LAUSR

Patient A20-year-old Hispanic male who is a semiprofessional soccer player with no medical history presented to the emergency department with 1 month of abdominal distension and 4 days of left lower extremity swelling. During initial interview, the patient offered that his testicle had been enlarged for approximately 4-6 years, without any workup or intervention. A firm nontender abdomen, enlarged left hemiscrotum, and left lower extremity swelling were noted on physical examination. A left supraclavicular lymph node was also palpable. Laboratory workup revealed a serum creatinine of 1.64mg/dL and estimated glomerular filtration rate of 59. Tumor markers were drawn and elevated (alpha-fetoprotein, 350; human chorionic gonadotropin, 440; and lactate dehydrogenase 262) (Fig. 1). Lower extremity duplex ultrasound confirmed noncompressible occlusive venous thrombosis involving the left external iliac, common femoral, great saphenous, femoral, and popliteal veins. Severe right and moderate left hydronephrosis were visualized on renal-bladder ultrasound, along with a large compressive intraabdominal cystic mass compressing bilateral ureters. Scrotal ultrasound was obtained confirming a 9.8£ 6.8£ 8.2 cm heterogeneous left testicular mass. Positron emission tomography-computed tomography imaging revealed a large left testicular cystic mass; a large volume of multiseptated cystic mass filling the entire abdomen and pelvis, encasing the great vessels and their branches and displacing all intraabdominal organs anteriorly and superiorly; and a large left neck mass. Bilateral hydronephrosis from extrinsic compression was also noted. Masses were hypometabolic on positron emission tomography imaging. There was no evidence of disease in the thorax or brain. Bilateral percutaneous nephrostomy tubes were placed with subsequent normalization of renal function. Biopsy of the retroperitoneal mass was