See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/272870697 Upper Gastrointestinal Bleeding as Initial Presentation of Burned-out Testicular Tumor Article in UHOD - Uluslararasi Hematoloji-Onkoloji Dergisi · December 2011 DOI: 10.4999/uhod.09113 CITATION READS 1 18 1 author: Haldun Kar İ zmir Atatürk E ğ itim ve Ara ş t ı rma Hastanesi 45 PUBLICATIONS 109 CITATIONS SEE PROFILE Some of the authors of this publication are also working on these related projects: degos disease View project All content following this page was uploaded by Haldun Kar on 22 November 2016. The user has requested enhancement of the downloaded file.
I nternational J ournal of H ematology and O ncology U LUSLARARAS ı H EMATOLOJI - O NKOLOJI D ERGISI C ASE R EPORT Upper Gastrointestinal Bleeding as Initial Presentation of Burned-out Testicular Tumor Haldun KAR 1 , Erdinc KAMER 1 , Nese EKINCI 2 , Cengiz GIRGIN 3 , Mehmet A. ONAL 1 , Murat ERMETE 2 1 Atatürk Training and Research Hospital, Clinics of 4th General Surgery 2 Atatürk Training and Research Hospital, Clinics of 2nd Pathology 3 Atatürk Training and Research Hospital, Clinics of 1st Urology, Izmir, TURKEY ABSTRACT We report a case of 33-year-old man who initially presented with upper gastrointestinal bleeding caused by metastatic testicular can- cer. Physical examination was significant for a palpable abdominal mass. Emergency gastroduodenoscopy yielded an ulcerated in- filtrating mass in the third portion of the duodenum. Computerized tomography of the abdomen demonstrated a retroperitoneal mass. Histological examination of the retroperitoneal mass biopsy showed a nonseminamatous germ cell tumor consisting of embr- yonal cell carcinoma. Examination of the testes revealed a normal-sized firm left testis, and a normal right one. Ultrasonography of the testes showed multiple left testicular calcifications. The patient underwent left radical inguinal orchiectomy and histological exa- mination of the resected testis showed spontaneous regression of testicular germ cell tumor. We suppose that the tumor was a so- called 'burned-out' testicular tumor. He was treated with four courses of chemotherapy with cisplatin, etoposide and bleomycin. At five year follow-up, the patient was doing well, with no recurrens. Keywords: Burned-out, Gastrointestinal bleeding, Metastatic testicular neoplasm, Testicular germ cell tumor ÖZET ‹lk Bulgusu Üst Gastrointestinal Sistem Kanamas› Olan Burned-out Testis Tümörü Bu çal›flmada, ilk flikayeti metastatik testiküler kanser nedeniyle üst gastrointestinal kanama olan 33 yafl›nda erkek hastay› sunduk. Fizik muayenede belirgin bat›nda belirgin kitle mevcuttu. Acil endoskopide duodenum 3. k›tada ülsere infiltratif kitle izlendi. Bat›n to- mografisinde retroperitoneal kitle tespit edildi. Retroperitoneal biyopsinin histolojik incelemesinde embriyonel hücreli karsinomadan oluflan nonseminamatöz germ hücreli tümör saptand›. Skrotal muayenede sol testis normal boyutlarda olup sert k›vamda, sa¤ testis ise normal palpe edildi. Testis skrotal ultrasonunda sol testisde multiple kalsifikasyonlar saptand›. Hastaya sol radikal inguinal orfliek- tomi uyguland› ve rezeke edilen testisin histolojik incelenmesinde testiküler germ hücreli tümörün spontan regresyone oldu¤u görül- dü. Tümörün burned-out testiküler tümör oldu¤u kan›s›na var›ld›. Dört kür cisplatin, etoposide, bleomycin kemoterapisi sonras› 5 y›l- d›r kontrolde olan hastada rekurrens saptanmad›. Anahtar Kelimeler: Burned-out, Gastrointestinal kanama, Metastatik testiküler neoplazm, Testisin germ hücreli tümörü Number: 4 Volume: 21 Year: 2011 doi: 10.4999/uhod.09113 245 UHOD
