0.05). CONCLUSION: Fluorine-18-FDG PET/CT was superior to CT in evaluation of therapy response, active disease in residual tissue and normal size lymph nodes, as well as when CT was negative and tumor markers were elevated. Elevated lactate dehydrogenase (LDH) contributes to positive 18F-FDG PET/CT findings.

Incidental Finding of Testicular Seminoma by 18F-Choline PET/CT in a Prostate Cancer Patient.

ABSTRACT: An 80-year-old man with a history of prostate cancer, treated with radical prostatectomy and bilateral obturator nodal dissection, underwent an 18F-choline PET/CT because of biochemical recurrence. The scan revealed an intense focal uptake in the right testicle. A subsequent orchifunicumlectomy demonstrated the presence of a classic seminoma. At present, 18F-FDG PET/CT is useful for initial staging of testicular cancer and determining the viability of residual masses >3 cm after completion of treatment, especially in patients with seminoma.

The utility of diffusion-weighted imaging and ADC values in the characterization of mumps orchitis and seminoma.

BACKGROUND: Diffusion-weighted imaging (DWI) can quantitatively reflect the diffusion characteristics of tissues, providing a theoretical basis for qualitative diagnosis and quantitative analysis of a disease. PURPOSE: To characterize testicular lesions that present as a hypointense signal on magnetic resonance imaging (MRI) T2-weighted images using DWI. MATERIAL AND METHODS: Study participants were divided into three groups. Group A were healthy controls (n = 35), group B included patients with mumps orchitis (n = 20), and group C included patients with seminoma (n = 15). DWI sequences used b-values of 0, 1000, and 2000 s/mm2. Apparent diffusion coefficient (ADC) values between 1000 and 2000 s/mm2 were calculated by MRI postprocessing software. The Kruskal-Wallis test and receiver operating characteristic analysis were performed to evaluate how well ADC values distinguished between mumps orchitis and seminoma. RESULTS: Normal testicular tissue showed a hyperintense signal on DWI and hypointensity on the ADC map: mean ADC value was 0.77 (0.69-0.85) ± 0.08 ×10-3 mm2/s. Mumps orchitis and seminoma showed slight hyperintensity on DWI: mean ADC values were 0.85 (0.71-0.99) ± 0.15 ×10-3 mm2/s and 0.43 (0.39-0.47) ± 0.04 × 10-3 mm2/s, respectively. There were statistically significant differences in mean ADC values between normal testicular tissue and seminoma and between mumps orchitis and seminoma. The cutoff ADC value for differentiating seminoma from mumps orchitis was 0.54 × 10-3 mm2/s. The sensitivity, specificity, and Youden Index for diagnosing seminoma were 99%, 31%, and 30%, respectively. CONCLUSION: High b-value DWI has potential utility for differentiating mumps orchitis from seminoma in the clinical setting.

Primary seminoma arising in the posterior mediastinum: a diagnostic challenge.

Primary mediastinal germ cell tumors are a rare finding, and one third of them are seminomas. Seminomas are found in the anterior mediastinum, whereas they are extremely rare within the posterior compartment. Most clinicians would not consider a primary seminoma in the differential diagnosis of a posterior mediastinal mass, as only two cases have been reported in literature. Here we present the case of a 57-year-old male with a primary seminoma arising in the left posterior mediastinum. He was asymptomatic and the mass was an incidental finding. Positron emission tomography (PET) revealed a small area with an avid tracer uptake. Transthoracic needle aspiration led to a non-diagnostic result. Due to the strong suspect of malignancy, a surgical excision was chosen to obtain a diagnosis. He underwent complete excision, and pathology report demonstrated a mediastinal seminoma. Subsequent further staging did not reveal any other location of the disease. Given the complete excision of the primary tumor, active surveillance was the treatment of choice. The patient is free of disease 48 months after diagnosis.

Tumor markers and 18F-FDG PET/CT after orchiectomy in seminoma: Is there any correlation?

OBJECTIVE: The aim of our study was to analyze the potential relationship between tumor markers and 18F-fluorodoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) results in patients affected by seminoma. MATERIAL AND METHODS: 65 18F-FDG PET/CT scans of 41 patients with diagnosis of seminoma were analyzed and compared to alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG). PET/CT studies were analyzed qualitatively and measuring the maximum and mean standardized uptake value body weight max (SUVbwmax, SUVbwmean), maximum SUV lean body mass (SUVlbm), maximum SUV body surface area (SUVbsa), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) of hypermetabolic lesions. All values were compared with serum markers. RESULTS: 31 PET/CT studies were true negative, 28 true positive, 6 false positive and 0 false negative with sensitivity of 100%, specificity of 84%, negative predictive value of 100%, positive predictive value of 82% and accuracy of 91%. No correlation between PET results and tumor marker levels was found and also between AFP and PET/CT semiquantitive parameters. All semiquantitative PET parameters were significantly related to hCG level. CONCLUSIONS: 18F-FDG PET/CT has good accuracy in evaluating patients with relapsed seminoma. HCG levels were significantly correlated with metabolic PET/CT parameters.

