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CASE REPORT
Year : 2004  |  Volume : 20  |  Issue : 2  |  Page : 54-55
 

Hematemesis and malena as the initial presentations of metastatic germ cell tumor of the testis: A case report


SGPGIMS, Lucknow, India

Correspondence Address:
Aneesh Srivastava
Department of Urology & Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014
India
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Source of Support: None, Conflict of Interest: None


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Keywords: Germ cell, tumor, gastrointestinal, hematemesis, malena


How to cite this article:
Singh V, Kumar D, Srivastava A. Hematemesis and malena as the initial presentations of metastatic germ cell tumor of the testis: A case report. Indian J Urol 2004;20:54-5

How to cite this URL:
Singh V, Kumar D, Srivastava A. Hematemesis and malena as the initial presentations of metastatic germ cell tumor of the testis: A case report. Indian J Urol [serial online] 2004 [cited 2019 Nov 13];20:54-5. Available from: http://www.indianjurol.com/text.asp?2004/20/2/54/37171



   Case Report Top


A 29 years old male presented with one episode of hematemesis and three episodes of malena over last 2 months. He had dull aching abdominal pain for 1 month. He had history of left hydrocelectomy 6 months back done at other hospital.The examination of abdomen revealed palpable hard retroperitoneal lymph node mass and bilateral inguinal lymphadenopathy.The examination of external genitalia and scrotum revealed a left testicular swelling with moderate vaginal hydrocele and normal right testis. His alpha feto protein was 200 ng/ml, β hcg 700 mIU/ml and LDH was 1800 iu/mI. The CT scan of the scrotum showed right testicular tumor with moderate hydrocele and normal left testis[Figure - 1].The oral and intravenous contrast CT scan of abdomen showed enlarged retroperitoneal lymph nodes and suspicious involvement of second part of duodenum [Figure - 2]. His upper gastrointestinal endoscopy revealed a blood oozing ulcer in second part of duodenum. The biopsy of the ulcer margin revealed it to be case of NSGC tumor. The patient was managed by right high inguinal orchiectomy. The histopathological examination of orchiectomy specimen revealed it to be a case of NSGCT germ cell tumor with predominant embryonal histology. The patient was given 4 cycles of cisplatinum, bleomycin and etoposide based chemotherapy and his gastrointestinal symptoms disappeared. The first cycle of chemotherapy was given at 80% of the calculated dose.

The endoscopic examination after completion of chemotherapy showed no evidence of ulcer in duodenum.The tumor markers became normal at the end of chemotherapy.The CT scan of abdomen at the end of chemotherapy showed normal retroperitoneum. At 9 months of follow-up he had extensive recurrences in retroperitoneum ,liver and lungs. He was advised for the second line of chemotherapy but he did not comply and died within one month.


   Comments Top


About 5% of testicular germ cell tumors have gastrointestinal tract involvement and the duodenum is the most commonly involved site [1],[2] . Among the non­seminomatous germ cell tumors, the embryonal cell carcinoma and choriocarcinoma most commonly involve the gastrointestinal tract [1] . The gastrointestinal tract involvement by seminoma is extremely rare [1] The patients with gastrointestinal presentation of their germ cell tumor most often belong to a poor- prognosis group, due to large volume disease elsewhere, independent of histopathology [1]. Our patient had extensive retroperitoneal lymphadenopathy and involvement of duodenum also [Figure - 2]. The upper gastrointestinal endoscopy revealed a bleeding ulcer in second part of duodenum. After testicular ablation these patients should be treated with extremely intensive chemotherapy [1],[3] . However in patients with bleeding from intestinal ulcer, the chemotherapy at reduced dose should be given at first cycle and the subsequent cycles should be at standard dose [1] . The patient in this case report was given first cycle of chemotherpy at 80% of the calculated dose and next 3 cycles at standard dose and he tolerated it well. The gastrointestinal hemorrhage sometimes can be life threatening if complicated with aorto-duodenal fistula [1],[3] . The patients can present initially with severe anemia and malena [3] . The gastrointestinal hemorrhage in young patients should always be investigated for germ cell tumors [1],[2] . The prognosis in such patients is poor [1],[2],[3] Though our patient tolerated chemotherapy well but he had recurrence of disease in retroperitoneum, lungs and liver after 9 months and died.

 
   References Top

1.Nord C., Fossa S.D., Giercksky K.E.: Gastrointestinal presentation of germ cell malignancy. Eur. Urol. 2000;38;721.  Back to cited text no. 1    
2.Rosenblatt G.S., Walsh J.C., and C. Simon.:Metastatic testis tumor presenting as gastrointestinal hemorrhage. J. Urol.2000;164:1655.  Back to cited text no. 2    
3.Schips L., Zigeuner R.E., Lipsky K., Galle G., Kasparek A.K., Uggowitzer M., Langner C. and Hubmer G. Testicular tumor with gastrointestinal hemorrhage. Urology 2002:59(2);297.  Back to cited text no. 3    


    Figures

  [Figure - 1], [Figure - 2]



 

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