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LETTER TO THE EDITOR
Year : 2015  |  Volume : 52  |  Issue : 1  |  Page : 59-60
 

Giant testicular tumor with pulmonary metastases: Stroke as the initial manifestation


1 Department of Surgery, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha, Maharashtra, India
2 Department of Pathology, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha, Maharashtra, India

Date of Web Publication3-Feb-2016

Correspondence Address:
A Agrawal
Department of Surgery, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.175607

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How to cite this article:
Agrawal A, Bhake A. Giant testicular tumor with pulmonary metastases: Stroke as the initial manifestation. Indian J Cancer 2015;52:59-60

How to cite this URL:
Agrawal A, Bhake A. Giant testicular tumor with pulmonary metastases: Stroke as the initial manifestation. Indian J Cancer [serial online] 2015 [cited 2021 Dec 7];52:59-60. Available from: https://www.indianjcancer.com/text.asp?2015/52/1/59/175607


Sir,

Mixed germ cell tumors with seminomatous and embryonal carcinoma component are highly aggressive lesion with the tendency for early hematogenous spread.[1],[2] The majority of patient embryonal carcinoma have metastatic disease at the time of diagnosis.[2] However, the development of brain metastases with hemorrhage is a rare clinicopathologic entity.[3],[4],[5] As in the present case, rarely these lesions can present with sudden intratumoral bleeding.[6] A 35-year-old male admitted with a history of sudden onset of headache followed-by weakness of the left side of body and altered sensorium and 2-3 episodes of vomiting. He was also having dry cough for last few days. He was managed outside at a peripheral hospital and a computed tomographic (CT) scan was performed that showed a tumor with bleed in right frontoparietal region. Pre-contrast CT scan revealed a mixed density mass within the right frontoparietal lobe, which was homogeneously enhancing after contrast administration [Figure 1]a and [Figure 1]b. Magnetic resonance imaging also showed evidence of tumor with bleed [Figure 1]c and [Figure 1]d. On examination, he was in altered sensorium with the left sided hemiplegia of grade 0/5 with facial asymmetry. He had crepitation on the right of the chest. Local examination we also noticed firm, tender enlargement of right testis that was there for last 1-year and the patient thought it to be a hydrocoele and did not seek any medical attention. X-ray chest showed a multiple canon ball lesions in the right lung field. He was started on anti-edema measures (mannitol and steroids) and anti-epileptics. In view, poor general condition the patient was planned for fine needle aspiration cytology from the right testicular mass lesion and it was suggestive of seminoma. As this, tumor is highly sensitive to chemotherapy even with systemic metastases and the solitary cerebral lesion was accessible to surgery he was surgical intervention. He underwent right frontoparietal craniotomy and excision of metastatic lesion, at the same time right high orchidectomy was also performed. His power in left upper and lower limbs was improved to grade 4/5. Histopathology of both the lesions revealed a mixed tumor of embryonal cell carcinoma and seminoma [Figure 2]a and [Figure 2]b. He received bleomycin, etoposide and cisplatin chemotherapy and doing well. Patient survived for 16 months and died because of extensive systemic recurrence.
Figure 1: Computed tomographic scan showing hyperdense lesion in right frontoparietal region (left), the lesion was enhancing after contrast administration (a and b), magnetic resonance imaging showing evidence of bleed and perilesional edema (c and d)

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Figure 2: (a) Photomicrograph showing embryonal component of testicular tumor (H and E, ×40) and (b) photomicrograph showing seminomatous component of testicular tumor (H and E, ×40)

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As in our case, testicular tumors with large retroperitoneal lymph nodes or supradiaphragmatic lymphadenopathy or a visceral metastasis or primary extragonadal, mediastinal or retroperitoneal disease are considered as advances disease.[2],[4] Presence of embryonal component makes them highly aggressive and usually the disease is advanced at the time of the presentation itself and associated with distant metastases.[2] Due to the rarity of brain metastases from these tumors and the considerable variability of the clinical presentations, even large treatment centers can gain only limited experience with the different treatment modalities available.[3] Presently cisplatin-based chemotherapy has dramatically improved the clinical outlook for patients with disseminated germ cell tumors.[4],[7],[8],[9] The gold standard regimen for metastatic testicular germ cell tumors is a combination of bleomycin, etoposide and cisplatin and there is evidence that a sufficient amount of cisplatin, etoposide and bleomycin cross the blood-brain barrier in patients with macroscopic intracerebral metastases.[1],[10],[11],[12] After chemotherapy with bleomycin, etoposide and cisplatin, the lung tumors can also disappear.[13] It has been recommended that surgical removal of tumor before initiating radiotherapy and chemotherapy for large brain metastasis will produce better results than using the nonsurgical treatments alone.[13] In selected cases early and aggressive surgical removal of cerebral metastatic lesion is advisable to get good functional results.[3],[6],[14] The presence of liver or central nervous system metastases, initially or at recurrence, is associated with high treatment failure rates.[3],[4],[15],[16] Despite their highly malignant nature, with aggressive treatment the overall 5-year survival rate of these patients has greatly improved over the last decade.[2],[3] The present case illustrate that cerebral metastases with hemorrhage leading to neurological deficits can be the initial manifestation from highly malignant testicular tumors. Unawareness in patent about the fact that painless enlargement of the testis can harbor the malignancy and delay the diagnosis.

