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Testicular carcinoma with superior vena cava obstruction and atrial extension
IMAGES IN CLINICAL UROLOGY
TESTICULAR CARCINOMA WITH SUPERIOR VENA CAVA OBSTRUCTION AND ATRIAL EXTENSION L. L. M. LOW, S. K. H. YIP, P. C. S. ANG,
AND
F. K. CHEAH
A
14-year-old boy with a history of asthma was admitted for increasing breathlessness for several weeks. He was found to have a painless hard testicular mass that, in retrospect, had been present for the past year. Other salient clinical findings included dilated veins over the upper thorax and engorged external jugular veins. All tumor markers were within the normal range. A chest x-ray showed the presence of multiple cannonball lesions, mediastinal widening, and a left pleural effusion. A staging computed tomography (CT) examination revealed enlarged mediastinal nodes enveloping the supra-aortic vessels and compressing the superior vena cava (SVC). A filling defect was seen within the right brachiocephalic vein and SVC, suggestive of possible tumor thrombus (Fig. 1). Pretracheal, hilar, and subcarinal nodes were also present, and there were multiple large pulmonary metastases (Fig. 2). Right inguinal orchiectomy was performed and histopathologic examination revealed embryonal carcinoma with extensive vascular emboli. Combination chemotherapy (bleomycin, etoposide, and cisplatin) was administered within 48 hours after surgery, with dramatic improvement of his symptoms. Anticoagulation therapy was given in view of the SVC thrombus. However, after two cycles of that chemotherapy regimen, he developed pulmonary embolism (confirmed by ventilation perfusion studies) for which he was treated conservatively. In view of the suboptimal response, chemotherapy was switched to VP-16, isofosphamide, and cisplatin. However, after two cycles (4 months from initial diagnosis), an echocardiogram detected intra-atrial extension, which was confirmed by CT and magnetic resonance imaging (MRI) of the cardiac cavity. The presence of an extensive retrocaval nodal mass with tumor extension into From the Departments of Urology, Oncology, and Diagnostic Radiology, Singapore General Hospital, Singapore Reprint requests: Sidney K. H. Yip, M.D., Department of Urology, Singapore General Hospital, Outram Road, Singapore 169608 Submitted: November 18, 1998, accepted (with revisions): February 3, 1999 © 1999, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
FIGURE 1. Contrast-enhanced CT thorax scan reveals a filling defect in the SVC and enlarged mediastinal nodes.
FIGURE 2. Contrast-enhanced CT thorax scan demonstrates pulmonary metastasis and enlarged pretracheal nodes compressing the trachea.
the left wall of the SVC (Fig. 3) and a tumor nodule in the left atrial wall extending into the atrial cavity and causing obstruction to the left pulmonary vein (Fig. 4) were noted. While further chemotherapy was being considered, he developed brain metastasis. There was a brief response to palliative irradiation, but he died shortly afterwards (6 months after initial diagnosis). UROLOGY 54: 363–364, 1999 • 0090-4295/99/$20.00 PII S0090-4295(99)00088-6 363
FIGURE 3. T1-weighted images (MRI) show extensive retrocaval nodal mass with tumor extension into the left wall of the SVC. A free-floating thrombus was present on the caudal images.
Husband and Bellamy1 extensively studied the unusual thoracoabdominal sites of metastasis from testicular tumors in 650 patients; SVC and atrial involvement were not noted. On the other hand, inferior vena cava involvement and pulmonary embolism have been reported.2 The SVC and atrial disease in this patient was likely from direct extension of the lymph node disease. As the imaging studies were diagnostic of the condition, endovascular biopsy3 was not contemplated. Surgical intervention was also deemed inappropriate, although the isolated intra-atrial tumor thrombus had been removed surgically.4 High-dose chemotherapy and autologous bone marrow transplantation in this highly resistant tumor may be considered.5 REFERENCES 1. Husband JE, and Bellamy EA: Unusual thoracoabdominal sites of metastases in testicular tumours. AJR Am J Roentgenol 145: 1165–1171, 1985.
364
FIGURE 4. T1-weighted postgadolinium axial scan (MRI) showing tumor in the left atrial wall extending into the atrial cavity (arrowhead) and causing occlusion of the left inferior pulmonary vein. Cystic pulmonary metastasis is noted adjacent to the right atrium (arrow).
2. Stockler M, and Raghavan D: Neoplastic venous involvement and pulmonary embolism in patients with germ cell tumors. Cancer 68: 2633–2636, 1991. 3. Fidias P, Fan CM, McGovern FJ, et al: Intracaval extension of germ cell carcinoma: diagnosis via endovascular biopsy and a review of the literature. Eur Urol 31: 376 –379, 1997. 4. Savarese DNF, Rohrer MJ, Pezzella AT, et al: Successful management of intracardiac extension of tumor thrombus in a patient with advanced nonseminomatous germ cell testicular cancer. Urology 46: 883– 887, 1995. 5. Motzer RJ, Mazumdar M, Gulati SC, et al: Phase II trial of high-dose carboplatin and etoposide with autologous bone marrow transplantation in first line therapy for patients with poor-risk germ cell tumors. J Natl Cancer Inst 85: 1828 –1835, 1993.
