Skin metastasis: a rare presentation in testicular germ cell tumour

Abstract

A 35-year-old man presented with a history of cough, haemoptysis, weight loss for 2 months along with ulceroproliferative lesions on the chin and the scalp. On evaluation he was found to have non-seminomatous germ cell tumour, stage 3 c, poor risk with Eastern Cooperative Oncology Group Performance Status of 4. The skin lesions were proven to be metastasis by fine-needle aspiration cytology. He showed significant improvement with a 3-day protocol of abbreviated etoposide and cisplatin chemotherapy and is planned for 4 cycles of VIP. This case describes an uncommon presentation of germ cell tumour in the form of skin metastasis with excellent response to chemotherapy.

Background

Testicular tumours constitute 1% of solid malignancy in men, out of which 95% are germ cell tumours (GCTs).¹ Knowledge of testicular GCTs is important as they have very good prognosis when diagnosed and treated appropriately. The common presentation of testicular GCT is scrotal swelling, back pain, or shortness of breath and haemoptysis in the presence of lung metastasis. Skin is an unusual site for metastasis in testicular GCT. To the best of our knowledge, <20 case reports of cutaneous metastases from testicular GCT are reported worldwide.^2–5 We describe one such unusual case.

Case presentation

A 35-year-old man was referred to our institute with the history of cough, haemoptysis, loss of weight and anorexia for 2 months. On examination, his Eastern Cooperative Oncology Group (ECOG) performance status was 4, was pale and tachypnoeic. He had 3×3 cm ulceroproliferative skin lesion on his chin, 1×1 cm skin nodule on his scalp and medial side of left thigh (figure 1A,C). Per abdomen examination revealed a palpable vague mass in the suprapubic region. Scrotal examination revealed the absence of both testes. On further questioning, the patient revealed he had empty scrotum since his birth, for which medical attention was not sought previously.

Figure 1.

(A) Ulceroproliferative skin lesion on his chin before chemotherapy. (B) Skin lesion on his chin after third cycle of VIP chemotherapy. (C) Skin nodule on the scalp before chemotherapy. (D) Skin nodule on the scalp resolved after third cycle of VIP chemotherapy.

Investigations

His haemogram, liver function tests and kidney function tests were normal except for normocytic normochromic anaemia. His chest X-ray revealed bilateral multiple, large well-circumscribed opacities suggestive of cannonball metastases. Contrast-enhanced CT of brain, chest, abdomen and pelvis showed 9.3×8.6×7.6 cm necrotic lobulated mass in pelvis, with bilateral external iliac, right paratracheal, precarinal, subcarinal lymph node enlargement, tumour deposits in liver, lung, brain and nodular deposits in scalp, submentum, bilateral ischiorectal fossa and skeletal deposits s/o metastasis (figure 2). Tumour marker estimation revealed beta-human chorionic gonadotropin (B-HCG) 296 024 mIU/mL (normal <5 mIU/mL), AFP 7 ng/mL (normal <10 ng /mL) and LDH 2235 U/L (normal <250 U/L). Fine-needle aspiration cytology of the scalp nodule revealed a moderately cellular smear with tumour cells in clusters as well as singly scattered in a haemorrhagic background. The mononuclear tumour cells were arranged in tight cluster entrapped in stromal component. Many tumour cells showed pleomorphic nuclei with moderate amount of cytoplasm. Few multinucleated giant tumour cells with hyperchromatic nuclei with conspicuous nucleoli and abundant vacuolated cytoplasm noted (figure 3). Aspirate morphology was consistent with non-seminomatous testicular germ cell tumour (NSGCT), however, component cannot be quantified due to lack of histopathological section. Since our patient was very sick, further attempt for typing of primary tumour could not be made. A final diagnosis of NSGCT, TxN2M1b stage 3 c, poor risk was made.

Figure 2.

(A) Chest X-ray showing multiple well-circumscribed opacities suggestive of lung metastases. (B) and (D) CECT showing tumour deposits in lung and brain. (C) Necrotic lobulated mass in pelvis. CECT, contrast-enhanced CT.

