|LETTER TO THE EDITOR
|Year : 2015 | Volume
| Issue : 1 | Page : 59-60
Giant testicular tumor with pulmonary metastases: Stroke as the initial manifestation
A Agrawal1, A Bhake2
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 Publication||3-Feb-2016|
Department of Surgery, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
|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
Mixed germ cell tumors with seminomatous and embryonal carcinoma component are highly aggressive lesion with the tendency for early hematogenous spread., The majority of patient embryonal carcinoma have metastatic disease at the time of diagnosis. However, the development of brain metastases with hemorrhage is a rare clinicopathologic entity.,, As in the present case, rarely these lesions can present with sudden intratumoral bleeding. 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., 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. 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. Presently cisplatin-based chemotherapy has dramatically improved the clinical outlook for patients with disseminated germ cell tumors.,,, 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.,,, After chemotherapy with bleomycin, etoposide and cisplatin, the lung tumors can also disappear. 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. In selected cases early and aggressive surgical removal of cerebral metastatic lesion is advisable to get good functional results.,, The presence of liver or central nervous system metastases, initially or at recurrence, is associated with high treatment failure rates.,,, Despite their highly malignant nature, with aggressive treatment the overall 5-year survival rate of these patients has greatly improved over the last decade., 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.
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