Aortoenteric Fistula in Advanced Germ Cell Tumor: A Rare Lethal Complication

Abstract

A 28-year-old man presented with low back pain and cough. Computerized tomography demonstrated diffuse pulmonary and hepatic metastases as well as bulky retroperitoneal nodal disease encasing vasculature and bowel. Sonography showed right testicular atrophy, and right orchiectomy revealed anaplastic seminoma. Relevant laboratory studies included an elevated -human chorionic gonadotropin of 12,444 IU/ml. (normal less than 5), an elevated lactate dehydrogenase of 384 units per l. (normal 100 to 190) and absent -fetoprotein. The patient was treated with 2 cycles of a standard chemotherapy regimen using bleomycin, etoposide and cisplatin. Approximately 4 weeks following course 2 of bleomycin, etoposide and cisplatin the patient had a syncopal episode, and hematemesis and hematochezia developed. He presented to the emergency department in hypovolemic shock and required extensive fluid resuscitation. Upper endoscopy revealed a massive amount of bright red blood gushing up from the duodenum. The bleeding was too brisk to identify the source. Emergent aorto-visceral angiography demonstrated an aortoduodenal fistula (part A of figure). An endovascular stent graft was subsequently placed across the fistula, with immediate control of the hemorrhage (part B of figure). Definitive surgical repair awaited patient recovery from multiple organ insult. Unfortunately, massive bleeding recurred 10 days after the first hemorrhage, and angiography showed development of a new larger fistula. Attempts at resuscitation and placement of 2 additional endovascular stent grafts were unsuccessful, and the patient died. Autopsy confirmed the presence of aortic necrosis and an aortoenteric fistula secondary to extensive metastatic choriocarcinoma.