Cutaneous Relapse of Testicular Embryonic Carcinoma

0022-5347/01/1653-0909/0 THE JOURNAL OF UROLOGY® Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.®

Vol. 165, 909, March 2001 Printed in U.S.A.

CUTANEOUS RELAPSE OF TESTICULAR EMBRYONIC CARCINOMA SVEIN DUELAND, ERIK WIST, MARIT LØBERG

AND

JON REIDAR IVERSEN

From the Departments of Oncology and Pathology, Ullevaal University Hospital, Oslo, Norway KEY WORDS: testicular neoplasms; testis; carcinoma, embryonal

Cutaneous metastases from testicular cancer are rare and only a few cases have been reported in the literature. Of 6 cases reported to date 5 had advanced disease with metastases to lung, liver or brain at the time of diagnosis of cutaneous metastases. CASE REPORT

A 30-year-old man with a testicular tumor containing components of embryonic carcinoma and seminoma had metastases to the lung and mediastinum at the time of diagnosis. He was initially treated with 4 cycles of chemotherapy, consisting of bleomycin, etoposide and cisplatin, with complete response. At 6-month followup computerized tomography (CT) revealed progression of a mediastinal lymph node. The patient underwent thoracotomy with resection of lymph nodes, which were histologically classified as embryonic carcinoma, and received 3 cycles of cisplatin, etoposide and ifosfamide. CT of the thorax, abdomen and pelvis were negative. Five months later the patient noticed a firm, elevated subcutaneous tumor below the left scapula proximal to the thoracotomy scar. Ultrasonography and CT showed a 17 ⫻ 30 mm. tumor (fig. 1). The mass was removed surgically and histological examination revealed embryonic carcinoma elements identical to the primary testicular tumor (fig. 2). No other manifestation was detected. The patient received local radiation therapy. At completion of the radiotherapy another subcutaneous tumor was detected cranially to the previously detected tumor and outside the previous surgical and irradiated site. Histological examination confirmed embryonic carcinoma components. At the time of detection and removal of the second subcutaneous metastasis CT of the thorax showed Accepted for publication October 20, 2000.

FIG. 2. Only embryonic component of primary testicular tumor was detected in subcutaneous metastatic lesion. Embryonic component reveals tumor cells with amphophilic cytoplasm and pleomorphic nuclei. Growth pattern is partly tubular and partly solid. H & E, reduced from ⫻200.

multiple lung metastases with 4 lesions in the right lung and 1 in the left lung. The patient had normal serum levels of ␣-fetoprotein, human chorionic gonadotropin and lactate dehydrogenase. He was treated with paclitaxel, bleomycin, etoposide and cisplatin. Brain metastases were diagnosed and treated with palliative radiotherapy. The patient died 15 months after the initial diagnosis of a metastatic skin lesion. DISCUSSION

To our knowledge only 6 cases of testicular cancer with cutaneous metastases have been reported and all were choriocarcinoma.1–3 Of these patients 1 had manifestations in the skin and testis only,1 whereas all of the others had advanced disease with multiple metastatic foci at the time cutaneous spread was diagnosed.1–3 Our patient did not have any other disease recurrence at initial diagnosis of the first cutaneous metastasis. To our knowledge we report the first case demonstrating that embryonic carcinomas may spread to skin. Our case also demonstrates that a metastatic skin lesion may be the first and only sign of relapse and tumor activity in testicular cancer cases. Of 6 patients with testicular cancer in the literature 4 died within 3 months of being diagnosed with metastatic skin lesions. Our patient survived for 15 months, indicating a dismal prognosis for most of these patients. REFERENCES

FIG. 1. CT of thorax shows subcutaneous metastatic lesion on left side (arrow) as only manifestation.

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1. Winter, C. C. and Trepaskko, D. W.: Rare solitary metastases from choriocarcinoma of testis. Urology, 33: 320, 1989 2. Chhieng, D. C., Jennings, T. A., Slominski, A. et al: Choriocarcinoma presenting as a cutaneous metastasis. J Cutan Pathol, 22: 374, 1995 3. Shimizu, S., Nagata, Y. and Han-yaku, H.: Metastatic testicular choriocarcinoma of the skin. Report and review of the literature. Am J Dermatopathol, 18: 633, 1996