Northern Mindanao Medical Center

DEPARTMENT OF SURGERY
SECTION OF UROLOGY

CASE PROTOCOL

F.C. 29/M,Cagayan de Oro City

HARRY G. LONGNO, MD, DPBU, FPUA, FPCS
SECTION HEAD
SECTION OF UROLOGY
A 29 year-old male with a history of infertility and bilateral cryptorchidism
ROMMEL B. VALLEJOS, MD, DPBU, FPUA
TRAINING OFFICER
presented to the Divison of Urology OPD Clinic due to chief complaint of a large
SECTION OF UROLOGY intra-abdominal mass. The patient was already initially managed in a local hospital
CONSULTANT STAFF:
and was referred to the Urology Service for further management. Patient has a 2
year history of gradually enlarging intra-abdominal mass at the left lower quadrant
GREGORIO M. CORDOVEZ, MD, DPBU, FPUA
area with noted changes in bowel movement. Patient sought consult at a General
PAUL NIMROD B. FIRAZA, MD, DPBU, FPUA
Surgery clinic 2 years prior and work up was done, CT scan of the whole abdomen
MELINDA R. GABALES, MD, AFPUA with contrast showed a heterogeneous enhancement mass with ill-defined
DIONISIO T. GAW, MD, FPUA
EMMANUEL B. SEBASTIAN, JR, MD, DPBU, hypoattenuation; occupying the center of the abdominal and pelvic cavities
FPUA,
FPCS
measuring 30 x 16.9 x 12.2 cm with omental and perihepatic soft tissue densities,
RAUL CARLO GUIDO C. ANDUTAN, MD, DPBU, mesenteric stranding and lymphadenopathy, to consider distant lymph node
FPUA
metastasis and carcinomatosis. He underwent ultrasound guided Fine Needle
Aspiration Biopsy. FNAB revealed Atypical Cells indicative of Poorly-
RESIDENTS:
JACKELINE O. LAO, MD Differentiated Malignancy. Primary Cytomorphologic considerations is malignant
CHIEF RESIDENT
RAUL MARTIN BRIEN C. ANDUTAN, MD
germ cell tumor of testicular origin- Embryonal carcinoma. Tumor markers (AFP,
JOSE APOLLO PACAMALAN JR., MD LDH and B-HCG) were within normal limits.
SALMAN O. LIMPAO, MD

Chemotherapy was initiated by the co-managing Medical Oncologist with

Bleomycin, Etoposide and Cisplatin for x 4 cycles. Post chemotherapy CT scan was
done and showed regression of the mass to 7.2 x 8.3 x 5.5 cm (from 30 x 16.9 x
12.2 cm) still with noted omental and perihepatic soft tissue densities with
consideration of distant lymph node metastasis and carcinomatosis, and was deemed
partially responsive. An additional 2 cycles of Etoposide and Cisplatin was done and
repeat CT scan showed further regression to 4.3 x 7.9 x 7.3 cm (from 7.2 x 8.3 x 5.5
cm) (Figure 1). Patient was then referred to the Urology service for further
management.

Upon consult at Urology OPD, these was noted palpable mass approximately 8 x 4
cm at the left lower quadrant area with noted bilateral empty scrotum and no
palpable testis. On further physical examination, there was noted normal pattern of
external genitalia, prominent rugae, phallus and urethra were normal (Figure 2).
Patient claimed to be involved in a long-term heterosexual relationship for 5 years
with no child despite attempts of more than 1 year to achieve conception. Patient has
no other co-morbidities, and no family history of cancer. Patient was diagnosed as a
case of Poorly-differentiated Intraabdominal Testicular Embryonal, Non-
Seminomatous Germ Cell Carcinoma, Left, Stage IIIC (cT3N2M1bS0),
Undescended Testis Bilateral, s/p Ultrasound-guided FNAB of Abdominal Mass
(Dec 2021, CUMC), s/p Neoadjuvant Chemotherapy BEP x 4 cycles (June 2022,
CUMC) EP x 2 cycles (October 2022, CUMC)
 Northern Mindanao Medical Center
DEPARTMENT OF SURGERY
SECTION OF UROLOGY