An annotated T2-weighted magnetic resonance image collection of testicular germ and non-germ cell tumors.

Testicular cancer is a rare tumor with a worldwide incidence that has increased over the last few decades. The majority of these tumors are testicular non-germ (TNGCTs) and germ cell tumors (TGCTs); the latter divided into two broad classes - seminomatous (SGCTs) and non-seminomatous germ cell tumors (NSGCTs). Although ultrasonography (US) maintains a primary role in the diagnostic workup of scrotal pathology, magnetic resonance imaging (MRI) has emerged as the imaging modality recommended for challenging cases, providing additional information to clarify inconclusive/equivocal US. In this work we describe and publicly share a collection of 44 images of annotated T2-weighted MRI lesions from 42 patients. Given that testicular cancer is a rare tumor, we are confident that this collection can be used to validate statistical models and to further investigate TNGCT and TGCT peculiarities using medical imaging features.

Primary mediastinal seminoma with florid follicular lymphoid hyperplasia: a case report and review of the literature.

BACKGROUND: First described in 1955 Primary mediastinal seminomas are rare. Only 1-4% of mediastinal tumours are germ cell tumors; majority of which are teratomas. They typically present in men aged between 20 and 40 years. Very few cases are reported in the literature. Florid follicular lymphoid hyperplasia can obscure the malignant cells and is a rarer finding still. We present a rare case of a 48 year old man with a primary mediastinal seminoma with florid follicular lymphoid hyperplasia; found following excision of a clinically presumed thymoma. CASE PRESENTATION: A 48 year old man was referred for excision of a thymic mass. The presumed diagnosis was a thymoma; following preoperative investigations. The mass was incidentally found on a radiological imaging. However, the patient did report mid-sternal discomfort on lying flat and breathlessness. The patient underwent a thymectomy via a partial median sternotomy with good recovery. Histological assessment was that the mass was in fact a primary mediastinal seminoma with florid follicular lymphoid hyperplasia. A primary testicular malignancy was excluded and the patient required no further oncological treatment. CONCLUSIONS: Only 11 cases have previously been reported of primary mediastinal seminoma with florid follicular lymphoid hyperplasia. Although rare, a primary mediastinal seminoma should be considered as a differential diagnosis for presentations with a thymic mass. Tumour markers can be helpful, however are only positive in third of cases. Ultrasound imaging of the gonads is essential to exclude a primary gonadal lesion. Pure seminomas are radiotherapy and chemotherapy sensitive however the mainstay treatment of primary mediastinal seminomas remains surgical excision. Radiotherapy is reserved postoperatively for incomplete surgical margins.

An incidental finding of testicular seminoma in the context of acute pulmonary embolism: a case report.

BACKGROUND: Clinical guidelines do not recommend further investigation for occult malignancy in the scenario of unprovoked venous thromboembolism in the absence of additional clinical features suggestive of malignancy. We present the case of a young gentleman with pulmonary embolism who was diagnosed with testicular seminoma despite lack of symptoms or signs suggestive of malignancy. This is a unique case describing a scenario not well documented in existing literature where contravention of clinical guidelines had a potentially advantageous outcome for the patient. CASE PRESENTATION: A 37-year-old white male presented with seemingly unprovoked acute pulmonary embolism with right heart strain. He did not have any predisposing factors for venous thromboembolism and did not have any symptoms or signs suggestive of malignancy. Clinical guidelines do not recommend further investigation to screen for malignancy in this scenario. Despite this, our young, otherwise healthy patient proceeded to computed tomography scanning, resulting in the diagnosis of localized testicular seminoma. Testicular ultrasound described normal-sized testes (despite a discrete lesion in the right testis), suggesting this was not detectable by the patient or clinician on routine examination. The patient was anticoagulated and had an inferior vena cava filter inserted to facilitate orchidectomy followed by adjuvant radiotherapy. CONCLUSIONS: This case highlights the importance of considering malignancy in seemingly unprovoked venous thromboembolism and the availability of guidelines to direct further investigation. Our patient's treatment was not in line with clinical guidelines and was considered a "lucky find."

Radiotherapy for Post-Chemotherapy Residual Mass in Advanced Seminoma: A Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography-Based Risk-adapted Approach.

