A 29-year-old man presented to the emergency department with right abdominal pain and nausea. He recently moved from Mexico and had not been evaluated by a physician prior. The man reported a 9-year history of progressive right abdominal fullness and pain for 2 months with a 20-pound weight loss. His only medical history was a left inguinal hernia repair. On physical examination, he had a large firm palpable right abdominal mass. His right testicle was not palpable, while his left testicle was normal on exam. The man reported that his right testicle had been impalpable since birth. Tumor markers were notable for alpha fetoprotein (AFP) of 4479, human chorionic gonadotropin (hCG) of 111, and lactate dehydrogenase (LDH) of 414. A computed tomography (CT) scan (Figure 1) revealed a 26 × 15 × 11cm intra-abdominal mass with no right spermatic cord or right testicle visible on CT.
The patient underwent exploratory laparotomy with removal of the mass intact. Final pathology revealed that this 27 cm, 3 kg mass was a mixed germ cell tumor: 80% seminoma, 10% embryonal, 5% yolk sac, and 5% teratoma (Figure 2).
The case was prepared by Kai B. Dallas, MD, Fellow, Female Pelvic Medicine and Reconstructive Surgery, Cedars-Sinai Medical Center, Los Angeles.