INTRODUCTION lar formations that was considered as embryonal cell carcinoma (Figure 2). Immunohistochemical stain Burned-out testicular tumor of the testis is a rare cli- for alpha-fetoprotein (AFP) was positive within the nical entity. It generally presents with metastases and tumor cells. Additional history of spontaneous reg- is nonpalpable during testicular examination. Immu- ression of a left scrotal swelling which had occured nological and ischemic causes have been suspected to play a role in its etiopathogenesis. 1,2 Diagnosis is one year before surgery was obtained. The patient had received antibiotic treatment with the diagnosis often difficult because primary lesion may not be fo- of epididymitis and also received treatment for infer- und initially. Fewer than 5% of the patients with me- tility (human chorionic gonodotropin 5000 IU for 6 tastatic testicular cancer present with gastrointestinal weeks). Histopathological results and urogenitale (GI) involvement. 3,4,5 Testicular burned-out tumor history of the patient necessitated consultation of an with GI involvement is even rarer with only a few re- urologist. Examination of the testes revealed a nor- ported cases in the English literature. We present a mal-sized but firm left testis without pain on palpati- case of testicular burned-out tumor having retroperi- on, and a normal right testis. Scrotal ultrasonography toneal lymph node metastases which has caused up- (SUS) showed multiple left testicular calcifications per GI bleeding. and an enlarged epididymis. The tumor markers AFP and beta-human chorionic gonodotropin (ß-HCG) CASE REPORT were 225 ng/mL (0-8 ng/mL), and 43.7 IU/L (<10 IU/L), respectively. CT scan of the chest was normal. A 33-year-old previously healthy man presented The patient underwent left radical inguinal orchiec- emergency room complaining of epigastric pain, fa- tomy and histological examination of the resected tigue and weakness. Physical examination was signi- testis showed spontaneous regression of testicular ficant for a palpable abdominal mass. Laboratory germ cell tumor (GCT). Grossly, there was a well-de- analysis revealed WBC: 13.6/mm, Hgb: 9.6 g/dl, lineated nodular scar tissue which was 1 cm in di- Hct: 31.8%. Stool was heme positive. Emergency ameter. Microscopically, this scar tissue was made up gastroduodenoscopy yielded an ulcerated infiltrating of ghost tubules with scattered hemosiderin laden mass in the third portion of the duodenum causing macrophages, coarse intratubuler calcifications and narrowing of the lumen. Biopsy of the ulcer lesion atrophic tubules in a hyalinised background. Interes- confirmed undifferantiated carcinoma. Computeri- tingly, there was intratubular germ cell neoplasia of zed tomography (CT) of the abdomen demonstrated unclassified type (IGCNU) in the seminiferous tubu- a retroperitoneal mass located between the tail of the les peripheral to the area of nodular scarring (Figure pancreas and iliac wing. Left psoas muscle was in- filtrated by the mass (Figure 1). The patient under- went emergency laparotomy with signs of acute ab- dominal pain on the second day of hospitalization. Exploration of the abdomen revealed a (10 x 10 cm) retroperitoneal mass extending into the mesentery of the small intestines. The mass was considered unre- sectable and incisional biopsies were obtained. As bile leak developed on the 2nd postoperative day, oral fluid intake was stopped. Octreotide treatment and total parenteral nutrition were initiated. Bile leak ceased on the 12th postoperative day. Histological examination of the retroperitoneal biopsy showed a nonseminamatous germ cell tumor consisting of embryonal cell carcinoma. Microscopically, the tis- sue was completely neoplastic which was mainly so- lid with foci of haemorrhage and necrosis. Sheets of Figure 1. CT scan of the abdomen showed a retroperitoneal cells with typical large, irregular shaped nuclei and mass. prominant nucleoli formed rare papillary and glandu- 246 Number: 4 Volume: 21 Year: 2011 UHOD
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