CASE PROTOCOL

Patient was then scheduled for Bilateral Orchiectomy. Intraoperatively, there was a
noted intra- abdominal mass (left) measuring 7 x 6 cm (Figure 3) which was identified
HARRY G. LONGNO, MD, DPBU, FPUA, FPCS
SECTION HEAD
as the left testis, and an incidental finding of persistent Mullerian ducts structures,
SECTION OF UROLOGY namely the uterus, fallopian tube and blind ending vagina (Figure 4). There was also
ROMMEL B. VALLEJOS, MD, DPBU, FPUA
a noted atrophic right testis (2 x 1.8 x 1 cm) located in a high “ovarian” position
TRAINING OFFICER (Figure 5). Resection of the intra-abdominal mass (left testicular mass), uterus,
SECTION OF UROLOGY fallopian tubes, blind ending upper part of the vagina and the Right testis was done.
th
CONSULTANT STAFF:
Patient tolerated the procedure and was discharged on the 4 postop day.
GREGORIO M. CORDOVEZ, MD, DPBU, FPUA Histopathology report confirmed no malignant cells seen on the left testicular mass
(Figure 6), persistent Mullerian duct structures namely uterus, fallopian tubes, upper
PAUL NIMROD B. FIRAZA, MD, DPBU, FPUA part of vagina (Figure 7, 8) and noted atrophic testis right (Figure 9). Post op tumor
MELINDA R. GABALES, MD, AFPUA
DIONISIO T. GAW, MD, FPUA
markers were requested which showed normal results. The final diagnosis was
EMMANUEL B. SEBASTIAN, JR, MD, DPBU, Persistent Mullerian Duct Syndrome, Poorly-differentiated Intraabdominal Testicular
FPUA,
FPCS
Embryonal Non-Seminomatous Germ Cell Carcinoma, Left, Stage IIIC (pT3N2M1aS0),
RAUL CARLO GUIDO C. ANDUTAN, MD, DPBU, Undescended Testis Bilateral, s/p
FPUA

Bilateral Orchiectomy, Total Abdominal Hysterectomy with Bilateral

RESIDENTS:
JACKELINE O. LAO, MD Salphingectomy (March 2023, NMMC) Ultrasound-guided FNAB of Abdominal
CHIEF RESIDENT
RAUL MARTIN BRIEN C. ANDUTAN, MD Mass (Dec 2021, CUMC), s/p Neoadjuvant Chemotherapy BEP x 4 cycles (June
JOSE APOLLO PACAMALAN JR., MD
SALMAN O. LIMPAO, MD 2022, CUMC) EP x 2 cycles (October 2022, CUMC).

Figure 1: CT scan of WA with contrast showed further regression to 4.3 x 7.9 x 7.3 cm
(from 7.2 x 8.3 x 5.5 cm), with omental and perihepatic soft tissue densities, mesenteric
stranding and lymphadenopathy, consideration is distant lymph node metastasis and
carcinomatosis
 Northern Mindanao Medical Center
DEPARTMENT OF SURGERY
SECTION OF UROLOGY

