A Diagnostic Dilemma: Metastatic Testicular Cancer and Systemic Sarcoidosis – A Review of the Literature

Sarcoidosis is a multisystem disease that most commonly involves the lungs and the lymph nodes, but with genitourinary tract involvement, can easily mimic testicular cancer with metastasis to the lungs. We describe the case of a 30-year-old African-American male who presented with complaints of a headache, skin lesions, and a scrotal mass. A computed tomography scan of the head showed lesions in the frontotemporal and pons region, causing obstructive hydrocephalus. An ultrasound of the scrotum showed an enlarged epididymis bilaterally as well as a solid hypoechoic ill-defined mass on the right side, separate from the intact testis. Given the high suspicion for testicular malignancy with brain metastasis, a right orchiectomy was completed. The pathology revealed non-caseating necrotizing granulomas that stained negative for tubercular and fungal organisms, which was consistent with sarcoidosis. Additionally, the patient's skin and central nervous system (CNS) lesions improved on steroids that had been started for cerebral edema. Given the predilection of testicular cancer for CNS metastasis, neurosarcoidosis can also be mistaken for testicular cancer metastasis to the CNS, as seen in our case. Differentiating testicular cancer from genitourinary sarcoidosis is difficult but can be clarified using a combination of clinical presentation, epidemiology, serum markers (ACE, AFP, B-HCG), biopsies from skin/lymph nodes, and sometimes imaging. It is critical to differentiate genitourinary sarcoidosis from malignancy, as a misdiagnosis can lead to unnecessary surgical interventions, which have important implications for future fertility. There can also be a coexistence of as well as an association between testicular cancer and sarcoidosis, which should be recognized by health care providers.