Testicular metastasis 9 years after resection of primary descending colon cancer with simultaneous pulmonary metastasis: a case report
Surgical Case Reports volume 9, Article number: 104 (2023)
Metastatic testicular cancer is rare. In particular, primary colorectal cancer rarely metastasizes to the testes. This study reports a case of testicular metastasis recurrence 9 years after the resection of a primary colorectal cancer and a simultaneous metastatic lung tumour.
A 69-year-old man underwent a laparoscopic left hemicolectomy for descending colon cancer. Preoperative computed tomography revealed a solitary left lung mass. Postoperative chemotherapy reduced the size of the lung mass, and 6 months after the primary resection, the patient underwent a left upper segmentectomy. Based on the pathological examination, he was diagnosed with pulmonary metastasis from colorectal cancer. After four courses of adjuvant chemotherapy, the patient was recurrence-free. However, 9 years and 6 months after the primary resection, he complained of discomfort in his left testicle. Physical examination revealed a left testicular mass. Since a malignancy was not excluded via imaging, left testicular resection was performed to confirm the diagnosis. The pathological diagnosis was testicular metastasis from colorectal cancer. The patient was followed up without medication, and remained healthy, without recurrence, 11 months postoperatively.
It is important to follow up with testicular metastasis in mind, although it is rare.
Metastatic testicular cancer rarely occurs, in two large autopsy series, metastasis of the testis have been reported to approximately 0.06% of autopsy specimens [1, 2]. In addition, in a retrospective autopsy study of adult male with solid malignant tumour, 0.68% of autopsy specimens were shown to have metastatic deposits within the testis . The most frequent primary lesion that metastasizes to the testis is prostate cancer, which accounts for 29–35% of metastatic testicular tumours. In contrast, testicular metastases from colorectal cancer (CRC) comprise 7–9% of all metastatic testicular lesions [4, 5]. This study reports a case of testicular metastasis recurrence 9 years after the resection of a primary CRC and a simultaneous metastatic lung tumour.
A 59-year-old man underwent chest radiography during a health check-up at his workplace.
A nodular shadow on the lateral side of the left middle lung was detected. After a close examination by his local doctor, he was diagnosed with descending colon cancer and a simultaneous lung tumour. The patient was then referred to our department for further treatment. His medical history was unremarkable. Laboratory examinations showed mild anaemia only. The other laboratory data, including the tumour markers carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9), were essentially normal. Plain chest computed tomography (CT) revealed a solitary well-defined mass, measuring approximately 30 mm, in the superior region of the upper lobe of the left lung (Fig. 1A). Abdominal contrast-enhanced CT revealed a subtotal mass lesion with a contrast effect in the middle segment of the descending colon (Fig. 1B). Positron emission tomography (PET)–CT revealed a maximum standardized uptake value (SUV) max of 9.2 for fluorodeoxyglucose (FDG) accumulation in S3a of the left upper lung lobe (Fig. 2A) and an SUV max of 9.8 with FDG accumulation in the descending colon (Fig. 2B). Colonoscopy revealed a semicircumferential type 2 lesion in the middle segment of the descending colon (Fig. 3A). This finding was consistent with the CT colonography findings in the same area (Fig. 3B). A laparoscopic left hemicolectomy with regional lymph nodes dissection, including nodes around origin of inferior mesenteric artery, was performed. Based on the pathological examination, the patient was diagnosed with moderately differentiated tubular adenocarcinoma. According to the eighth version of the Union for International Cancer Control for International Cancer Control TNM classification for CRC, the patient had cStage IVA disease . Subsequently, he received chemotherapy with tegafur/gimeracil/oteracil (S-1), combined with oxaliplatin (SOX) and bevacizumab for four cycles. Shrinkage of the left lung tumour was observed (Fig. 4). The patient underwent close surveillance during chemotherapy treatment to monitor the occurrence of additional lung metastatic lesions or other metastatic lesions. However, there was no evidence of new lesion formations during the observation period. Left upper segmentectomy was performed 6 months after the primary resection. Based on the pathological examination, most of the central part of the tumor was necrotic, and only a few atypical ducts of moderately differentiated adenocarcinoma showing a tendency to coalesce were observed only in the marginal part. In addition, the patient was diagnosed with metastatic lung tumours from CRC. The pathological diagnosis of CRC was well-differentiated adenocarcinoma > moderately differentiated adenocarcinoma, pT3N1a(1/9)M1a [PUL], pStage IVA, Ly1a, V0, PM0, DM0. He received adjuvant chemotherapy with SOX for four cycles after undergoing a pneumonectomy. Thereafter, he underwent follow-up for 5 years, during the follow-up evaluation, a contrast-enhanced CT