CASE PROTOCOL
E.B. 29/M,Cagayan de Oro City
HARRY G. LONGNO, MD, DPBU, FPUA, FPCS Chief Complaint: Large Intra-abdominal Mass
SECTION HEAD
SECTION OF UROLOGY History of Present Illness:
A 29 year-old male with a history of infertility and bilateral cryptorchidism presented to
ROMMEL B. VALLEJOS, MD, DPBU, FPUA
TRAINING OFFICER
the Section of Urology OPD Clinic due to a chief complaint of a large intra-abdominal
SECTION OF UROLOGY mass. The patient was already initially managed in a local hospital and was referred to
CONSULTANT STAFF:
the Urology Service for further management.
GREGORIO M. CORDOVEZ, MD, DPBU, FPUA
14 months PTA:
(+) 2 year history of gradually enlarging, painless, intra-abdominal mass
PAUL NIMROD B. FIRAZA, MD, DPBU, FPUA
MELINDA R. GABALES, MD, AFPUA at the left lower quadrant area with noted changes in bowel movement.
DIONISIO T. GAW, MD, FPUA Patient sought consult at a General Surgery Clinic, and work up was done,
EMMANUEL B. SEBASTIAN, JR, MD, DPBU,
FPUA, CT scan of the whole abdomen with contrast showed a heterogeneous
FPCS enhancement mass with ill-defined hypoattenuation; occupying the
RAUL CARLO GUIDO C. ANDUTAN, MD, DPBU,
FPUA center of the abdominal and pelvic cavities measuring 30 x 16.9 x 12.2
cm with omental and perihepatic soft tissue densities, mesenteric
RESIDENTS:
stranding and lymphadenopathy, to consider distant lymph node
JACKELINE O. LAO, MD metastasis and carcinomatosis
CHIEF RESIDENT
RAUL MARTIN BRIEN C. ANDUTAN, MD
Pt underwent ultrasound guided Fine Needle Aspiration Biopsy. FNAB
JOSE APOLLO PACAMALAN JR., MD revealed Atypical Cells indicative of Poorly-Differentiated Malignancy.
SALMAN O. LIMPAO, MD
Primary Cytomorphologic considerations is Malignant Germ Cell Tumor of
testicular origin- Embryonal carcinoma. Tumor markers (AFP, LDH and B-
HCG) were within normal limits
.
8 months PTA:
Chemotherapy was initiated by the co-managing Medical Oncologist with
Bleomycin, Etoposide and Cisplatin for x 4 cycles.
Post chemotherapy CT scan was done and showed regression of the mass
to 7.2 x 8.3 x 5.5 cm (from 30 x 16.9 x 12.2 cm) still with noted omental
and perihepatic soft tissue densities with consideration of distant lymph
node metastasis and carcinomatosis, and was deemed partially
responsive.
An additional 2 cycles of Etoposide and Cisplatin was done and repeat CT
scan showed further regression to 4.3 x 7.9 x 7.3 cm (from 7.2 x 8.3 x 5.5
cm) (Figure 1).
 Northern Mindanao Medical Center
DEPARTMENT OF SURGERY
SECTION OF UROLOGY

CASE PROTOCOL
HARRY G. LONGNO, MD, DPBU, FPUA, FPCS
SECTION HEAD
SECTION OF UROLOGY
2 months PTA:
Pt was referred to Urology OPD, there was noted palpable mass
ROMMEL B. VALLEJOS, MD, DPBU, FPUA
TRAINING OFFICER
approximately 8 x 4 cm at the left lower quadrant area with noted bilateral
SECTION OF UROLOGY empty scrotum and no palpable testis.
CONSULTANT STAFF:
On further physical examination, there was noted normal pattern of
external genitalia, prominent rugae, phallus and urethra were normal
GREGORIO M. CORDOVEZ, MD, DPBU, FPUA (Figure 2).
Patient claimed to be involved in a long-term heterosexual relationship for
PAUL NIMROD B. FIRAZA, MD, DPBU, FPUA
MELINDA R. GABALES, MD, AFPUA
5 years with no child despite attempts of more than 1 year to achieve
DIONISIO T. GAW, MD, FPUA conception.
EMMANUEL B. SEBASTIAN, JR, MD, DPBU, Pt was then advised surgery
FPUA,
FPCS
RAUL CARLO GUIDO C. ANDUTAN, MD, DPBU,
FPUA

RESIDENTS:
JACKELINE O. LAO, MD
CHIEF RESIDENT
RAUL MARTIN BRIEN C. ANDUTAN, MD
JOSE APOLLO PACAMALAN JR., MD
SALMAN O. LIMPAO, MD

