Abstract:We present the first report of an immature teratoma arising from a germ cell testicular cancer invading the duodenum. While other seminomatous and non-seminomatous germ cell tumors are known to metastasize to the duodenum, this is the first such case involving an immature teratoma directly invading the duodenum from a metastatic retroperitoneal mass.Keywords: Testis cancer, teratoma, duodenum.
CASE REPORTA 26-year-old male underwent radical inguinal orchiectomy at an outside facility for a pT1 Nx Mx mixed nonseminomatous germ cell tumor (65% mature teratoma, 30% yolk sac, 15% embryonal). Preoperative tumor markers showed ( -fetoprotein (AFP), 2096 ng/mL and -Human chorionic gonadotropin (B-HCG), 139 mIU/ml). Postoperative tumor markers normalized AFP 3.6 ng/mL and B-HCG <2 mIU/ml) and CT scans of the chest and abdomen showed no signs of metastasis. Eighteen months later, the patient presented to our facility with progressive nausea and vomiting. Abdominal CT scan ( Fig. 1) and CT-guided biopsy revealed a 9.4 cm retroperitoneal tumor consistent with teratomatous elements of a mixed germ cell tumor. The duodenum proximal to the mass was dilated, indicating an element of obstruction. In retrospect, there was discontinuity of the duodenal wall indicating possible invasion by the mass (Fig. 1). Four months later, following four cycles of etoposide and cisplatin, the tumor shrunk to 5.8 cm. At this point, there were punctuate calcifications within the mass; the mass remained intimately associated with the anterior aorta and the undersurface of the third portion of the duodenum with interval clinical relief of the duodenal obstruction (Fig. 2). The patient's tumor markers remained within normal limits (AFP, <5 ng/mL and B-HCG, <1 mIU/ml). The patient underwent a retroperitoneal lymph node dissection and mass removal. Intraoperatively, the mass was easily dissected off the aorta and inferior vena cava but was found to be directly invading the duodenum, requiring resection of a portion of the duodenal wall to achieve negative surgical margins. Pathology revealed a mass consisting of 90% mature teratoma and 10% immature teratoma (Fig. 3), with invasion of the wall of duodenum, as confirmed by two subspeciality genitourinary pathologists. His clinical course was complicated by a readmission within the first 30 post-operative days, due to nausea and vomiting, *Address correspondence to this author at the Department of Urology, 1365 Clifton Road NE, Atlanta, GA 30322, USA; Tel: 404-778-3859; E-mail: vmaster@emory.edu Fig. (1). A, axial enhanced CT image and B, coronal enhanced CT reconstruction demonstrate invasion of the duodenum by metastatic adenopathy from testicular cancer. The duodenal wall (black arrows) is disrupted by tumor (white arrows).