and colonoscopy were performed, and the tumour markers were measured. No recurrence was observed during the follow-up evaluation. However, 9 years and 6 months after the primary resection, he experienced discomfort in the left testicle. Magnetic resonance imaging (MRI) revealed a tumour, measuring 17 mm, with a low signal intensity on T1- and T2-weighted imaging of the cephalic side of the left testis (Fig. 5A, B). PET–CT yielded a SUV max of 4.4 FDG accumulation, confined to the testis in the same area (Fig. 5C). The tumour markers, particularly the human chorionic gonadotropin, fetoprotein, CEA, and CA19-9, were within the normal ranges. In addition to malignancy, epididymal fibroma and epididymitis were raised as radiological differential diagnoses. Epididymal fibroma are mostly treated with radical orchiectomy, because preoperative diagnosis confirming the benign nature is difficult . Therefore, a left orchiectomy was performed for diagnostic purposes. Based on the postoperative pathological examination and immunostaining results, the patient was diagnosed with testicular metastasis from CRC (Figs. 6 and 7). The carcinoma was located mainly in the testis and epididymis, but it also invaded the spermatic cord. He received adjuvant chemotherapy, consisting of capecitabine and oxaliplatin, but the medications were discontinued after one cycle due to the occurrence of epigastric discomfort after taking capecitabine. The patient was followed up without medication at his request. He is currently healthy, without recurrence, 11 months postoperatively.
Metastatic testicular cancers are rare, and the primary lesion seldom comes from the large intestine [1,2,3,4,5]. The details of the route of metastasis to the testis are unknown. Aside from the hematogenous and lymphatic routes, retrograde invasion of the ductus deferens, direct invasion along the spermatic cord, and peritoneal dissemination via congenital testicular effusion with patency of the sheath-like process were considered possible routes . Since the pathological examination in this case showed lymphatic invasion at the time of the primary resection, lymphatic recurrence was considered likely. In addition, the pathology of the resected testis showed invasion of the spermatic cord, suggesting a slight possibility of direct invasion along the spermatic cord. A PubMed search for testicular metastases from CRC, using the keywords “Colorectal Cancer, Testicular Metastasis,” yielded 16 cases. Among these studies, ten involved heterochronic recurrences, and the details of these ten cases are summarized in Table 1[9,10,11,12,13,14,15,16,17,18]. The median age at the time of the primary resection was 64.5 years, while the median time from primary resection to recurrence was 24 months. Recurrence was independent of age, primary stage, primary localization, or histological type. According to the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology for colon cancer, patients with stage IV CRC without evidence of disease after curative-intent surgery and subsequent adjuvant treatment are recommended to undergo follow-up for 5 years. During the follow-up evaluation, a contrast-enhanced CT is performed, and the CEA is measured . Among the 10 cases of heterochronic recurrence, some patients developed recurrence more than 5 years after the primary resection. The recurrence rate of CRC beyond 5 years after radical resection due to distant metastasis has reported to be 0.9% . Liver (0.24%), lungs (0.22%) and peritoneum (0.09%) are the most common sites of recurrence due to distant metastases, in that order . Even among Stage IV patients with distant metastases who have undergone radical resection, the most common sites of recurrence is reported to be the liver and lungs . Accumulation of long-term follow-up results after radical resection in patients with stage IV CRC is needed, but testis is predicted to be an unlikely site of recurrence. With regard to histological types of CRC, approximately 95% of CRC in Japan are adenocarcinomas, most of which are well or moderately differentiated adenocarcinomas [23, 24]. Of the 10 cases of heterochronic recurrence, four showed a histological type other than well or moderately differentiated adenocarcinoma, which is clearly higher than the epidemiological ratio. This matter may have some relevance to the pathogenesis of testicular metastasis of CRC, but the number of cases in this study was small and further case accumulation is needed. Based on the results of the review, scrotal swelling was the most common diagnostic indicator of recurrence.
This study reported a case of testicular metastasis 9 years after the resection of primary descending colon cancer and pulmonary metastases. Patients with CRC rarely develop metastatic testicular recurrence 9 years after the primary resection.
Availability of data and materials
The data set, supporting the conclusions of this article, is available in the Springer Open.
Carbohydrate antigen 19-9
Positron emission tomography
Standardized uptake value
- TNM classification:
Tegafur/gimeracil/oteracil (S-1) combined oxaliplatin
Magnetic resonance imaging
Klinger ME. Secondary tumors of the genito-urinary tract. J Urol. 1951;65(1):144–53.
Pienkos EJ, Jablokow VR. Secondary testicular tumors. Cancer. 1972;30(2):481.