Figure 1: CT scan of WA with contrast showed further regression to 4.3 x 7.9 x 7.3 cm
(from 7.2 x 8.3 x 5.5 cm), with omental and perihepatic soft tissue densities, mesenteric
stranding and lymphadenopathy, consideration is distant lymph node metastasis and
carcinomatosis
 Northern Mindanao Medical Center
DEPARTMENT OF SURGERY
SECTION OF UROLOGY
CASE PROTOCOL
Past Medical Hx:
(-) HTN (-) DM (-) previous hospitalization, No known allergies to food and medications
Family Hx:
(+) Hypertension- Maternal Side
(-) Hx of Cancer
Personal and Social History:
HARRY G. LONGNO, MD, DPBU, FPUA, FPCS (-) Smoker
SECTION HEAD Non-alcoholic beverage drinker
SECTION OF UROLOGY
In a 4-year relationship with a Female partner, failure of numerous attempts to achieve
ROMMEL B. VALLEJOS, MD, DPBU, FPUA conception
TRAINING OFFICER
SECTION OF UROLOGY
Physical Examination:
Vital Signs: BP: 110/80 HR:78 RR: 20 O2: 99% Temp: 36.4 C
CONSULTANT STAFF: HEENT: Anicteric sclera, pink palpebral conjunctivae, no palpable lymphadenopathy
GREGORIO M. CORDOVEZ, MD, DPBU, FPUA Chest and Lungs: No gynecomastia, No retractions, Equal chest expansion, Clear breath
sounds
PAUL NIMROD B. FIRAZA, MD, DPBU, FPUA Cardiovascular: Adynamic precordium, Distinct heart sounds, no murmur, PMI 5th ICS
MELINDA R. GABALES, MD, AFPUA
DIONISIO T. GAW, MD, FPUA
Abdomen: Flabby, normoactive bowel sounds, tympanitic, palpable mass on hypogastric
EMMANUEL B. SEBASTIAN, JR, MD, DPBU, area up to the left iliac region measuring about 4x7cm , circular border, firm, movable
FPUA,
FPCS
Genitourinary: No external lesions, no inguinal mass, Grossly Male with triangular
RAUL CARLO GUIDO C. ANDUTAN, MD, DPBU, orientation of evenly distributed pubic hair, Empty scrotal sac bilateral, negative for kidney
FPUA punch sign bilaterally; no palpable inguinal lymph nodes
DRE: No perianal lesions, tight sphincteric tone, no palpable mass, prostate size less than 20
RESIDENTS: grams, smooth, non nodular, non tender, fecal material seen on examining finger
JACKELINE O. LAO, MD
CHIEF RESIDENT Skin and Extremities: No lesions, no jaundice, warm, good turgor
RAUL MARTIN BRIEN C. ANDUTAN, MD No edema, full and equal pulses in all extremities, CRT < 2 seconds
JOSE APOLLO PACAMALAN JR., MD
SALMAN O. LIMPAO, MD

Figure 2: . Image showing normal pattern of external genitalia, prominent rugae,

phallus and urethra were normal. Noted bilateral empty scrotum and no palpable testis.
 Northern Mindanao Medical Center
DEPARTMENT OF SURGERY
SECTION OF UROLOGY
CASE PROTOCOL

Labs:

HARRY G. LONGNO, MD, DPBU, FPUA, FPCS

SECTION HEAD
SECTION OF UROLOGY

ROMMEL B. VALLEJOS, MD, DPBU, FPUA

TRAINING OFFICER
SECTION OF UROLOGY

CONSULTANT STAFF:

GREGORIO M. CORDOVEZ, MD, DPBU, FPUA

PAUL NIMROD B. FIRAZA, MD, DPBU, FPUA

MELINDA R. GABALES, MD, AFPUA
DIONISIO T. GAW, MD, FPUA
EMMANUEL B. SEBASTIAN, JR, MD, DPBU,
FPUA,
FPCS
RAUL CARLO GUIDO C. ANDUTAN, MD, DPBU,
FPUA

