INTRA-ABDOMINAL SEMINOMA TESTIS IN ADULT: CASE REPORT

The available evidence demonstrates that both laparoscopic and open ligament release associated with celiac ganglionectomy are effective in provide celiac artery revascularization and sustained symptom relief in the majority of patients with the syndrome 2,3,5. The laparoscopic approach is feasible, safe, and successful, if performed by experienced laparoscopic surgeons. Although the laparoscopic treatment of celiac axis compression syndrome is a new technique, several authors have demonstrated its affectivity in providing symptom relief in patients 1,2,8. In addition, this access has several advantages, such as reduction of postoperative pain and blood loss, shorter hospital stay and faster recovery. More recently, this syndrome has been effectively treated with robot-assisted surgery 3. The advantages of this approach compared to the laparoscopic access have not yet been completed evaluated. The high cost of robot-assisted surgery is an important drawback in our country. Laparoscopic treatment of celiac axis compression syndrome (CACS) and hiatal hernia: Case report with bleeding complications and review. Int Laparoscopic versus robot-assisted surgery for median arcuate ligament syndrome. release of celiac artery compression syndrome facilitated by laparoscopic ultrasound scanning to confirm restoration of flow.


INTRODUCTION
The cryptorchidism is the most common congenital malformation of the genitourinary tract 4 . The intra-abdominal testicle is subject to complications such as cancer, ischemia and infertility 1 . The most common malignant transformation of undescended testicle is the seminoma 2,3,5 . Here is presented a case of adult massive pelvic mass corresponding to seminoma developed in intra-abdominal testis.

CASE REPORT
MC'S, man, 32, with a history of progressive and painless increased abdominal size four weeks ago, no other complaints. He had also several congenital malformations including: pectus excavatum, congenital dislocation of the hip and clubfoot (operated in childhood). Physical examination revealed ascites, bilateral pleural effusion and a hardened mass located in flank and the right iliac fossa of about 20 cm. Was detected the absence of the right testicle in scrotum. No abnormal laboratory tests were present. Computed tomography and magnetic resonance imaging of the abdomen and pelvis showed ascites and heterogeneous pelvic mass ( Figure 1). The cytological study of ascites and pleural effusion showed no neoplastic cells. Laparotomy was performed which identified a large solid mass in the right iliac fossa partially adhered to the right inguinal canal, and dry easily. The surgical specimen measured 25x19x12 cm and weighed 2350 g ( Figure 2). Histopathological examination revealed seminoma of undescended testis with extensive area of coagulation necrosis and angiolymphatic neoplastic embolization. The patient was discharged on the sixth day after surgery. The left testicle was evaluated and was normal. The staging was completed and once considered the patient in stage III (ascites), was subjected to four cycles of chemotherapy with bleomycin, etoposide and cisplatin, keeping normalization of markers and improvement of ascites. He is currently with eight years of evolution, and in that period maintained regular outpatient follow-up showing no measurable disease to blood tests and imaging.

DISCUSSION
The cryptorchidism results from abnormalities in the formation and testicular descent during the embryonic period 4 . It is present in 6% of newborns at term and in 0.8% of infants under one year of age. Can be bilateral in up to 10% of cases, and sometimes is associated with other defects in genitourinary tract 5 .
The most feared complication of undescended testicle is cancer, ranging from 3.5-14.5% among patients with cryptorchidism 5 . The testis are intra-abdominal in 10% of cases and at risk 200 times greater in malignant transformation 3 . Malignant degeneration has the peak incidence in third and fourth decade of life 2,3 . They are usually asymptomatic and are identified incidentally by imaging tests. When symptomatic, diagnosis is difficult and the symptoms may mimic acute appendicitis, urinary calculus and mass effects, compressive symptoms of the gastrointestinal and genitourinary tracts 3 . Imaging tests, US, CT and MRI show pelvic or retroperitoneal mass, well defined, homogeneous, without obvious evidence of necrosis or calcification 2,3,5 . These findings have as main differential diagnoses lymphadenopathy and sarcoma, which are more common situations. The predominant histological type is pure seminoma (43%), followed by embryonic carcinoma (28%), teratocarcinoma (27%) and choriocarcinoma (2%) 3 . Surgical treatment is mandatory, with resection of intra-abdominal mass and chemotherapy may be an alternative, depending on the stage and histological type of malignant transformation 2 .

INTRODUCTION
H epatocellular adenoma (HA) is a rare benign neoplasm of the liver. It is strongly associated with oral contraceptive used by woman in childbearing age, by men receiving anabolic steroids and metabolic diseases. HA incidence has raised over the years from 5 per 1 milion in 1964 9 to 4 per 100.000 3 , for unknown reasons.
HA is important because of its risk of complications such as life threatening rupture of the tumor and malignant transformation. Surgical treatment in ruptured HA has a high mortality rate but it is still the standard procedure in those cases 5 . Emergency liver resection in ruptured HA has a mortality rate from 5-10%, but in elective resections the mortality rate is under 1%.
Different procedures have been suggested to decrease mortality rates and spare liver parenchyma, such as arterial embolization of ruptured adenomas, although it is not an available procedure in most centers.

CASE REPORT
A 44-year-old woman admitted in the emergency department of another hospital with complaints of sudden upper quadrant abdominal pain. She had been using oral contraceptives for 31 years. She presented with acute mild abdominal pain in epigastrium as well as right hypochondrium pain followed by light dyspnea and dizziness. She was treated with analgesics and ordered an abdominal ultrasound made only three days after the pain. The ultrasound showed a solid liver mass in the right hepatic lobe measuring 150x100x100 mm 3. She was discharged without additional treatment.
After almost five months after the occurrence, she was referred to our surgical department for diagnostic investigation after another episode of abdominal pain just like the last time, followed by tachycardia and cold sweating. Physical examination revealed mild anemia and a diffuse abdominal pain, without peritonitis or palpable masses.
Abdominal CT and MRI showed an enlarged liver, with a contrast enhanced liver mass involving segments VI and VII. The liver mass measured 118x70mm 2 associated with a perilesional voluminous hematoma measuring 8cm and haemoperitoneum. The radiologic findings suggested a ruputured hepatocellular adenoma (Figure 1) Patient was admitted and sent to observation room to be prepared for surgical procedure after clinical improvement. She was transfused with two bags of packed red bloods cells and intensive electrolytes control. Patient was sent to the operation room and had an open laparotomy with Chevron incision. During operative exploration was found a voluminous liver lesion involving segments VI and VII, large subcapsular hematoma over the right hepatic lobe and mild hemoperitoneum. The right lobe of the liver had strong adhesions to the right diaphragm. It was decided to make an anterior approach with inflow control due to the risk of bleeding, by ligation of the right portal vein and the right hepatic artery. The procedure continued with parenchyma right transection in the cantlie´s line, showed Financial source: none Conflicts of interest: none