Figure 3.

(A) Tumour cells in tight clusters (400×). (B) Mononucleated tumour cells in loose clusters (600×). (C) Tumour cells in tight cohesive clusters (1000×). (D) Tumour cells showing marked pleomorphism and multinucleated giant cells with vacuolated cytoplasm (1000×).

Treatment

He was started on abbreviated cisplatin and etoposide for 3 days along with supportive measures. He tolerated the chemotherapy well without any immediate events like bleeding or tumour lysis syndrome. He is planned for four cycles VIP (etoposide, ifosfamide, cisplatin) as definitive therapy. He completed three cycles at the time of submission of manuscript.

Follow-up

The patient improved symptomatically, B-HCG decreased to 30 mIU/mL and skin lesions reduced in size (figure 1B,D) after third cycle of VIP chemotherapy.

Discussion

Cutaneous metastases from internal malignancy may appear as a result of haematogenous, lymphatic or direct tissue invasion or iatrogenic implantation.⁶ Cutaneous metastases are commonly seen from primary sites like breast, skin, stomach, lung and colo-rectum.⁷ Among these, melanoma has the highest predilection to metastasize to the skin (45%) followed by breast (30%). Skin constitute only 1.1%–2.5% of metastatic sites from urological malignancy and 0.4% from testicular GCT.^{2 5}

Common histologies of NSGCT include embryonal carcinoma, choriocarcinoma, yolk sac tumour and teratoma. Embryonal carcinoma is the most undifferentiated type and predominantly has lymphatic spread. Choriocarcinoma spreads haematogenously and tends to have a distant metastatic disease at the time of presentation due to its highly malignant nature. Choriocarcinoma is usually characterised by high serum B-HCG levels, diffuse lung metastases, visceral metastasis usually brain and liver and increased risk of bleeding from disease sites. Skin metastases and other uncommon sites are reported more with choriocarcinoma among NSGCT histologies.

In most cases, cutaneous metastasis develops after the primary diagnosis and in few along with the primary diagnosis. Rarely it may herald the diagnosis of internal malignancy. Chuang et al describe a case of testicular GCT with skin metastases at the scalp and upper abdomen as the initial presentation of GCT.⁵ Second, skin metastasis usually signal extensive metastatic disease and a poor prognosis.^{4 5} Third, it is important to take note of a suspicious skin lesion during follow-up of GCT as they could be a site of recurrence rarely. Joe et al reported a follow-up case of GCT who presented with ulceroproliferative growth over lower limb as the only site of disease after 6 years of initial treatment high required salvage chemotherapy and local radiation and surgery thus highlighting the importance of recognising and investigating skin nodules in follow-up case of GCT.³

Cryptorchidism is a well-known risk factor for GCT. GCT in uncorrected cryptorchid testis is extremely rare in West, but we continue to see few such cases in our part of world even now. Increasing the awareness, screening and correction of cryptorchidism at young age will help in early diagnosis and treatment of GCT at initial stages. In our patient, diagnosis was made with clinical history and examination and high level of HCG and imaging studies s/o extensive metastasis including skin, bone, brain and liver. Raised B-HCG levels usually suggest the presence of choriocarcioma component which was evident as multinucleated giant cells in the aspirate (figure 3). Management of such patient with an extensive disease can be complicated by tumour lysis syndrome or haemorrhage from metastatic sites. Our patient is planned for 4 cycles of VIP in view of extensive lung involvement. The 5-year progression-free survival of the above stage 3C, poor risk patient with standard chemotherapy is 45%.

Patient’s perspective.

The diagnosis of cancer was a blow to me and my family. I feel happy I am responding well to treatment.

Learning points.

• Cutaneous metastases as manifestations of internal malignancy are rare and under recognised.

• It is prudent to always consider germ cell tumour (GCT) as a differential diagnosis in young men with disseminated malignancy.

• Even poor risk GCTs have excellent response to treatment, hence, prompt initiation of chemotherapy is essential with aggressive supportive care.