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Synchronous Presentation of Nonseminomatous Germ Cell Tumor and Renal Cell Carcinoma: A Case Report
0022-534 7/86/1366-1309$02.00/0 THE JOURNAL OF UROLOGY
Vol. 136, December
Copyright© 1986 by The Williams & Wilkins Co.
Printed in U.S.A.
SYNCHRONOUS PRESENTATION OF NONSEMINOMATOUS GERM CELL TUMOR AND RENAL CELL CARCINOMA: A CASE REPORT MICHAEL R ELLEN, THOMAS K AHLERING AND DONALD G. SKINNER From the Division of Urology, Department of Surgery, University of Southern California-Los Angeles County Medical Center, Los Angeles, California
ABSTRACT
The synchronous presentation of 2 separate neoplasms is extremely unusual. We report a case of a synchronous nonseminomatous germ cell testicular tumor and renal cell carcinoma. Germ cell tumors usually manifest in the third decade of life. Renal cell carcinoma usually presents in older age groups but it has been reported in children and young adults. The synchronous presentation of 2 different types of carcinoma is extremely rare and we report such a case.
Our patient was managed on the assumption that the left renal mass was renal cell carcinoma. Our options included a right thoracoabdominal, midline or left thoracoabdominal approach. We believed that a left thoracoabdominal incision would facilitate optimally the radical nephrectomy and maximize the chances for survival if the renal mass were renal cell carcinoma. The abdominal portion of the incision was midline, and the bilateral retroperitoneal node dissection proceeded easily and allowed for complete removal of the remaining right spermatic vessels. As noted, the pathological examination confirmed the synchronous presentation of renal cell carcinoma and nonseminomatous testis tumor.
CASE REPORT
A 23-year-old Hispanic man presented with a 6-month history of right testicular pain with recent onset of increased severity. He denied systemic symptoms, including flank pain, hematuria, weight loss or gynecomastia. Right radical orchiectomy was performed and pathological examination revealed a nonseminomatous germ cell tumor composed of embryonal (fig. 1) and choriocarcinomatous elements. Preoperative a-fetoprotein and ,6-human chorionic gonadotropin serum levels were normal. Metastatic studies included a normal chest radiograph and abdominal computerized tomography (CT), which demon-· strated no obvious retroperitoneal adenopathy, although a 4 x 4 cm. complex cystic mass was identified in the upper pole of the left kidney (fig. 2, A). Left renal arteriography demonstrated neovascularity most consistent with renal cell carcinoma (fig. 2, B). Left radical nephrectomy with en bloc bilateral retroperitoneal lymph node dissection was performed through a left thoracoabdominal incision along with removal of the right spermatic cord. Pathological examination revealed no evidence of positive retroperitoneal nodes from either primary, thus, demonstrating stage A nonseminomatous testis tumor coexisting with stage I renal cell carcinoma (fig. 3). The patient did well and was discharged from the hospital 6 days postoperatively. DISCUSSION
Germ cell tumors are the most common tumors in 15 to 34year-old male subjects. 1 Metastatic spread is known to involve the retroperitoneum first, followed by the lungs, liver and, less commonly, the brain and skeleton. Although metastasis to the kidney in autopsy studies has been found in up to 25 per cent of nonseminomatous tumors,2 we have been unable to find any reports of a solitary metastasis to the kidney. Because the testis tumor in our case contained elements of choriocarcjnoma it, nonetheless, remained possible that a single blood borne metastasis had lodged in the left kidney. In distinction, renal cell carcinoma occurs most frequently in the 50 to 69-year age range 3 but it is not uncommonly reported in young adults. Therefore, because of the suggestive angiogram and the normal ,6-human chorionic gonadotropin levels we believed that the most likely diagnosis for the renal mass was renal cell carcinoma. However, we were unable to find any reports in the literature of synchronous presentation of a testicular carcinoma and renal cell carcinoma. Accepted for publication July 25, 1986.
FIG. 1. Photomicrograph of testis demonstrates embryonal carcinoma with typical solid trabecular pattern. H & E, reduced from XlOO.
FIG. 2. A, CT scan of retroperitoneum shows no lymphadenopathy but complex cystic mass is demonstrated in upper pole of left kidney. B, selective left renal angiogram demonstrates neovascular upper pole mass.
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ELLEN, AHLERING AND SKINNER
Fm. 3. A, gross photograph of left kidney. B, photolmicrograph of kidney demonstrates clear cell renal adenocarcinoma and shows tubular arrangement of clear cells (grade I). H & E, reduced from XlOO.
REFERENCES 1. Crawford, E. D. and Scardino, P. T.: Testicular carcinoma: an
overview. In: Genitourinary Cancer Surgery. Edited by E. D. Crawford and T. A. Borden. Philadelphia: Lea & Febiger, chapt. 27, p. 247, 1982.
2. Johnson, D. E., Appelt, G., Samuels, M. L. and Luna, M.: Metastases from testicular carcinoma: study of 78 autopsied cases. Urology, 8: 234, 1976. 3. Borden, T. A.: Renal cell carcinoma: an overview. In: Genitourinary Cancer Surgery. Edited by E. D. Crawford and T. A. Borden. Philadelphia: Lea & Febiger,. sect. II, chapt. 3, p. 23, 1982.
