IS Case 405: Stage III choriocarcinoma

Meena Moorthy, MD

University of Rochester

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Imaging Sciences URMC 2010
Publication Date: 2010-08-27

History

Patient is a 35-year-old male with no significant past medical history presenting with hemoptysis.

Findings

PA and lateral images of the chest demonstrate a diffuse reticulonodular pattern of bilateral lungs. There are several large focal nodular densities, the largest measures 1.6 cm in the left mid-lung zone.

Further imaging with CT showed innumerable, round soft tissue densities in the lungs, measuring up to 2.0 cm. Of note, there is a large necrotic supraclavicular lymph node, as well as a complex necrotic mass in the retroperitoneum which is a presumed lymph node as well.

Testicular ultrasound revealed only a small (5 mm) hypoechoic nodule in the inferomedial aspect of the right testis, suspected burned-out germ cell tumor.

Diagnosis

Stage III choriocarcinoma

Discussion

his patient is a young male, with no significant past medical history who presents with a primary complaint of hemoptysis. Initial radiography shows diffuse nodular disease in the lungs, which are later discovered to be metastatic testicular choriocarcinoma. Interestingly, the primary tumor is, at this point, a small 5 mm lesion in the right testis. Pathology of the supraclavicular lymph node is positive for choriocarcinoma, which is supported by a markedly elevated human chorionic gonadotrophin (hCG). Pathology of the right testis only reveals a sub tunica albuginea intertubular seminoma.

Testicular germ cell tumors (GCT) are the most common malignancy in males aged 15-35. There are several subtypes of the testicular GCTs including seminoma (40%), embryonal tumor (25%), teratocarcinoma (25%), teratoma (5%), and choriocarcinoma (1%).

Choriocarcinoma is a very aggressive, malignant trophoblastic cancer. Choriocarcinoma most commonly occurs in the placenta; other primary locations include the ovary and testis, however these are extremely rare. It is characterized by early hematogenous and lymphatic spread.

As noted above choriocarcinoma is the most rare form of testicular cancer. Unlike the others, the primary testicular tumor is often small or "burned out", and the most common presentation is symptoms of the metastatic disease, which is most often in the lungs, liver and/or brain.

Treatment is radical orchiectomy along with chemotherapy and radiation; however mortality is high as the disease is usually widely metastatic at the time of diagnosis.

References

1. Williams MB, Schellhammer P, Davis JW, Testicular choriocarcinoma. e-Medicine, May 21, 2009. http://emedicine.medscape.com/article/435577-overview
2. Kasper DL, Braunwald E, Hauser S, et al. Harrison's Principles of Internal Medicine, 16th edition. McGraw-Hill, 2005:550.