Mixed germ cell tumor metastatic to the skin: Case report and literature review
© Chuang et al; licensee BioMed Central Ltd. 2010
Received: 4 January 2010
Accepted: 23 March 2010
Published: 23 March 2010
Testicular cancer is the most common cancer for males aged 15~35 years old. The initial presentation is typically an asymptomatic enlarged testicle. The retroperitoneum is the most common metastatic area. Other metastatic sites include the lung, liver, brain, adrenal glands, gastrointestinal tract and spleen. Skin metastasis is a rare event and frequently associated with poor prognosis.
A 19-year old male was diagnosed testicular mixed germ cell tumor with initial presentation of cutaneous metastasis at scalp and upper abdomen. After radical orchiectomy and four courses of cisplatin-based chemotherapy, the scalp and upper abdominal lesions regressed completely. The size of lung metastases remained unchanged.
For advanced stage testicular cancer, cisplatin-based chemotherapy is still effective to achieve partial response.
Cutaneous manifestation of an internal malignancy is rare, with an incidence of 2.9-9%[1, 2]. The frequencies of skin metastases in females are 69% for breast cancer, 9% for colon cancer, and 5% for melanoma. In males the frequencies of cutaneous metastases are 24% for lung cancer, 19% for colon cancer, and 13% for melanoma [3, 4] Cutaneous metastases of the genitourinary tract tumors have been associated with cancers of the prostate , bladder , and kidney . This report describes a case of testicular germ cell tumor with skin metastases at the initial presentation.
Cutaneous metastases originating from a solid organ are roughly 2% . Most of the cutaneous metastases were noted by a prior cance diagnosis; While only 8% of cases represented the first indication of an internal malignancy . The most common sites of metastastatic disease from urologic malignancies are lymph nodes, bone, lung, and liver . The incidence of cutaneous metastasis from all urologic malignancies is 1.1% to 2.5% . The relative incidences of metastasis to the skin among gentitourinary cancers are 3.4% to 4.0% for renal cell carcinoma, 0.84% to 3.6% for transitional cell carcinoma, 0.4% for germ cell tumors, and 0.36% to 0.7% for prostate adenocarcinoma.
Testicular mixed germ cell tumors are common, comprising roughly 33% of all testicular tumors. The reason for such a high incidence of testicular mixed germ-cell tumors is because germ cells in the testes are totipotent and can undergo either trophoblast or somatic differentiation. Among all the subtypes of testicular germ cell tumor, choriocarcinoma is the most aggressive with highly metastatic potential .
The cutaneous metastasis as the first sign of metastatic choriocarcinoma could have been either an occult or a slow growing primary testis germ cell tumor [11–15]. Cutaneous metastasis of the genitourinary malignant neoplasm is often related to advanced local extension, disseminated metastasis and poor prognosis. In this case, no retroperitoneal lymph node metastasis was observed.
According to the International Germ Cell Consensus Prognosis for Testicular Cancer, the 5-year progression-free survival rate is 41% for non-seminoma origin and non-pulmonary visceral metastasis. The present case was classified as poor prognostic. After four courses of PEB regimen (cisplatin, etoposide, bleomycin), the scalp and abdominal lesions achieved complete response but the lung metastasis remained stable in size.
The skin is an uncommon site for testicular germ cell metastasis. A cutaneous lesion can be difficult to be differentiated from a primary cutaneous neoplasm. Excisional biopsy is required for definite diagnosis. For advanced stage testicular cancer, cisplatin-based chemotherapy is still effective to achieve biochemical remission.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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