Vol. 136, December
Copyright© 1986 by The Williams & Wilkins Co.
Printed in U.S.A.
SYNCHRONOUS PRESENTATION OF NONSEMINOMATOUS GERM CELL TUMOR AND RENAL CELL CARCINOMA: A CASE REPORT MICHAEL R ELLEN, THOMAS K AHLERING AND DONALD G. SKINNER From the Division of Urology, Department of Surgery, University of Southern California-Los Angeles County Medical Center, Los Angeles, California
ABSTRACT
The synchronous presentation of 2 separate neoplasms is extremely unusual. We report a case of a synchronous nonseminomatous germ cell testicular tumor and renal cell carcinoma. Germ cell tumors usually manifest in the third decade of life. Renal cell carcinoma usually presents in older age groups but it has been reported in children and young adults. The synchronous presentation of 2 different types of carcinoma is extremely rare and we report such a case.
Our patient was managed on the assumption that the left renal mass was renal cell carcinoma. Our options included a right thoracoabdominal, midline or left thoracoabdominal approach. We believed that a left thoracoabdominal incision would facilitate optimally the radical nephrectomy and maximize the chances for survival if the renal mass were renal cell carcinoma. The abdominal portion of the incision was midline, and the bilateral retroperitoneal node dissection proceeded easily and allowed for complete removal of the remaining right spermatic vessels. As noted, the pathological examination confirmed the synchronous presentation of renal cell carcinoma and nonseminomatous testis tumor.
CASE REPORT
A 23-year-old Hispanic man presented with a 6-month history of right testicular pain with recent onset of increased severity. He denied systemic symptoms, including flank pain, hematuria, weight loss or gynecomastia. Right radical orchiectomy was performed and pathological examination revealed a nonseminomatous germ cell tumor composed of embryonal (fig. 1) and choriocarcinomatous elements. Preoperative a-fetoprotein and ,6-human chorionic gonadotropin serum levels were normal. Metastatic studies included a normal chest radiograph and abdominal computerized tomography (CT), which demon-· strated no obvious retroperitoneal adenopathy, although a 4 x 4 cm. complex cystic mass was identified in the upper pole of the left kidney (fig. 2, A). Left renal arteriography demonstrated neovascularity most consistent with renal cell carcinoma (fig. 2, B). Left radical nephrectomy with en bloc bilateral retroperitoneal lymph node dissection was performed through a left thoracoabdominal incision along with removal of the right spermatic cord. Pathological examination revealed no evidence of positive retroperitoneal nodes from either primary, thus, demonstrating stage A nonseminomatous testis tumor coexisting with stage I renal cell carcinoma (fig. 3). The patient did well and was discharged from the hospital 6 days postoperatively. DISCUSSION
Germ cell tumors are the most common tumors in 15 to 34year-old male subjects. 1 Metastatic spread is known to involve the retroperitoneum first, followed by the lungs, liver and, less commonly, the brain and skeleton. Although metastasis to the kidney in autopsy studies has been found in up to 25 per cent of nonseminomatous tumors,2 we have been unable to find any reports of a solitary metastasis to the kidney. Because the testis tumor in our case contained elements of choriocarcjnoma it, nonetheless, remained possible that a single blood borne metastasis had lodged in the left kidney. In distinction, renal cell carcinoma occurs most frequently in the 50 to 69-year age range 3 but it is not uncommonly reported in young adults. Therefore, because of the suggestive angiogram and the normal ,6-human chorionic gonadotropin levels we believed that the most likely diagnosis for the renal mass was renal cell carcinoma. However, we were unable to find any reports in the literature of synchronous presentation of a testicular carcinoma and renal cell carcinoma. Accepted for publication July 25, 1986.
FIG. 1. Photomicrograph of testis demonstrates embryonal carcinoma with typical solid trabecular pattern. H & E, reduced from XlOO.
FIG. 2. A, CT scan of retroperitoneum shows no lymphadenopathy but complex cystic mass is demonstrated in upper pole of left kidney. B, selective left renal angiogram demonstrates neovascular upper pole mass.
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ELLEN, AHLERING AND SKINNER
Fm. 3. A, gross photograph of left kidney. B, photolmicrograph of kidney demonstrates clear cell renal adenocarcinoma and shows tubular arrangement of clear cells (grade I). H & E, reduced from XlOO.
REFERENCES 1. Crawford, E. D. and Scardino, P. T.: Testicular carcinoma: an
overview. In: Genitourinary Cancer Surgery. Edited by E. D. Crawford and T. A. Borden. Philadelphia: Lea & Febiger, chapt. 27, p. 247, 1982.
2. Johnson, D. E., Appelt, G., Samuels, M. L. and Luna, M.: Metastases from testicular carcinoma: study of 78 autopsied cases. Urology, 8: 234, 1976. 3. Borden, T. A.: Renal cell carcinoma: an overview. In: Genitourinary Cancer Surgery. Edited by E. D. Crawford and T. A. Borden. Philadelphia: Lea & Febiger,. sect. II, chapt. 3, p. 23, 1982.