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| LETTER TO EDITOR |
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| Year : 2020 | Volume
: 3
| Issue : 4 | Page : 836-837 |
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Adrenal metastasis in an older patient with seminoma
Archisman Basu1, Meheli Chatterjee1, Deepak Dabkara1, Bivas Biswas1, Sandip Ganguly1, Joydeep Ghosh1, Priya Ghosh2
1 Department of Medical Oncology, Tata Medical Center, Kolkata, West Bengal, India
2 Department of Radiology, Tata Medical Center, Kolkata, West Bengal, India
| Date of Submission | 21-Jul-2020 |
| Date of Decision | 28-Aug-2020 |
| Date of Acceptance | 27-Sep-2020 |
| Date of Web Publication | 25-Dec-2020 |
Correspondence Address:
Deepak Dabkara
Department of Medical Oncology, Tata Medical Center, Kolkata, West Bengal
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/CRST.CRST_250_20
How to cite this article:
Basu A, Chatterjee M, Dabkara D, Biswas B, Ganguly S, Ghosh J, Ghosh P. Adrenal metastasis in an older patient with seminoma. Cancer Res Stat Treat 2020;3:836-7 |
How to cite this URL:
Basu A, Chatterjee M, Dabkara D, Biswas B, Ganguly S, Ghosh J, Ghosh P. Adrenal metastasis in an older patient with seminoma. Cancer Res Stat Treat [serial online] 2020 [cited 2021 Jan 26];3:836-7. Available from: https://www.crstonline.com/text.asp?2020/3/4/836/304954 |
Here, we report a case of testicular germ cell tumor (TGCT) in an older patient who presented to our hospital with adrenal metastasis. TGCT is an uncommon malignancy with one of the lowest incidence rates in India. It commonly affects individuals in the age group of 15–35 years. The occurrence of TGCT in patients aged over 50 years is very rare. The common sites of metastasis for TGCT are the retroperitoneal nodes, lungs, liver, and bones. They rarely metastasize to the brain. To the best of our knowledge, the adrenal gland as a site of metastasis, either at presentation or at disease relapse, has rarely been described in the literature.
A 57-year-old male presented to our hospital in July 2019 with the complaint of a painless, left testicular swelling that had persisted for 2.5 years. Ultrasonography (USG) of the scrotum showed a left testicular mass of size 15.8 × 13.5 × 5.6 cm. Computed tomography scan of the abdomen revealed a left adrenal mass of size 4.6 × 4.1 × 5.6 cm, with left paraaortic lymphadenopathy of 4 × 4 cm [Figure 1]. Adrenal biopsy was indicative of germ cell tumor metastasis. On clinical evaluation, no abnormalities other than an enlarged left testis were observed. The alpha-fetoprotein level was 3.46 ng, beta-human chorionic gonadotropin (BHCG) was 118 U, and lactate dehydrogenase (LDH) was 7828 U. Computed tomography (CT) scan of the chest was normal. The adrenal biopsy was rereviewed at our center. A histopathological examination confirmed metastatic deposits favoring a germ cell tumor. Microscopic examination revealed that tumor cells with polygonal nuclei and prominent nucleoli infiltrating the tissue core [Supplementary Figure 1]a and [Supplementary Figure 1]b. The patient underwent left-sided high inguinal orchiectomy on July 23, 2019. Histologically, the testicular mass was a seminoma with lymphovascular and rete testis invasion (pT2Nx). A microscopic examination showed a malignant round-cell tumor with pleomorphism and hyperchromasia (focal necrosis, tumor infarction, and stromal fibrosis) [Supplementary Figure 2]a and [Supplementary Figure 2]b. Post orchiectomy, the tumor markers were normal. The patient was diagnosed with a seminomatous germ cell tumor, pT2N2M1b, of intermediate-risk category as per the International Germ Cell Consensus Classification (IGCCC). In view of his age, he was considered for four cycles of etoposide-cisplatin. Chemotherapy was completed in October 2019. Positron emission tomography (PET)-CT done after 2 months of completion of chemotherapy showed non-FDG-avid para-aortic nodes of size 1.7 × 1.5 cm with complete resolution of adrenal metastasis [Figure 2] suggesting a complete metabolic response. The patient was last followed up on August 24, 2020.
 | Figure 2: Post chemotherapy PET-CT scan showing complete resolution of adrenal metastasis postchemotherapy
Click here to view |
The differential diagnoses for a testicular mass in patients aged over 50 years include lymphoma, sex cord-stromal tumors, and leiomyoma. The occurrence of TGCT in men aged >50 years is rare and is described as case reports in the literature. The oldest age reported in the literature for the occurrence of TGCT is 92 years. Two of the largest studies on TGCT in men aged over 50 years reported the incidences of 11% and 5.6%.[1],[2] In addition, the literature suggests that patients with TGCT aged >50 years often present at a higher stage and tend to have greater complications due to chemotherapy. The differential diagnoses of an adrenal mass in those aged over 50 years include– adenoma, pheochromocytoma, adrenocortical carcinoma, and metastasis. Adrenal metastasis from TGCTs is rare. A case of adrenal metastasis in a patient with seminoma has been reported in the literature.[3] Another series by Husband and Bellamy described four cases of adrenal metastasis from teratoma.[4] Another report describes a case of synchronous testicular seminoma and adrenocortical carcinoma.[5]
In conclusion, seminoma in patients aged >50 years is extremely rare. Adrenal metastasis in patients with seminoma is even rarer. Here, we report the case of a 57-year-old man with testicular seminoma that had metastasized to the retroperitoneal nodes and the adrenal gland and was treated with chemotherapy. Advanced testicular seminoma in older patients can be difficult to treat as these patients may have more complications due to chemotherapy. Fortunately, our patient did not experience any chemotherapy-associated complications. At short follow-up, the patient is in remission [Figure 3].
Statement of patient's consent
The patient's consent was obtained for the publication of the images and discussion of the clinical course.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Kawai T, Tanaka Y, Cancer Registration Committee of the Japanese Urological Association. Clinical characteristics of testicular germ cell tumors in patients aged 50 years and older: A large-scale study from the Cancer Registration Committee of the Japanese Urological Association. Int J Urol 2017;24:124-8.  |
| 2. | |
| 3. | Zakaria B, Pierre-Etienne T, Véronique D, Vincent M, Walid M, Hervé B. A case of adrenal metastasis in seminoma. Case Rep Urol 2013;2013:495743. |
| 4. | Husband JE, Bellamy EA. Unusual thoracoabdominal sites of metastases in testicular tumors. AJR Am J Roentgenol 1985;145:1165-71. |
| 5. | Inoue T, Terai A, Terachi T, Souma T, Yoshida O. Synchronous testicular seminoma and adrenocortical carcinoma: A case report. Int J Urol 1998;5:615-7. |
[Figure 1], [Figure 2], [Figure 3]
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