AIMS: There is a lack of consensus regarding the management of post-chemotherapy residual mass in classical seminoma. The use of fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) may aid the detection of residual masses harbouring viable disease and help to tailor therapy. The aim of this study was to evaluate if PET-CT could identify patients who will benefit from locoregional radiotherapy. MATERIALS AND METHODS: This ethics-approved study included patients with advanced classical seminoma primarily treated with standard platinum-based first-line chemotherapy. Patients were either observed or given adjuvant radiotherapy based on the clinician's preference and followed up. For this study, patients were stratified into two groups based on FDG PET-CT residual nodal maximum standardised uptake value (SUVmax): low risk (SUVmax <3) and high risk (SUVmax ≥3). Further subgroup analysis was carried out for patients with residual nodal size ≥3 cm and SUVmax ≥3, and this was considered as the very high risk group. The diagnostic accuracy of FDG PET-CT was assessed and survival was compared between the different groups. RESULTS: Sixty-nine patients were included in the study: 48 patients were observed and 21 received radiotherapy. The low and high risk groups contained 50.7% and 49.3% of the patients, respectively. The very high risk subgroup had 24 patients. At a median follow-up of 44 months, locoregional failures in the radiotherapy and observation cohorts were 0% and 30% (P = 0.059) in the very high risk subgroup and 5.8% and 29.4% (P = 0.078) in the high risk group. The positive predictive value for the very high risk and high risk groups was 30% and 17.1%, respectively. The benefit of locoregional control failed to translate into overall survival benefit. CONCLUSION: A tailored, FDG PET-based risk-adapted treatment approach can refine the management of post-chemotherapy residual masses in seminoma. In this study, with the largest cohort of advanced seminoma patients treated with radiotherapy reported to date, radiotherapy seems to benefit patients with post-chemotherapy residual mass SUVmax ≥3.

The potential role of MR based radiomic biomarkers in the characterization of focal testicular lesions.

How to differentiate with MRI-based techniques testicular germ (TGCTs) and testicular non-germ cell tumors (TNGCTs) is still under debate and Radiomics may be the turning key. Our purpose is to investigate the performance of MRI-based Radiomics signatures for the preoperative prediction of testicular neoplasm histology. The aim is twofold: (i), differentiating TGCTs and TNGCTs status and (ii) differentiating seminomas (SGCTs) from non-seminomatous (NSGCTs). Forty-two patients with pathology-proven testicular neoplasms and referred for pre-treatment MRI, were retrospectively enrolled. Thirty-two out of 44 lesions were TGCTs. Twelve out of 44 were TNGCTs or other histologies. Two radiologists segmented the volume of interest on T2-weighted images. Approximately 500 imaging features were extracted. Least Absolute Shrinkage and Selection Operator (LASSO) was applied as method for variable selection. A linear model and a linear support vector machine (SVM) were trained with selected features to assess discrimination scores for the two endpoints. LASSO identified 3 features that were employed to build fivefold validated linear discriminant and linear SVM classifiers for the TGCT-TNGCT endpoint giving an overall accuracy of 89%. Four features were employed to build another SVM for the SGCT-SNGCT endpoint with an overall accuracy of 86%. The data obtained proved that T2-weighted-based Radiomics is a promising tool in the diagnostic workup of testicular neoplasms by discriminating germ cell from non-gem cell tumors, and seminomas from non-seminomas.

Apparent diffusion coefficient values of cryptorchid testes and malignant transformation of cryptorchidism (MTC) (seminoma) in postpubertal patients.

OBJECTIVES: Diffusion-weighted imaging signal contrast can be quantified by apparent diffusion coefficient (ADC) maps, which reflect the diffusion properties of the examined tissue and are helpful for identifying pathology. To determine ADC values of cryptorchid testes in post-pubertal patients and assess performance for characterizing cryptorchid testes. METHODS: The medical records from 35 patients with unilateral scrotal vacuity were retrospectively reviewed. Data were analyzed in three groups: Group A, normal testes (i.e. the contralateral testes of the patients with cryptorchidism or MTC); Group B, cryptorchid testes; and Group C, malignant transformation of cryptorchidism (MTC) (seminoma). DWI used b-values of 0 and 800 s/mm2. Mean ADC values were compared using the independent samples t-test. The ability of ADC values was assessed using receiver operating characteristic curve analysis. The sensitivity, specificity, and accuracy were calculated. RESULTS: Mean ADC values for normal testes, cryptorchid testes, and MTC were 1.18 ± 0.18×10-3 mm2/s, 1.82 ± 0.40×10-3 mm2/s, and 0.80 ± 0.06×10-3 mm2/s, respectively. There were statistically significant differences in mean ADC values between normal testes and cryptorchid testes or MTC (p < 0.001). The cut-off ADC value for differentiating normal testes from cryptorchid testes was 1.47 × 10-3 mm2/s. The sensitivity, specificity, and accuracy were 88%, 91%, and 90%, respectively. The cut-off ADC value for differentiating normal testes from MTC was 1.22 × 10-3 mm2/s. The sensitivity, specificity, and accuracy were 100%, 31%, and 43%, respectively. CONCLUSION: ADC values of cryptorchid testes may be used to inform clinical decision-making and also monitor testicular function in patients who retain undescended testicles or post-operatively. ADVANCES IN KNOWLEDGE: Mean ADC values of cryptorchidism and MTC (seminoma) were used to reflect their pathological features.