RESIDENTS:
JACKELINE O. LAO, MD
CHIEF RESIDENT
RAUL MARTIN BRIEN C. ANDUTAN, MD
JOSE APOLLO PACAMALAN JR., MD
SALMAN O. LIMPAO, MD

Pre-operative Diagnosis: Poorly-differentiated Intraabdominal Testicular Embryonal,

Non- Seminomatous Germ Cell Carcinoma, Left, Stage IIIC (cT3N2M1bS0), Undescended
Testis Bilateral, s/p Ultrasound-guided FNAB of Abdominal Mass (Dec 2021, CDOC), s/p
Neoadjuvant Chemotherapy BEP x 4 cycles (June 2022, CDOC) EP x 2 cycles (October
2022, CDOC)

Plan: Orchiectomy, Left; Orchidopexy, Right

 Northern Mindanao Medical Center
DEPARTMENT OF SURGERY
SECTION OF UROLOGY
CASE PROTOCOL:

Question Guide for Each Institution (2 Rounds)

1st Round (Short PPT presentation of 1-3 slides)
I. Clinical History:
Cite the key points in the History of Present Illness. Which aspects of the patient's history would
you consider crucial in understanding the origin and nature of the intra-abdominal mass and
HARRY G. LONGNO, MD, DPBU, FPUA, FPCS
SECTION HEAD infertility? (Example: the two year hx of a gradually enlarging, painless, intra-abdominal mass;
SECTION OF UROLOGY the Failure to achieve conception despite attempts for more than 1 year, etc.)
ROMMEL B. VALLEJOS, MD, DPBU, FPUA Are there any other points in the history of the patient that you would like to elicit?
TRAINING OFFICER II. Physical Examination:
SECTION OF UROLOGY
In your opinion, what specific findings during the physical examination are most significant in
CONSULTANT STAFF: assessing the patient's condition? Cite the most significant PE findings.
GREGORIO M. CORDOVEZ, MD, DPBU, FPUA How would you interpret the absence of palpable testes and the presence of a palpable mass?
III. Laboratory Investigations:
PAUL NIMROD B. FIRAZA, MD, DPBU, FPUA What laboratories would you like to request?
MELINDA R. GABALES, MD, AFPUA Considering the tumor markers are within normal limits, are there additional specific markers or
DIONISIO T. GAW, MD, FPUA
EMMANUEL B. SEBASTIAN, JR, MD, DPBU,
hormonal assays you would recommend, especially in light of the complex presentation with
FPUA, bilateral cryptorchidism?
FPCS
RAUL CARLO GUIDO C. ANDUTAN, MD, DPBU,
IV. Diagnostic Approach:
FPUA How would you approach the diagnostic workup in this case? What imaging modalities would you
request?
RESIDENTS: Would you also do FNAB for the initiation of Neoadjuvant Chemotherapy as what was done in the
JACKELINE O. LAO, MD case?
CHIEF RESIDENT
RAUL MARTIN BRIEN C. ANDUTAN, MD Are there additional tests or imaging modalities you would recommend?
JOSE APOLLO PACAMALAN JR., MD
SALMAN O. LIMPAO, MD

V. Differential Diagnosis:
Cite a short list of your differential diagnosis
VI. Working Impression:
State your working impression
2nd Round (Short PPT presentation of 1-3 slides)
I. Treatment Plan:
Given the patient's history and response to chemotherapy, what is your proposed treatment plan?
How do you decide the optimal timing for surgery in relation to the chemotherapy cycles?
II. Surgical Considerations:
What factors would influence your decision whether to do orchidopexy or bilateral orchiectomy?
How would you manage an incidental finding of persistent Mullerian duct structures during
surgery?
Are there other possible surgical options for the preservation of fertility or sperm retrieval in this
case?
III. Follow-up and Surveillance:
What is your recommended postoperative surveillance plan for this patient? How frequently
would you conduct imaging studies and assess tumor markers based on the guidelines?