TESTICULAR MIXED GERM-CELL TUMOR METASTATIC TO THE CHOROID Mohammed K. ElMallah, MD,* Allen M. Chernoff, MD,† Norman P. Blair, MD*
Purpose: To describe the fundus findings, ultrasonography, and fluorescein angiography of a testicular mixed germ-cell tumor metastatic to the choroid and to report prompt resolution of the choroidal lesion with systemic chemotherapy. Methods: Observational case report. A 21-year-old man presented with a 10-cm testicular tumor. Ophthalmic examination revealed a large, dome-shaped choroidal lesion in the left eye, filling the entire superotemporal quadrant and extending into the macula. Ultrasonography showed a 10.3 mm in thickness hyperechoic mass. The patient was started on vinblastine, mesna, ifosfamide, and cisplatin. Results: On ophthalmic examination 6 weeks after initiation of chemotherapy, the choroidal lesion had completely resolved, leaving only pigmentary changes. Final ophthalmology follow-up 8 months after presentation demonstrated no recurrence of choroidal metastases. Conclusion: Testicular germ-cell tumors have now been well described to metastasize to the choroid. These choroidal metastases can show a prompt, favorable response to chemotherapy. RETINAL CASES & BRIEF REPORTS 2:172–174, 2008
From the Departments of *Ophthalmology & Visual Sciences and †Urology, University of Illinois at Chicago.
A
21-year-old man presented to the emergency room with a complaint of flank pain. Examination revealed a 10-cm left testicular mass. Further evaluation revealed multiple lesions in his lungs and brain. The flank pain was attributed to a perinephric hematoma. Left radical orchiectomy was performed and pathology demonstrated a mixed germ-cell tumor with elements of choriocarcinoma and teratoma (Figure 1). On postoperative day 1, the patient reported he had had blurred vision in his left eye for 1 week. Ophthalmic evaluation revealed 20/20 vision in both eyes. On fundus examination, a large, dome-shaped choroidal Fig. 1. Mixed germ-cell tumor with elements of choriocarcinoma (arrow) and teratoma (arrowhead).
Supported in part by the Illinois Eye Fund, Chicago, and an unrestricted grant from Research to Prevent Blindness, Inc., New York, New York. None of the authors has a proprietary interest in the material presented. Correspondence to: Norman Blair, MD, 1905 W. Taylor St., Chicago, IL 60612; e-mail: [email protected]
lesion was present in the left eye (Figure 2, A and B). The lesion filled the entire superotemporal quadrant and extended into the macula; there was a small 172
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TESTICULAR MIXED GERM-CELL TUMOR METASTATIC TO THE CHOROID
Fig. 3. Hyperechoic mass on b-scan ultrasonography.
pocket of subretinal fluid overlying the mass causing a corresponding secondary retinal detachment. Ultrasonography showed a 10.3 mm in thickness hyperechoic mass presumed to be a choroidal metastasis (Figure 3). The patient was started on vinblastine, mesna, ifosfamide, and cisplatin. On ophthalmic examination 6 weeks after initiation of chemotherapy, his choroidal lesion had completely resolved, leaving only pigmentary changes (Figure 2C). Final ophthalmology follow-up 8 months after presentation showed no recurrence of choroidal metastases. Discussion
Fig. 2. A, Choroidal lesion; black arrow denotes venous bifurcation present on all images. B, Fluorescein angiogram. C, Fundus photograph 6 weeks after initiation of chemotherapy.
