TESTICULAR BUT NOT TESTICULAR: A GERM CELL TUMOR PRESENTING AS ACUTE RESPIRATORY FAILURE

Abstract

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Germ cell tumors (GCTs) of the testes account for 95% of the testicular tumors. The most aggressive and least common type of the GCTs is choriocarcinoma (CC). It is a highly malignant tumor and patients typically present with early metastases, with lungs being the most common site. Given the rarity of the disease and its unusual presentation, CC remains a challenging diagnosis often leading to high mortality in young males. We present a very rare entity of CC known as the 'burned out phenomenon' in which an extra gonadal GCT develops without traces of neoplasm in the testes. CASE PRESENTATION: A 41-year-old previously healthy male presented with one month history of shortness of breath and cough. He was tachypneic and tachycardic with reduced oxygen saturation of 86% on room air. Physical exam revealed crackles in bilateral lungs. Chest x- ray showed diffuse bilateral pulmonary opacities concerning for malignancy. CT chest revealed a large left upper lobe mass measuring 10x9x12 cm and innumerable round pulmonary nodules in both lungs. Patient became progressively tachypneic requiring BiPAP and he was admitted to the ICU. His hypoxia and tachypnea worsened to the extent of requiring invasive ventilation, but patient opted against it and support was continued on the BiPAP. Further workup for his lung metastases with CT of the abdomen-pelvis revealed extensive metastatic disease involving the liver and adrenal glands. CT guided biopsy of the lung revealed necrotic tissue. There was a suspicion for GCT and ultrasound of the testes was done but no discrete testicular lesion was found. Tumor markers revealed a B-HCG level that was significantly elevated at 156,000 IU with normal alpha feto-protein. Based on the biopsy findings, elevated B-HCG levels, normal alpha feto-protein, and the metastatic presentation, the patient was diagnosed with CC. Despite multiple lines of chemotherapy, patient died within a month due to rapid disease progression with further metastases to brain. DISCUSSION: CC does not require histological confirmation and in rare cases no testicular lesion can be found. The primary tumor is thought to regress spontaneously in the testes, so the initial presentation is a manifestation of the metastases. Clinical picture, specific serum markers, and imaging findings can be diagnostic. In the early stage of advanced CC patients usually have no obvious clinical signs. The pulmonary symptoms can range from a mild cough, shortness of breath or hemoptysis. The latter usually presents in severe cases with multiple metastases. This was a challenging diagnosis due to absence of a palpable testicular mass, no tissue proven diagnosis, and rapid progression of the disease. CONCLUSIONS: Our case underlines the importance of having a high suspicion for CC in young males presenting with pulmonary symptoms and chest-x ray findings concerning for malignancy. Early chemotherapy is recommended. Reference #1: Horwich A, Shipley J, Huddart R. Testicular germ-cell cancer. Lancet. 2006;367:754–65 Reference #2: Ohno, Y., Yamauchi, T., Ueda, T., Aizawa, T., Kawakami, S., Tachibana, Y., Tsuchiya, S. (1993). A case of testicular choriocarcinoma achieving pathological complete response by “COMPE” chemotherapy, consisting of cisplatin, vincristine, methotrexate, peplomycin, and etoposide. Acta Urologica Japonica, 39(2), 183–187 DISCLOSURES: No relevant relationships by Muhamad Alhaj Moustafa, source=Web Response No relevant relationships by Nebiyu Biru, source=Web Response No relevant relationships by Rama Hritani, source=Web Response No relevant relationships by James Shaw, source=Web Response No relevant relationships by Anusha Vakiti, source=Web Response