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Abdominal lump in an infertile man
  1. B M Biswala,
  2. M Madhavanb,
  3. S R Anasc
  1. aSchool of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia: Division of Radiotherapy, bDivision of Pathology, cDivision of Surgery
  1. Dr B M Biswal, Department of Nuclear Medicine Radiotherapy and Oncology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia (b_biswal{at}hotmail.com)

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A 44 year sexually active man presented with pain in his abdomen, dysuria, haematuria, constipation, and a lump in the suprapubic area of over four months' duration. Further exploration into his medical history revealed that he had been married for 20 years but had no children and had been diagnosed as having primary infertility. Examination showed a man of average build, with a mass in the lower abdomen. The intra-abdominal mass measured 12 × 12 cm and spanned from the umbilicus to pubis vertically and from left flank to across the midline horizontally. The consistency of the lump was firm to hard, non-tender, and fixed to underlying structures. Distension of the large bowel was evident above the mass. There was no testicle in the left scrotum and a small right testicle in the groin.

With a presumptive diagnosis of pelvic malignancy, complicated with intestinal obstruction, radiography of the abdomen was undertaken and this showed evidence of subacute intestinal obstruction. Gastrograffin enema x rays revealed a soft tissue mass adherent to the rectosigmoid junction suggestive of carcinoma of the urinary bladder. Subsequent contrast enhanced computed tomography of the abdomen and pelvis revealed an isodense soft tissue mass with areas of hypodensity arising from pelvis measuring 12 × 12 × 12 cm with minimal peripheral enhancement (fig 1). There was no definite cleavage between tumour and the bladder wall. Serum α-fetoprotein and β-human chorionic gonadotrophin concentrations were within normal limits.

Figure 1

Contrast enhanced computed tomogram at the level of lower abdomen showing a bulky enhanced mass.  

An explorative laparotomy was performed which revealed a large cystic tumour arising from retropubic space of the pelvis pushing the sigmoid colon up and right. The above tumour was measuring 10 × 16 cm in size with distended venous markings overlying. The tumour weighed 1.68 kg. Cut section of the mass showed a grey-white lobular mass with little areas of necrosis (fig 2). There were multiple lymph nodes in the mesentery and paraortic area. Microscopic examination showed uniform looking cells arranged in nests with intervening delicate fibrovascular stroma. The tumour cells were large and have clear cytoplasms. Periodic acid schiff stain for glycogen was strongly positive. The nuclei were centrally located, vesicular, and hyperchromatic, showing numerous mitotic figures (21 per 10 high power field) (fig 3). The sampled tissue from sigmoid colon, bladder, mesenteric and paraotic lymph nodes showed tumour infiltration.

Figure 2

Cut section of the tumour is solid, homogenous and grey-white in colour.  

Figure 3

Lobules of monotonous tumour cells with clear cytoplasm and centrally located vesicular nucleus (haematoxylin and eosin, magnification × 400).

Questions

(1)
What is the probable diagnosis of this condition?
(2)
Which is the best treatment in this situation?
(3)
What is the chance of second cancer in the opposite testis?

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