Mixed Germ Cell Testicular Carcinoma

Abdominal CT at time of initial presentation (not available) demonstrated massive retroperitoneal and periaortic lymphadenopathy measuring 25 cm. in greatest diameter.

The patient underwent a right radical orchiectomy revealing a mixed germ cell tumor with componenets of yolk sac tumor, embryonal cell carcinoma, and seminoma. Tumor involved the epididymis and spermatic cord with vascular invasion extending to the surgical margins.

The patient was subsequently treated with four cycles of Bleomycin, Etoposide, and Platinum (BEP) with resolution of pain. On follow up CT scan, lymphadenopathy had decreased by 50%. Follow up tumor markers were AFP 23.3 ng/ml and, ß-HCG 2 ng/ml. The patient underwent retroperitoneal lymph node dissection (RPLND) for diagnosis, staging and debulking. Pathology demonstrated one area of scattered malignant cells with apoptotic features, and follow up chemotherapy was initiated.

Pathology

Percaval, periaortic, and perihilar masses: Necrotic tissue, no viable tumor. Fibroadipose tissue with reparative changes.
Infra-aortic bifurcation mass: Scattered malignant cells with apoptotic features.

Abdominal CT

Germ Cell Tumors of the Testis

Testicular cancer is the most common malignancy in men between the ages of fifteen and thirty-five, with 2 to 3 cases occuring per 100,000 per year.³ Mixed Germ Cell Tumors account for 25 to 40% of testicular neoplasms, and 6% have seminoma as one of their components.⁴ Mixed seminomatous tumors behave like Non-Seminomatous Germ Cell Tumors (NSGCT), and are treated with the same protocols. Sixty to seventy percent of NSGCT present with metastatic disease and prognosis is less favorable than for pure seminomas.¹ Retroperitoneal lymphadenopathy is the most common site of metastasis for NSGCT.

In patients with NSGCT, 50 to 70% have an elevated AFP level and 40 to 60% have an elevated b-HCG level.¹ At least one tumor marker is raised in 90% of NSGCT.⁵ However, because 10 to 15% of patients with advanced disease have normal AVP and B-HCG levels, abdominal CT scans with serial marker determinations are used to evaluate disease progression.¹

In patients with bulky retroperitoneal disease (> 3 cm. nodes on CT), multidrug chemotherapy has been shown to be effective. In the 1980's, RPLND after chemotherapy demonstrated necrosis and fibrosis in 33% of lesions, teratoma in 47%, and residual cancer in 20%.¹ The figures now are 50%, 40%, and 10% respectively. Because CT is unable to differentiate fibrosis from teratoma or malignancy, residual retroperitoneal mass warrants RPLND to rule out cancer, and remove teratoma.⁶ Even for those patients who normalize their markers and have no masses evident on CT, some still advocate RPLND since viable Germ Cell Tumor has been seen to persist in up to 10% of cases.² Any patient found surgically to still harbor residual tumor typically undergoes another two cycles of chemotherapy to complete their treatment. Current statistics show that patients with bulky retroperitoneal disease who undergo primary chemotherapy followed by RPLND have a 5 year disease free survival rate of 55 to 80%.⁴

References

Richie J. Neoplasms of the testis: Campell's Urology, 6th ed. Walsh PC et al (editors). Saunders, 1992.
Toner GC et al. Adjunctive surgery after chemotherapy for nonseminomatous germ cell tumor: recommendations for patient selection. J Clin Oncol, 1990, 8:1683.
Boring CC, Squires TS, Tong T. Cancer statistic, 1993. CA Cancer J Clin, 1993, 43:7.
Presti JC, Herr HW. Genital tumors. In: Smith's General urology, 14th ed. Tanagho EA et al. Appleton & Lange, 1995.
Barzell WE, Whitmore WF Jr. Clinical significance of biological markers: memorial hospital experience. Semin Oncol, 1979, 6:48.
Stomper PC, Jochelson MS, Garnick MB, and Richie JP. Residual abdominal masses following chemotherapy for nonseminomatous testicular cancer: correlation of CT and histology. AJR, 1985, 145:743.

Michael Kearney is a fourth year medical student at Boston University Medical School