Patient aged 15 years with no previous history of interest. He was seen in the emergency department for vomiting and epigastric pain of three days' evolution, and reported a weight loss of 7 kg in the previous two months. Physical examination revealed moderate mucocutaneous pallor, hepatosplenomegaly of two finger widths and epigastric pain on deep palpation. Scrotal examination revealed an enlarged left teste (three to four times larger than normal) with a hard consistency, irregular surface and non-painful. On cross-examination, the patient confirmed that he had noticed a progressive and painless enlargement of the teste for about a year.
The ED blood test showed only a haematocrit of 35%, haemoglobin 11.3 g/dl and LDH 2802 U/L.
The abdominal and testicular ultrasound showed the existence of a very enlarged left teste with heterogeneous echogenicity, with foci of necrosis and liquid areas; and at the hepatic level there were extensive images suggestive of metastasis.
Chest X-ray revealed multiple pulmonary metastases and discrete pleural effusion, which after thoracentesis revealed haematic pleural fluid.
Twelve hours after admission, a thoracoabdominal CT scan showed extensive metastatic involvement, with multiple bilateral pulmonary nodules, right pleural effusion, mediastinal and retroperitoneal lymphadenopathy, hepatomegaly with massive metastatic involvement, and possibly splenic and pancreatic metastases. There was no intraperitoneal free fluid.
Blood samples were obtained for testicular markers: alpha-fetoprotein 15000 ng/ml and betaHCG of 200,000 mIU/ml, and orchiectomy was scheduled for the following day.
Thirty-six hours after admission, rapidly onset hypovolaemic shock with pain and abdominal bulging occurred, requiring urgent laparotomy after abdominal ultrasound, which showed a large amount of intraperitoneal fluid. During laparotomy, extensive metastatic involvement was found in the tail of the pancreas, spleen and liver with rupture of splenic and hepatic metastases and massive haemoperitoneum due to active bleeding and diffuse hepatic haematoma. Splenectomy was performed with suture and surgicel tamponade of the bleeding liver areas; at the same time, radical left orchiectomy was performed.
The macroscopic anatomopathology describes: "piece of radical orchiectomy, weighing 233 grams and measuring 8x9x5 cm, accompanied by 7 cm of cord; on serial sections the testicular parenchyma shows an almost total replacement by a whitish tumour, with areas of necrosis and haemorrhage that does not appear to go beyond the testicular coverings".
Microscopic histopathology of the testicle showed a mixed germinal malignant neoplasm with areas of embryonal carcinoma, endodermal sinus tumour, choriocarcinoma and teratoma.
The spleen measured 15x7x3 cm and weighed 180 g. Serial sections showed six nodular, rounded, whitish formations with central necrosis. Microscopy confirmed that the splenic lesions were metastases of the testicular neoplasm.
Forty-eight hours after the operation, the patient suffered a new episode of hypovolemic shock with evident signs of intra-abdominal bleeding, so a new laparotomy was performed, verifying the existence of a hepatic burst at the level of the right and left lobe, with incoercible haemorrhage and death shortly afterwards.
