CASE REPORT: Ileocecal Valve Metastasis of a Nonseminomatous Germ Cell Tumor
By: Désirée Louise Draeger, MD; Annette Zimpfer, MD; Oliver Hakenberg, MD | Posted on: 01 Feb 2022
A 37-year-old man presented with exhaustion and reduced strength in his right arm. Physical examination showed marked anemia and a hard, large tumor of the left testicle, which the patient had been observing for several months. There was a history of extensive cocaine and nicotine consumption. Scrotal ultrasound confirmed a large testicular tumor. Serum tumor markers were increased (Α-fetoprotein [AFP] 15.9 ng/ml [<5.8 ng/ml], Β-human chorion gonadotropin [Β-HCG] 128,292 IU/ml [<2 IU/ml] and lactate dehydrogenase 363 U/L [<250 U/L]). Computerized tomography scan of the thorax, abdomen and pelvis showed multiple metastases in the retroperitoneal lymph nodes, liver and lungs. Magnetic resonance imaging (MRI) of the head showed 3 supra- and infratentorial lesions with pronounced perifocal edema and displacement of the hemispherical gap.
The patient was offered sperm cryoconservation and systemic chemotherapy with cisplatin, etoposide and ifosfamide (PEI) was started, with a dose reduction during the first cycle. With chemotherapy, there was a marked improvement of the neurological symptoms. Blood transfusions were given, but anemia persisted. Further evaluation showed iron deficiency anemia, and the patient also reported repeated rectal blood discharge. Upper gastrointestinal endoscopy was normal, but on colonoscopy an ulcerated tumor of the ileocecal valve was seen (fig. 1). Biopsy confirmed a poorly differentiated, pleomorphic cell carcinoma with mononuclear and multinucleated giant cells and very strong expression of ß-HCG (fig. 2).
A total of 4 cycles of PEI polychemotherapy were given and well tolerated. Under chemotherapy, the rectal bleeding stopped, the hemoglobin level normalized and the patient had better appetite and gained 17 kg in body weight. The reduction in serum tumor markers was adequate (AFP 1.7 ng/ml, Β-HCG 110 IU/ml, lactate dehydrogenase 264 U/L). After the 4 cycles, computerized tomography scanning showed a clear regression of the intra-abdominal and thoracic metastases. Repeat colonoscopy could no longer detect the previously seen tumor of the ileocecal valve.
Then the left testicle was surgically removed and a still large, but largely devitalized, germ cell tumor was seen with the only still vital tumor tissue described as mature teratoma. Cerebral MRI did, however, show only a mixed treatment response. There was stable disease noted in the previously seen cerebral lesions, but both supra- and infratentorially, several new, small metastases were detected (fig. 3). After extensive multidisciplinary discussions, high-dose chemotherapy of PEI with subsequent autologous stem cell transplantation and additive stereotactical radiotherapy of the cerebral metastases were started. For this purpose, blood stem cells were taken from the patient before chemotherapy, which will be transferred after the treatment is completed. High-dose chemotherapy is currently only performed in special centers.
This case is unique in that intermittent rectal bleeding occurred in metastatic testicular tumor disease caused by an ileocecal valve metastasis leading to marked iron-deficiency anemia. Intestinal metastasis of testicular cancer is rare and is seen in less than 5% of germ cell tumors.1,2 It occurs more often with nonseminomas and especially with embryonal carcinoma. Presumably this ileocecal valve metastasis arose from direct spread from the retroperitoneal lymph node metastases.1,3–6 Gastrointestinal metastases of germ-cell tumors do not occur without other widespread metastatic disease and can lead to bleeding with anemia as in this patient, but also to gastric pain, intestinal obstruction, perforation or even intussusception.2,6 First line treatment for gastrointestinal tract metastases is systemic chemotherapy.7,8 Furthermore, this case again illustrates the devastating effect of treatment delay, as this patient had observed his increasing testicular tumor for many months.
Clinical Practice Points
In patients with advanced testicular cancer, gastrointestinal symptoms can rarely be caused by gastrointestinal metastasis.
- Chait MM, Kurtz RC and Hajdu SI: Gastrointestinal tract metastasis in patients with germ-cell tumor of the testis. Am J Dig Dis 1978; 23: 925.
- Muhanna A, Nimri F, Almomani ZA et al: Small bowel metastasis as a presentation of testicular seminoma. Cureus 2021; 13: e17962.
- Senadhi V and Dutta S: Testicular seminoma metastasis to the gastrointestinal tract and the necessity of surgery. J Gastrointest Cancer 2012; 43: 499.
- Miocinovic R and Abaza R: Testicular seminoma presenting with duodenal perforation: a case report. J Med Case Rep 2008; 2: 294.
- Duygulu ME, Kaymazli M, Goren I et al: Embryonal testicular cancer with duodenal metastasis: could nausea and vomiting be alarm symptoms? Euroasian J Hepatogastroenterol 2016; 6: 198.
- Al Ani AH and Al Ani HA: Testicular seminoma metastasis to duodenum. Misdiagnosed as primary duodenal tumor. Int J Surg Case Rep 2016; 25: 149.
- Thompson JL and Blute ML: Coffee grounds emesis: rare presentation of testicular cancer treated with neoadjuvant chemotherapy. Urology 2004; 64: 376.
- Brown RS, Yassin J, Colville DH et al: First report of an isolated jejunal seminoma: presentation with melaena and iron deficiency anaemia. Clin Oncol (R Coll Radiol) 2001; 13: 455.