Testicular germ-cell tumors disseminate primarily via the lymphatic system to retroperitoneal lymph nodes. Hematogenous spread is less common and sites of metastasis are primarily the lungs, followed by liver, brain, and bones. The proportion of uveal metastases that are of testicular origin varies depending on the population studied. Testicular tumors represented the primary tumor in approximately 0.2% of uveal metastases (1 out of 520 eyes) in an outpatient oncology clinic.1 However, in a study of surgical specimens, testicular tumors represented the source in 3.0% of ocular metastases (6 out of 199 patients).2 Several case reports have also described testicular germ-cell tumors metastatic to the eye3– 8 with one previous report also documenting resolution with chemotherapy.5 Blurred vision has been previously reported as the presenting complaint of testicular germ-cell tumors.5 A young man presenting with a choroidal mass should undergo a systemic evaluation which includes evaluation for testicular cancer. Conversely, a patient with testicular cancer should be questioned about visual symptoms and, if present, should undergo ophthalmic evaluation. Testicular germ-cell tumors have now
RETINAL CASES & BRIEF REPORTSℜ
174
been well-described to metastasize to the choroid; choroidal lesions can show a prompt, favorable response to chemotherapy. References 1. 2.
3. 4.
Shields CL, Shields JA, Gross NE, et al. Survey of 520 eyes with uveal metastases. Ophthalmology 1997;104:1265–1276. Ferry AP, Font RL. Carcinoma metastatic to the eye and orbit. I. A clinicopathologic study of 227 cases. Arch Ophthalmol 1974;92:276–286. Goldstein IWD. Metastasis in the choroid from adenocarcinoma of testis. Arch Ophthalmol 1935;13:207–211. Rotkis WM, Kulander BG, Chandler JW, Kaiser FS. Diagnosis
5. 6.
7.
8.
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2008
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of anterior chamber metastasis by serologic marker found during anterior chamber paracentesis. Am J Ophthalmol 1986; 102:179–181. Zech JC, Subiger L, Chiquet C, et al. Testicular choriocarcinoma metastatic to the choroid. Retina 1999;19:164–165. Mehriyar M, Jahadi SH, Kavian N, Kumar PV. Testicular germ cell tumor metastatic to the retina: vitreous fluid cytologic findings. Acta Cytol 2003;47:531–533. Aznabaev MT, Gabdrakhmanova AF, Babushkin AE, et al. [A case of metastasis of embryonal testicular cancer into the eye.] Vestn Oftalmol 2004;120:48–49. Nakajima H, Oki M, Matsukura S, et al. Germ cell tumors. Case 1. Intraocular metastases from testicular cancer. J Clin Oncol 2004;22:1753–1755.
Purpose: To describe the fundus findings, ultrasonography, and fluorescein angiography of a testicular mixed germ-cell tumor metastatic to the choroid and to report prompt resolution of the choroidal lesion with systemic chemotherapy. Methods: Observational case report. A 21-year-old man presented with a 10-cm testicular tumor. Ophthalmic examination revealed a large, dome-shaped choroidal lesion in the left eye, filling the entire superotemporal quadrant and extending into the macula. Ultrasonography showed a 10.3 mm in thickness hyperechoic mass. The patient was started on vinblastine, mesna, ifosfamide, and cisplatin. Results: On ophthalmic examination 6 weeks after initiation of chemotherapy, the choroidal lesion had completely resolved, leaving only pigmentary changes. Final ophthalmology follow-up 8 months after presentation demonstrated no recurrence of choroidal metastases. Conclusion: Testicular germ-cell tumors have now been well described to metastasize to the choroid. These choroidal metastases can show a prompt, favorable response to chemotherapy. RETINAL CASES & BRIEF REPORTS 2:172–174, 2008
From the Departments of *Ophthalmology & Visual Sciences and †Urology, University of Illinois at Chicago.
A
21-year-old man presented to the emergency room with a complaint of flank pain. Examination revealed a 10-cm left testicular mass. Further evaluation revealed multiple lesions in his lungs and brain. The flank pain was attributed to a perinephric hematoma. Left radical orchiectomy was performed and pathology demonstrated a mixed germ-cell tumor with elements of choriocarcinoma and teratoma (Figure 1). On postoperative day 1, the patient reported he had had blurred vision in his left eye for 1 week. Ophthalmic evaluation revealed 20/20 vision in both eyes. On fundus examination, a large, dome-shaped choroidal Fig. 1. Mixed germ-cell tumor with elements of choriocarcinoma (arrow) and teratoma (arrowhead).
