case report - WHO EMRO

case report Choroid and cutaneous metastasis from a testicular tumor Surendra Nath Senapati,a Dipti Rani Samanta,b Prafulla Kumar Das,c Anish Byondyopadhyay,a Asit Mohantya From the Divisions of aRadiation Oncology, bMedical Oncology, and cSurgical Oncology, A.H. Regional Cancer Centre, Orissa, India Correspondence: Surendra Nath Senapati, MD · Division of Radiation Oncology, A.H. Regional Cancer Centre, Mangalabag, Cuttack, Orissa 753001, India · T: +91-671-230-3333 F: +91-671-230-4444 · [email protected] · Accepted for publication October 2008 Hematol Oncol Stem Cel Ther 2008; 1(4): 249-251

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horoid metastasis from an extraocular primary malignancy is a rare event. Most of these mett tastases are carcinomas arising from the breast and lung.1,2 A mixed germ cell tumor of the testis commt monly metastasizes to lung, but choroid and cutaneous metastasis is rare. We encountered a mixed germ cell tumor of the left testis with a choriocarcinomatous element, presenting with multiple pulmonary, bilateral choroid and isolated skin metastases. This case merits documentation due to its rarity and to further support the evidence of choroid and cutaneous metastasis in mixed germ cell tumor of the testis having a choriocarcinomatous element.

was 1000 IU/L. Ultrasonography of the abdomen and pelvis revealed extensive retroperitoneal lymphadenopat athy. A posterior-anterior x-ray of the chest was normal. The patient was subsequently treated with four cycles of chemotherapy (bleomycin, etoposide, cisplatinum) starting from March 2005. A post-chemotherapy CT scan revealed residual retroperitoneal lymhadenopathy. He underwent retroperitoneal lymph node dissection in June 2005. Histopathology of the dissected lymph node revealed necrotic and hemorrhagic areas with no evidence of malignancy. He was asymptomatic for 1 year until he presented with the complaints mentioned previously.

CASE In July 2006, a 23-year-old male presented with gradual diminution of vision of 3 months duration in both eyes. He also had respiratory distress with a single episode of hemoptysis and a swelling on his back of 2-months durt ration. On examination, the patient was found to have a decreased visual field on the temporal half of both eyes, but more so in the left eye, with subconjunctival hemot orrhage and congestion in both eyes. Examination of the chest revealed decreased breath sounds in the lower zone of the right lung. Physical examination revealed a skin lesion—a mobile, nontender and firm swelling of 3 cm×4 cm in size on his back (Figure 1). The patient had a past history of an undescended left testis since birth, which became symptomatic in January 2005 for which orchidectomy of the left testis was done. Histopathology of the resected specimen revealed solid sheets of neopt plastic cells and glands along with scattered syncytiott trophoblastic giant cells adjacent to sinusoidal blood vessels indicative of a mixed germ cell tumor of the testt tes, consisting of both an embryonal cell carcinoma and choriocarcinoma (Figures 2, 3). The spermatic cord was not involved. Serum alpha-fetoprotein (AFP) was 74.3 ng/mL and β-human chorionic gonadotropin (β-hCG)

Hematol Oncol Stem Cell Ther 1(4)

October 2008 hemoncstem.edmgr.com

Figure 1. Clinical photograph showing cutaneous metastasis on the back.

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bilateral choroid and isolated cutaneous metastases of stage IIIC. He was treated with four cycles of salvage chemotherapy consisting of ifosfamide, vinblastine and cisplatinum. There was complete resolution of the pulmt monary lesion and near complete recovery of his vision. There was no local recurrence of the cutaneous lesion. At the time of writing, the patient was lost to follow up.

DISCUSSION

Figure 2. Photomicrograph showing neoplastic germ cells arranged in solid sheets and tubules with syncytiotrophoblastic giant cells (hematoxylin and eosin, ×100).

Figure 3. Photomicrograph showing sinusoidal blood vessels, areas of hemorrhage and syncytiotrophoblastic giant cells (hematoxylin and eosin, ×100).

