Methods A 43-year-old African American male presented with a 3-month history of painless enlargement of his right testicle. On physical exam, a firm, 5 cm mass was palpated in the right testis. The patient underwent a right radical orchiectomy.
Results The specimen submitted to pathology was a 9 3 8 3 6.5 cm mass, with almost complete replacement of testicular parenchyma. Final results revealed the tumor to be a primary testicular lymphoma. An ultrasound of the opposite testis was performed, which was normal. Bone marrow aspiration and biopsy were also negative for disease. CT chest/abdomen/pelvis and MRI brain following the radical orchiectomy showed no evidence of disease. This patient is currently being treated with Cytoxan, vincristine, Adriamycin, and prednisone (CHOP chemotherapy), along with Rituxan, given that the tumor was strongly CD20 positive. He is also receiving intrathecal methotrexate prophylactically, and plans are for testicular radiation therapy when chemotherapy is completed.
Conclusions Testicular lymphoma is exceedingly rare in a person of this age. It comprises approximately 5% of all testicular neoplasms and is the most common primary testicular neoplasm in men over the age of 60. Patients typically present with painless testicular enlargement. At presentation, two-thirds of cases are confined to the testis alone. It is the most common bilateral testicular neoplasm, involving the contralateral testis in approximately 20%. Other sites of spread include the CNS, skin, and Waldeyer's ring. The majority are diffuse large B-cell lymphomas. Initial staging should include ultrasound of the contralateral testis, and if a mass is seen it should be assumed to be lymphoma. CT chest/abdomen/pelvis, MRI brain, bone marrow aspirate/biopsy, and diagnostic LP also must be performed. Testicular lymphoma is associated with a poor prognosis and early distant spread. Median survival reported in most series is less than 1 year, with less than 20% of patients surviving 5 years. Treatment is with combination chemotherapy and radiation to the involved testis if resection is not performed. Given the propensity for early spread of this disease, radiation therapy should be given to the contralateral testis, and CNS prophylaxis should also be considered.
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