Abstract
Testicular mixed germ cell tumors (TMGCTs) are rare malignant tumors comprising of two or more types of germ cell tumors. Their onset may be undetectable and the patient may first present with symptoms of metastasis. We hereby report a case of a young male who presented with respiratory discomfort and had no symptoms of primary testicular tumor. CT-guided FNAC lung revealed mainly necrotic, keratinous debris with a focus of chondromyxoid stroma. Differential diagnoses of components of teratoma, squamous cell carcinoma and inclusion cyst was considered. FNAC was reported out for the possible presence of teratoma components. Retrospectively, physical examination and subsequent USG revealed testicular tumor. The case led to a diagnostic dilemma as the patient presented with no prior history suggestive of metastasis from testicular mixed germ cell tumor. The aim of the current case report is to alert the pathologists and clinicians about this uncommon clinical presentation and diagnostic relevance of FNA. It highlights that FNA lung revealing keratinous material should always be searched for the possibility of teratoma component.
Keywords: Testis, Testicular mixed germ cell tumor, Metastasis, FNAC
Introduction
Testicular mixed germ cell tumor (TMGCT) is a relatively rare malignant tumor of the testis and represents 1% of male tumors and 5% of all the urological malignancies [1]. The major etiological factors for testicular tumors are cryptorchidism with two- to four fold higher risk and others being family history, testicular trauma, high maternal estrogen level and prior history of testis cancer or extragonadal germ cell tumor [2, 3]. Germ cell tumors are classified as seminomatous and non-seminomatous, with 60% of germ cell tumors being reported as mixed germ cell tumors [4]. TMGCTs demonstrate a wide spectrum of histopathological, genetic, pathogenetic, and immunocytochemical characteristics, as well as various clinical-biological profiles and prognoses. Germ cell tumors can metastasize to the lungs with complaints of chest pain, cough, and dyspnea [5, 6]. We hereby present a case of a 27-year-old male who presented with respiratory discomfort and had a lung mass on CT examination. He was first diagnosed on CT-guided FNAC lung for the possibility of teratoma component which eventually turned out to be metastatic deposits of testicular mixed germ cell tumor.
Case Description
A 27-year-old male presented with dyspnea and significant weight loss of 2-month duration. CT showed a large lobulated, enhancing mass of 11.2 × 10 cm in the right lower lung lobe, extending into the middle and posterior mediastinum. CT-guided FNAC revealed mainly necrotic, keratinous debris and foci of chondromyxoid stroma. No cellular component was seen (Figs. 1 and 2). Differential diagnosis of components of teratoma, squamous cell carcinoma, and inclusion cyst was considered. Retrospectively, a thorough physical examination revealed an enlarged right testis. Subsequent USG showed a heterogeneous mass of 81 × 65 mm. FNAC testis yielded mainly necrosis with few scattered malignant cells. Biochemical markers, alpha-fetoprotein, beta-hCG, and LDH were raised. Radical inguinal orchidectomy showed a variegated tumor measuring 6.5 × 5 × 4 cm with areas of necrosis and cystic change. Histopathology showed large areas of necrosis with germ cell tumor components—mature teratoma and seminoma (Fig. 3). Despite extensive sectioning, other components of mixed germ cell tumor (choriocarcinoma and yolk sac tumor corresponding to raised beta-hCG, alpha-fetoprotein) could not be ruled out due to necrosis. IHC was performed at the primary tumor site—teratoma component was positive for CK, seminoma was positive for PLAP, and hCG was negative due to the absence of a viable choriocarcinoma component. The patient was taken up for chemotherapy, but survival was just for 3 months as he already had metastasis on the first presentation.
Fig. 1.
CT-guided FNAC revealed necrotic, keratinous debris (MGG)
Fig. 2.
CT-guided FNAC revealed foci of chondromyxoid stroma (H&E)
Fig. 3.
Gross specimen showing tumor with large areas of necrosis. Histopathology shows mixed germ cell tumor components—mature teratoma and seminoma (H&E)
Discussion
MGCTs are composed of two or more types of germ cell tumors, which primarily are detected in the testis. These tumors show a bimodal age distribution pattern and are most common in the group of 15–35 years and also around 60 years. Clinically, its pulmonary metastasis is usually associated with secondary hemoptysis and dyspnea; gastrointestinal system metastasis with gastrointestinal bleeding; and brain metastasis with neurological symptoms [7–9]. Our patient was a 27-year-old who presented with respiratory discomfort, but had no symptoms of primary testicular tumor which led to a diagnostic dilemma. CT-guided FNAC lung revealed mainly necrotic, keratinous debris with a focus of chondromyxoid stroma. So, differential diagnosis of squamous cell carcinoma, inclusion cyst, and components of teratoma was considered. Diagnostic clue to rule out squamous cell carcinoma was total absence of atypical squamous cells. Lack of combination of anucleated/nucleated squames and weight loss were less favorable for inclusion cyst. FNAC was reported out for the possible presence of teratoma components. This case was a diagnostic dilemma as the patient presented with no prior history suggestive of metastasized teratoma as a part of mixed germ cell tumor. Similarly, in a study by Dagli et al. [10], a 33-year-old male patient who initially presented with a neck mass and had shortness of breath was detected with a mediastinal mass on CT and was further subjected to FNA. Correlating with high alpha-fetoprotein levels and genitourinary system examination, ultrasonography revealed a mass in the right testis, and subsequently, on histopathological examination, diagnosis of mixed germ cell tumor was confirmed [10]. In another similar case report study, a 21-year-old male patient was diagnosed with testicular mixed germ cell tumor with isolated metastasis to unilateral pleura [11]. Pleural mass revealed metastatic differentiated teratoma. Similar results were seen in another case report of a 31-year-old male who initially had hemoptysis and dyspnea and had high beta-hCG levels; CT examination confirmed a lung mass and was diagnosed with testicular mixed germ cell tumor (80% teratoma) on orchiectomy [12]. In a study by Shabb et al. [13], cystic, necrotic, and fibrotic characteristics were seen on FNAC of mediastinal lesions in a young individual. Their overall specimen adequacy was 83% with a diagnostic accuracy of 86% [13]. It was reported in another study that cytological examination along with immunohistochemical analysis is quite reliable in the diagnosis of germ cell tumors [14]. Therefore, FNAC is highly helpful for early diagnosis of metastasized mixed germ cell tumors.
Conclusion
This case report highlights that FNA lung revealing keratinous material should always be searched for the possibility of teratoma component.
Declarations
Conflict of Interest
The authors declare no competing interests.
Footnotes
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