In July 2006, a posterior-anterior chest x-ray revt vealed multiple pulmonary metastases in both lung fields. Ophthalmological examination revealed bilateral decreased visual acuity and field with exudative retint nal detachment of the left eye. On B-scan ultrasonogrt raphy of the eyes, a hyperechoic lesion of 3×3 mm in the lateral aspect of the right eye and an isoechoic lest sion 13.8×7.6 mm in size in the medial aspect of the choroid in the left eye was noticed, suggestive of metastt tases with calcification and retinal detachment (Figure 4). Excision biopsy of the skin lesion revealed stratified squamous epithelium over dense stroma with a chort riocarcinomatous element. Serum markers revealed increased β-hCG (3902.45 IU/L) and a normal AFP level (1.13 ng/mL). The patient was diagnosed with mixed germ cell tumor of the left testis having multiple pulmonary,

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Testicular tumor is the most common solid tumor bett tween the ages of 20 to 35 years. It commonly spreads to the para-aortic lymph nodes and lungs. Metastasis to the choroid is a rare event. The overall frequency of orbital metastasis in cancer is approximately 12%, of which choroid metastasis is estimated to be 2% to 7%.1,2 Very few cases has been reported describing choroid metastasis from a testicular tumor. Kiyamez et al from Turkey described a case of choroid as well as intracraniat al metastasis having primary embryonal cell carcinoma of the testis.3 Nakajima et al described testicular tumor with lung and brain as well as intraocular metastasis in a 23-year-old man.4 Zech also reported a case of chort riocarcinoma of the testis metastasizing to the choroid.5 Cutaneous metastasis from testicular primary tumor is also a rare occurrence. Tinkle et al reported a case of choriocarcinoma of the testis with skin metastasis.6 Saito reported a choriocarcinoma of the testis with cutaneous metastasis.7 Thus, a review of the available literature reveals that cutaneous metastases from a testt ticular primary tumor is mostly of choriocarcinomatous histology. However, only 11 cases of cutaneous metastast sis due to choriocarcinoma of testis or ovary were found in a review of the literature. The present case had lung and choroid as well as cutaneous involvement, which is a rare event. Most patt tients with testicular tumor and choroid as well as cutt taneous metastasis are reported to have histopathologict cal evidence of a choriocarcinomatous element. In our patient, the histopathology of the primary tumor was a mixed germ cell tumor of the testis with a choriocarcint nomatous element and elevated β-hCG. The incidence of bilateral choroid metastasis is appt proximately 4.4%.8 In the present case, the patient had bilateral choroid metastases with a solitary lesion in each eye. The median interval from diagnosis to develot opment of ocular metastasis is 36 months (range, 8 to 24 months).9 The patient developed choroid metastasis 18 months after the detection of the primary tumor. In another report, a B-scan ultrasound of the metastatic choroid lesion presented with an acoustically solid convt vex mass with a low height-to-base ratio,10 which was



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choroid and cutaneous metastasis

Figure 4. B-scan ultrasound showing choroid metastasis in both eyes.

also evident in the present case. Radiotherapy plays an important role in the treatment of choroid metastasis. Chemotherapy to treat choroid metastasis is not widely reported in the medical literature is not thought to that chemotherapy does not reach the choroid. As the patt tient had multiple pulmonary, choroid and cutaneous metastasis due to mixed germ cell tumor of testis, he was treated with chemotherapy and there was complete disappearance of the pulmonary lesion and near total complete recovery of vision, so chemotherapy mat in

fact reach the choroid. Testicular tumor with a choriocarcinomatous elemt ment has a predilection for choroid and cutaneous mett tastasis. Our case, with pulmonary, choroid and cutaneot ous metastasis, is a rare one, which also further strengthet ens the evidence of choroid and cutaneous metastasis in testicular tumor having a choriocarcinomatous element. These patients should be followed regularly to detect choroid metastasis early, thus allowing for effective and the ability to maintain a better quality of life.

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from testicular Cancer. J Clin Oncol. 2004;22:175355. 5. Zech JC, Subiger L, Chiquet C, Bouvier R, Trepsl sat C. Testicular choriocarcinoma metastatic to the choroid. Retina. 1999;19(2):164-65. 6. Tinkle LL, Graham BS, Spillane TJ, Barr RJ. Testl ticular choriocarcinoma metastatic to the skin: an additional case and literature review. Cutis 2001;67(2):117-20. 7. Saito J, Miyagawa Y, Kamoto A, Yokoyama S, Kakuta Y, Mori N, Ichimaru N, Hara T, Nonomura N, Yamaguchi S, Okuyama A. Testicular cancer


metastatic to multiple organs including the stomal ach, kidneys, and skin: a case report. Hinyokika Kiyo. 2006;52(4):297-301. 8. Ferry AP, Font RL. Carcinoma metastatic to the eye and orbit. A clinicopthologic study of 227 casel es. Arch Opthalmol. 1987;105:1215-1219. 9. Singh D, Sharma A, Arora B, Shukla NK, Mohanti BK. Adenocarcinoma esophagus with choroid metl tastasis. Indian J Gastroenterol. 2004;23:112-113. 10. Coleman DJ, Abramson DH, Jack RL, Franzen LA. Ultrasonic diagnosis of tumors of the choroid. Arch Ophthalmol. 1974;91:344-54.

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