González RG, Pinto J, Bernal JFV. Testicular metastases from solid tumors: an autopsy study. Ann Diagn Pathol. 2000;4(2):59–64.
Haupt HM, Mann RB, Trump DL, Abeloff MD. Metastatic carcinoma involving the testis. Clinical and pathologic distinction from primary testicular neoplasms. Cancer. 1984;54(4):709–14.
Dilworth JP, Farrow GM, Oesterling JE. Non-germ cell tumors of testis. Urology. 1991;37(5):399–417.
Brierley JD, Gospodarowicz MK, Wittekind C. UICC TNM classification of malignant tumors. 8th ed. New York: John Wiley & Sons, LTD.; 2017.
Anraku T, Hashidate H, Nakahara A, Imai T, Kawakami Y. A 40-year-old man with a rapidly growing intrascrotal tumor in the fibroma–thecoma group. IJU Case Rep. 2022;5(3):175–8.
Hanash KA, Carney JA, Kelalis PP. Metastic tumors to testicles: routes of metastasis. J Urol. 1969;102(4):465–8.
Kasahara M, Shimizu T, Aoki H, Okawa M, Yamabe F, Kobayashi H, Nagao K, Nakajima K, Mitsui Y. Colon cancer metastasis to the right testis: case report and review of literature. Case Rep Urol. 2022;2022:2649259.
Liu M, Fan Y, Zhu S, Zhu S. Paratesticular metastasis arising from colonic mucinous adenocarcinoma: a rare case report. J Int Med Res. 2022;50(5):3000605221101332.
Wald M. Paratesticular colon cancer metastasis in an area of remote trauma. BMJ Case Rep. 2020;13(2): e233106.
Law TYX, Chiong E. Patent processus vaginalis as a conduit for tumoral seeding: a rare presentation of port site metastasis. ANZ J Surg. 2019;89(5):E216–7.
Zhou X, Jiang Y. Colonic carcinoma metastatic to the left testis, epididymis & spermatic cord. Indian J Med Res. 2016;143(6):836–7.
Al-Ali BM, Augustin H, Popper H, Pummer K. A case of descending colon carcinoma metastasized to left spermatic cord, testis, and epididymis. Cent Eur J Urol. 2012;65(2):94–5.
Venkitaraman R, George M, Weerasooriya S, Selva-Nayagam S. Late solitary testicular metastasis from rectal cancer. J Cancer Res Ther. 2010;6(1):89–91.
Hatoum HA, Yassine HR, Otrock ZK, Taher AT, Khalifeh MJ, Shamseddine AI. Testicular metastasis from primary rectal carcinoma. Colorectal Dis. 2006;8(6):529–30.
Charles W, Joseph G, Hunis B, Rankin L. Metastatic colon cancer to the testicle presenting as testicular hydrocele. J Clin Oncol. 2005;23(22):5256–7.
Kulkarni S, Coup A, Kershaw JB, Buchholz NPN. Metastatic appendiceal adenocarcinoma presenting late as epididymo-orchitis: a case report and review of literature. BMC Urol. 2004;4:1.
Benson AIB, Venook AP, AI-Hawary MM, et al. NCCN Clinical Practice Guidelines in Oncology Colon Cancer Ver 1.2023. National Comprehensive Cancer Network, Inc; 2023.
Tan WJ, Tan HJ, Dorajoo SR, Foo FJ, Tang CL, Chew MH. Rectal cancer surveillance-recurrence patterns and survival outcomes from a cohort followed up beyond 10 years. J Gastrointest Cancer. 2018;49(4):422–8.
Hashiguchi Y, Muro K, Saito Y, Ito Y, Ajioka Y, et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer. Int J Clin Oncol. 2020;25(1):1–42.
Miyoshi N, Ohue M, Shingai T, Noura S, Sugimura K, et al. Clinicopathological characteristics and prognosis of stage IV colorectal cancer. Mol Clin Oncol. 2015;3(5):1093–8.
Tamakoshi A, Nakamura K, Ukawa S, Okada E, Hirata M, et al. Characteristics and prognosis of Japanese colorectal cancer patients: the BioBank Japan Project. 2017;27(3S):S36–S42.
Yoshida T, Akagi Y, Kinugasa T, Shiratsuchi I, Ryu Y, Shirouzu K. Clinicopathological study on poorly differentiated adenocarcinoma of the colon. Kurume Med J. 2011;58(2):41–6.
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Yoshimura, D., Sekido, Y., Takahashi, H. et al. Testicular metastasis 9 years after resection of primary descending colon cancer with simultaneous pulmonary metastasis: a case report. surg case rep 9, 104 (2023). https://doi.org/10.1186/s40792-023-01684-x