UROLOGY 54 (2), 1999
TESTICULAR CARCINOMA WITH SUPERIOR VENA CAVA OBSTRUCTION AND ATRIAL EXTENSION L. L. M. LOW, S. K. H. YIP, P. C. S. ANG,
AND
F. K. CHEAH
A
14-year-old boy with a history of asthma was admitted for increasing breathlessness for several weeks. He was found to have a painless hard testicular mass that, in retrospect, had been present for the past year. Other salient clinical findings included dilated veins over the upper thorax and engorged external jugular veins. All tumor markers were within the normal range. A chest x-ray showed the presence of multiple cannonball lesions, mediastinal widening, and a left pleural effusion. A staging computed tomography (CT) examination revealed enlarged mediastinal nodes enveloping the supra-aortic vessels and compressing the superior vena cava (SVC). A filling defect was seen within the right brachiocephalic vein and SVC, suggestive of possible tumor thrombus (Fig. 1). Pretracheal, hilar, and subcarinal nodes were also present, and there were multiple large pulmonary metastases (Fig. 2). Right inguinal orchiectomy was performed and histopathologic examination revealed embryonal carcinoma with extensive vascular emboli. Combination chemotherapy (bleomycin, etoposide, and cisplatin) was administered within 48 hours after surgery, with dramatic improvement of his symptoms. Anticoagulation therapy was given in view of the SVC thrombus. However, after two cycles of that chemotherapy regimen, he developed pulmonary embolism (confirmed by ventilation perfusion studies) for which he was treated conservatively. In view of the suboptimal response, chemotherapy was switched to VP-16, isofosphamide, and cisplatin. However, after two cycles (4 months from initial diagnosis), an echocardiogram detected intra-atrial extension, which was confirmed by CT and magnetic resonance imaging (MRI) of the cardiac cavity. The presence of an extensive retrocaval nodal mass with tumor extension into From the Departments of Urology, Oncology, and Diagnostic Radiology, Singapore General Hospital, Singapore Reprint requests: Sidney K. H. Yip, M.D., Department of Urology, Singapore General Hospital, Outram Road, Singapore 169608 Submitted: November 18, 1998, accepted (with revisions): February 3, 1999 © 1999, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
FIGURE 1. Contrast-enhanced CT thorax scan reveals a filling defect in the SVC and enlarged mediastinal nodes.
FIGURE 2. Contrast-enhanced CT thorax scan demonstrates pulmonary metastasis and enlarged pretracheal nodes compressing the trachea.
the left wall of the SVC (Fig. 3) and a tumor nodule in the left atrial wall extending into the atrial cavity and causing obstruction to the left pulmonary vein (Fig. 4) were noted. While further chemotherapy was being considered, he developed brain metastasis. There was a brief response to palliative irradiation, but he died shortly afterwards (6 months after initial diagnosis). UROLOGY 54: 363–364, 1999 • 0090-4295/99/$20.00 PII S0090-4295(99)00088-6 363
FIGURE 3. T1-weighted images (MRI) show extensive retrocaval nodal mass with tumor extension into the left wall of the SVC. A free-floating thrombus was present on the caudal images.
Husband and Bellamy1 extensively studied the unusual thoracoabdominal sites of metastasis from testicular tumors in 650 patients; SVC and atrial involvement were not noted. On the other hand, inferior vena cava involvement and pulmonary embolism have been reported.2 The SVC and atrial disease in this patient was likely from direct extension of the lymph node disease. As the imaging studies were diagnostic of the condition, endovascular biopsy3 was not contemplated. Surgical intervention was also deemed inappropriate, although the isolated intra-atrial tumor thrombus had been removed surgically.4 High-dose chemotherapy and autologous bone marrow transplantation in this highly resistant tumor may be considered.5 REFERENCES 1. Husband JE, and Bellamy EA: Unusual thoracoabdominal sites of metastases in testicular tumours. AJR Am J Roentgenol 145: 1165–1171, 1985.
364
FIGURE 4. T1-weighted postgadolinium axial scan (MRI) showing tumor in the left atrial wall extending into the atrial cavity (arrowhead) and causing occlusion of the left inferior pulmonary vein. Cystic pulmonary metastasis is noted adjacent to the right atrium (arrow).
2. Stockler M, and Raghavan D: Neoplastic venous involvement and pulmonary embolism in patients with germ cell tumors. Cancer 68: 2633–2636, 1991. 3. Fidias P, Fan CM, McGovern FJ, et al: Intracaval extension of germ cell carcinoma: diagnosis via endovascular biopsy and a review of the literature. Eur Urol 31: 376 –379, 1997. 4. Savarese DNF, Rohrer MJ, Pezzella AT, et al: Successful management of intracardiac extension of tumor thrombus in a patient with advanced nonseminomatous germ cell testicular cancer. Urology 46: 883– 887, 1995. 5. Motzer RJ, Mazumdar M, Gulati SC, et al: Phase II trial of high-dose carboplatin and etoposide with autologous bone marrow transplantation in first line therapy for patients with poor-risk germ cell tumors. J Natl Cancer Inst 85: 1828 –1835, 1993.
UROLOGY 54 (2), 1999