 
  References Top

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Shoji S, Shima M, Usui Y, Nagata Y, Uchida T, Terachi T. A case report: Simultaneous bilateral testicular tumors with different cell types – Complete response after combination chemotherapy of cisplatin and irrinotecan hydrochloride. Hinyokika Kiyo 2006;52:303-6.  Back to cited text no. 1
    
2.
Vugrin D, Chen A, Feigl P, Laszlo J. Embryonal carcinoma of the testis. Cancer 1988;61:2348-52.  Back to cited text no. 2
    
3.
Fosså SD, Bokemeyer C, Gerl A, Culine S, Jones WG, Mead GM, et al. Treatment outcome of patients with brain metastases from malignant germ cell tumors. Cancer 1999;85:988-97.  Back to cited text no. 3
    
4.
Gholam D, Fizazi K, Terrier-Lacombe MJ, Jan P, Culine S, Theodore C. Advanced seminoma: Treatment results and prognostic factors for survival after first-line, cisplatin-based chemotherapy and for patients with recurrent disease: A single-institution experience in 145 patients. Cancer 2003;98:745-52.  Back to cited text no. 4
    
5.
Kamiya K, Yamashita N, Nagai H, Misawa I. A case of cranial and intracranial metastasis from testicular seminoma. No Shinkei Geka 1991;19:63-7.  Back to cited text no. 5
    
6.
Nishizaki T, Orita T, Tsuha M, Wakuta Y, Fujii M, Ito H. Brain metastasis of testicular tumor with massive hemorrhage: Report of two cases. Neurol Med Chir (Tokyo) 1991;31:586-9.  Back to cited text no. 6
    
7.
Einhorn LH. Treatment of testicular cancer: A new and improved model. J Clin Oncol 1990;8:1777-81.  Back to cited text no. 7
    
8.
Alimehmeti R, Campanella R, Bauer D, Balbi S, Rampini P, Egidi M, et al. Intracranial metastasis of testicular seminoma in an HIV-positive. Case report and review. J Neurooncol 2003;65:135-40.  Back to cited text no. 8
    
9.
Rick O, Siegert W, Schwella N, Dubiel M, Krusch A, Beyer J. High-dose chemotherapy as salvage treatment for seminoma. Bone Marrow Transplant 2002;30:157-60.  Back to cited text no. 9
    
10.
Culine S. Chemotherapy for metastatic germ cell tumours of the testis. Rev Prat 2007;57:385-8.  Back to cited text no. 10
    
11.
Ginsberg S, Kirshner J, Reich S, Panasci L, Finkelstein T, Fandrich S, et al. Systemic chemotherapy for a primary germ cell tumor of the brain: A pharmacokinetic study. Cancer Treat Rep 1981;65:477-83.  Back to cited text no. 11
    
12.
Stewart OJ, Richard M, Hugenholtz H, Dennery J. VP-16 (VP) and VM-26 (VM) penetration into human brain tumours (BT). Proc Am Assoc Cancer Res 1983;24:133.  Back to cited text no. 12
    
13.
Yoshida S, Morii K. Brain metastasis from germinal tumors of the testis. Case report. J Neurosurg 1998;88:761-3.  Back to cited text no. 13
    
14.
International Germ Cell Consensus Classification: A prognostic factor-based staging system for metastatic germ cell cancers. International Germ Cell Cancer Collaborative Group. J Clin Oncol 1997;15:594-603.  Back to cited text no. 14
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15.
Spears WT, Morphis JG 2nd, Lester SG, Williams SD, Einhorn LH. Brain metastases and testicular tumors: Long-term survival. Int J Radiat Oncol Biol Phys 1992;22:17-22.  Back to cited text no. 15
    
16.
Bokemeyer C, Nowak P, Haupt A, Metzner B, Köhne H, Hartmann JT, et al. Treatment of brain metastases in patients with testicular cancer. J Clin Oncol 1997;15:1449-54.  Back to cited text no. 16
    


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