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| Journal of the New Zealand Medical Association,
05-March-2010, Vol 123 No 1310
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Testicular seminoma metastasis to pancreas: a rare
cause of obstructive jaundice
Mohit Girotra, Niraj Jani, Javaid M Khan, Viplove Senadhi,
Sudhir K Dutta
Testicular cancer represents the most common malignancy in
men from age 15–35 years. The North American standard
classification1 divides testicular cancers into
Germ cell tumours (GCT) and Non-Germ cell tumours. The lymphatic
spread2 of GCT usually involves the
retroperitoneal lymph nodes.3 However, this
spread to retroperitoneum rarely involves the upper gastrointestinal tract.
Case report:A 43-year-old African-American man presents to the ER with
right upper quadrant abdominal pain and pruritus of 2-week duration. He also had
dark stools and increasing constipation. On exam, notable findings included
icteric sclera, right upper quadrant and epigastric tenderness. Laboratory
studies revealed a total bilrubin of 6.3mg/dl, AST/ALT of 52/143 units/L, and
ALP of 408 units/L. CT abdomen showed a large soft tissue mass at the
2nd and 3rd
portions of the duodenum with intra and extra-hepatic biliary dilatation
At endoscopy, the entire second portion of the duodenum was
found to be ulcerated, friable, and the major papilla could not be identified
(Figure 1). EUS revealed a 5-cm hypoechoic lesion extending from the pancreatic
head to the duodenum with a grossly dilated bile duct upstream (Figure 2). ERCP
was attempted for biliary decompression followed by EUS-FNA for staging and
diagnosis. The patient had a percutaneous transhepatic catheter placed for
biliary decompression. Endoscopic biopsy and cytology specimens of pancreatic
mass revealed a poorly differentiated neoplasm with features resembling
testicular seminoma (Figure 3). Immunostains for hPLAP (human Placental Alkaline
Phosphatase) positivity confirmed metastatic seminoma.
As his bilirubin decreased, he began to feel better and was
then started on chemotherapy. He was readmitted 2 months later for massive upper
GI bleed and EGD showed a bleeding duodenal mass near the ampulla. Haemostasis
was achieved with a heat probe application and an epinephrine injection. Tagged
RBC scan showed no specific bleeding site to embolise. He underwent a right
hepatic artery ligation and a pylorus sparing Whipple procedure (R0 resection).
The patient was discharged home after 3 weeks and continued on adjuvant therapy
with chemo and radiation.
The patient had initially presented 1 year back with right
lower quadrant abdominal pain radiating to his groin with a swollen and tender
right testicle (6cm). He underwent a right inguinal orchiectomy and was found to
have T3N0M0 testicular seminoma. Chemotherapy and radiation were recommended but
the patient did not pursue.
Figure 1. Endoscopic appearance of pancreatic
tumour in the 2nd and
3rd part of duodenum, loss of duodenal
papilla
 Figure 2. Endoscopic ultrasound appearance of
pancreatic tumour
 Figure 3. Pathology slide of pancreatic mass
showing the features of testicular seminoma
 DiscussionGCT metastasis to the upper gastrointestinal (GI) tract is
uncommon (<5%). Non-seminomatous GCT is much more likely to spread to the GI
tract than seminomas.8 A case series from
Memorial Kettering described 16 cases of metastatic pancreatic cancers, but none
of them were testicular in origin.9 Another
postmortem case series did not document any purely seminomatous tumours
metastasising to the upper GI tract7.
Our patient was initially diagnosed with testicular cancer
and underwent surgical orchiectomy, but refused any post-operative chemotherapy
and radiation. The tumour was T3N0M0 and no evidence of metastases was noted at
that time. He later presented with obstructive jaundice, and was found to have a
large pancreatic head mass pressing into the duodenum. The pathology and
immunostaining of the mass was consistent with patient’s earlier diagnosis
of testicular seminoma. He was started on chemotherapy with BEP (bleomycin,
etoposide, and cisplatin) and responded well, with decrease in size of the mass
on serial CT scans and also symptomatic relief from his jaundice. He later had
GI bleed, which is a common complication of GI tumours, and underwent Right
hepatic artery ligation followed by R0 Whipple’s resection. Later adjuvant
therapy with chemo and radiation were continued and patient responded well.
Seminoma is a highly chemosensitive tumour and modern
chemotherapeutic regimens (BEP) have shown high success
rates.10 Most cases of metastases have been
documented in patients not receiving chemotherapy. Our case is unique in being
the first to report pancreatic metastasis of testicular seminoma, and emphasises
the importance of adjuvant therapy (chemo/radiation therapy) following the
surgical resection of large testicular tumours to prevent future complications
and metastases.
Author information: Mohit Girotra, Viplove
Senadhi, Javaid M Khan, Internal Medicine Residents, Johns Hopkins
University/Sinai Hospital Program, Baltimore; Niraj Jani,
Assistant Professor of Medicine, Johns Hopkins University School of
Medicine, Baltimore; Sudhir K Dutta, Professor of Medicine,
University of Maryland School of Medicine, Baltimore, MD, USA
Correspondence: Mohit Girotra, M.D.,
Division of Gastroenterology, Morton Mower Medical Office Building, Suite
305, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA. Fax: +1 (410)
6015757; email: girotra.mohit@gmail.com
References:
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