Supported in part by the Illinois Eye Fund, Chicago, and an unrestricted grant from Research to Prevent Blindness, Inc., New York, New York. None of the authors has a proprietary interest in the material presented. Correspondence to: Norman Blair, MD, 1905 W. Taylor St., Chicago, IL 60612; e-mail: [email protected]
lesion was present in the left eye (Figure 2, A and B). The lesion filled the entire superotemporal quadrant and extended into the macula; there was a small 172
173
TESTICULAR MIXED GERM-CELL TUMOR METASTATIC TO THE CHOROID
Fig. 3. Hyperechoic mass on b-scan ultrasonography.
pocket of subretinal fluid overlying the mass causing a corresponding secondary retinal detachment. Ultrasonography showed a 10.3 mm in thickness hyperechoic mass presumed to be a choroidal metastasis (Figure 3). The patient was started on vinblastine, mesna, ifosfamide, and cisplatin. On ophthalmic examination 6 weeks after initiation of chemotherapy, his choroidal lesion had completely resolved, leaving only pigmentary changes (Figure 2C). Final ophthalmology follow-up 8 months after presentation showed no recurrence of choroidal metastases. Discussion
Fig. 2. A, Choroidal lesion; black arrow denotes venous bifurcation present on all images. B, Fluorescein angiogram. C, Fundus photograph 6 weeks after initiation of chemotherapy.
Testicular germ-cell tumors disseminate primarily via the lymphatic system to retroperitoneal lymph nodes. Hematogenous spread is less common and sites of metastasis are primarily the lungs, followed by liver, brain, and bones. The proportion of uveal metastases that are of testicular origin varies depending on the population studied. Testicular tumors represented the primary tumor in approximately 0.2% of uveal metastases (1 out of 520 eyes) in an outpatient oncology clinic.1 However, in a study of surgical specimens, testicular tumors represented the source in 3.0% of ocular metastases (6 out of 199 patients).2 Several case reports have also described testicular germ-cell tumors metastatic to the eye3– 8 with one previous report also documenting resolution with chemotherapy.5 Blurred vision has been previously reported as the presenting complaint of testicular germ-cell tumors.5 A young man presenting with a choroidal mass should undergo a systemic evaluation which includes evaluation for testicular cancer. Conversely, a patient with testicular cancer should be questioned about visual symptoms and, if present, should undergo ophthalmic evaluation. Testicular germ-cell tumors have now
RETINAL CASES & BRIEF REPORTSℜ
174
been well-described to metastasize to the choroid; choroidal lesions can show a prompt, favorable response to chemotherapy. References 1. 2.
3. 4.
Shields CL, Shields JA, Gross NE, et al. Survey of 520 eyes with uveal metastases. Ophthalmology 1997;104:1265–1276. Ferry AP, Font RL. Carcinoma metastatic to the eye and orbit. I. A clinicopathologic study of 227 cases. Arch Ophthalmol 1974;92:276–286. Goldstein IWD. Metastasis in the choroid from adenocarcinoma of testis. Arch Ophthalmol 1935;13:207–211. Rotkis WM, Kulander BG, Chandler JW, Kaiser FS. Diagnosis
5. 6.
7.
8.
●
2008
●
VOLUME 2
●
NUMBER 2
of anterior chamber metastasis by serologic marker found during anterior chamber paracentesis. Am J Ophthalmol 1986; 102:179–181. Zech JC, Subiger L, Chiquet C, et al. Testicular choriocarcinoma metastatic to the choroid. Retina 1999;19:164–165. Mehriyar M, Jahadi SH, Kavian N, Kumar PV. Testicular germ cell tumor metastatic to the retina: vitreous fluid cytologic findings. Acta Cytol 2003;47:531–533. Aznabaev MT, Gabdrakhmanova AF, Babushkin AE, et al. [A case of metastasis of embryonal testicular cancer into the eye.] Vestn Oftalmol 2004;120:48–49. Nakajima H, Oki M, Matsukura S, et al. Germ cell tumors. Case 1. Intraocular metastases from testicular cancer. J Clin Oncol 2004;22:1753–1755.
