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Testicular Seminoma as a Cause of Paraplegia: A Case Report
Vol. 95, Jan. Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1966 by The Williams & Wilkins Co.
TESTICULAR SEMINOMA AS A CAUSE OF PARAPLEGIA: A CASE REPORT JOHN W. NELSON
AND
EUGENE H. RUFFOLO
From the Department of Pathology, Tampa General Hospital, Tampa, Florida
The differential diagnosis of paraplegia includes metastatic extradural neoplasm. Investigators of this phenomenon have designated malignant lymphoma, lung and breast as the most common sites of the primary tumor. 1- 4 Testicular seminoma does not appear in the tabulation of primary sites in these reviews, which include 174 cases of metastatic extradural neoplasm. Barron presented an analysis of 127 necropsies performed on subjects having symptomatic involvement of the cord and cauda equina and listed 1 seminoma as the primary neoplasm. 5 Our case report describes a seminoma, previously undiagnosed, which initially presented as rapidly developing paraplegia.
the umbilicus bilaterally. Position and vibratory senses were absent as was the cremasteric reflex. Urinalysis revealed a specific gravity of 1.020; sugar, negative; albumin, 10 mg. per cent; 85 to 90 white and 5 to 8 red blood cells per high power field and bacteria (Pseudomonas aeruginosa). Other laboratory reports including serology were non-contributory. Roentgenologic examination of the chest revealed increased parenchymal density in the right upper lobe and lobular masses in the medisastinum on either side of the ninth through tenth thoracic vertebrae. Laminography of this region suggested that the masses were most likely mediastinal nodes. No convincing roentgen involvement of bone was present. A complete obstruction of cephalad flow of the opaque medium in the region of the midcentrum of Tll was evident in the thoracic myelogram. This was interpreted as most likely due to a regional extension of a neoplastic process previously observed in the mediastinum. A malignancy in the right upper lobe of the lung was considered the most probable site of the primary growth. Bilateral abdominal pain had been experienced a few days previously but was not present at the time of examination. A decompression laminectomy was performed. Infiltrating tumor was encountered in the paravertebral muscles on either side of T9 to TlO. A frozen section was reported as metastatic grade 4 adenocarcinoma. Laminectomy revealed the epidural tumor which had encircled the dural sac. After the operation, the patient continued to have urinary tract infection and his general condition deteriorated. He died 12 days postoperatively.
CASE REPORT
A 63-year-old white man was hospitalized for psychiatric observation and evaluation. The physical examination and complete review of symptoms were negative. A diagnosis of paranoid psychosis and involutional psychotic reaction was established and the patient was discharged after 14 days. Ataxia had been noted for a few days prior to discharge and attributed to librium therapy. The day following discharge the patient was readmitted because of difficulty in voiding and gradual weakening of the legs. Neurologic signs developed rapidly and within 3 days flaccid paralysis was complete. Examination revealed absent deep tendon reflexes and hypesthesia to Accepted for publication March 15, 1965. 1 Kennedy, J. C. and Stern, W. E.: Metastatic neoplasms of the vertebral column producing compression of the spinal cord. Amer. J. Surg., 104: 155-168, 1962.
2 Mullan, J. and Evans, J.P.: Neoplastic disease of the spinal extradural space. Arch. Surg.,
AUTOPSY
74: 900-907, 1957. 3 Perese, D. JVI.: Treatment of metastatic extra-
Gross examination. The abdominal cavity contained a greenish serous fluid which filled the pelvis. The fluid was emanating from a perforated ulcer on the lesser curvature of the stomach. The peritoneum was covered by fine fibrinous exudate. The opened stomach revealed 4 other well demarcated ulcerations along the lesser curvature. No tumor was found in either the main stem
dural spinal cord tumors. A series of 30 cases. Cancer, 11: 214-221, 1958. 4 Rowbotham, G. F.: Early diagnosis of compression of the spinal cord by neoplasms. Lancet,
2: 1220-1222, 1955.
5 Barron, K. D., Hirano, A., Araki, S. and Terry, R. D.: Experiences with metastatic neoplasms involving the spinal cord. Neurology, 9:
91-106, 1959. 70
TESTICULAR SEMIN01YIA AS CAUSE OF PARAPLEGIA
.J
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1j I4'
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Fm. l. Bulk of metastatic nodal masses in relation to spinal cord and vertebrae. Notice osseous involvement.
-I
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Fm. 2. A, epidural metastasis. B, obvious atrophy of removed cord
72
NELSON AND RUFFOLO
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Frn. 3. Cut surfaces of testes reveal primary seminoma within right testicle. bronchi or within the pulmonary parenchyma. Multiple emboli were found adherent to the walls of the secondary pulmonary arteries. The para-aortic nodes from the level of the aortic arch down into the pelvis (iliac nodes) were bilaterally enlarged to 8 cm. in diameter. One node beneath the medial end of the left clavicle obstructed the subclavian vein and caused distal thrombosis of the subclavian-axillary venous system. The nodes at the level of L4 to 5 displaced the inferior vena cava anteriorly causing distal thrombosis of the iliac venous system bilaterally. The cut surface of these nodes r~vealed complete replacement by soft, white, partially necrotic tumor (fig. 1). Tumor extended through the nodes, through adjacent paravertebral muscles and through the vertebrae causing extradural compression atrophy of the cord at the level of T9 to 12 (fig. 2). Examination of the genitalia revealed both testes to be equal in size (4 cm. diameter) and cut surfaces revealed a soft grey-white 2 cm. nodule in the right testicle (fig. 3). The cranium was opened and examination of the brain was not remarkable. Microscopic examination. The testicular tumor was composed of sheets of large cells with definite cell membranes, clear cytoplasm and vesicular nuclei. There was a sprinkling of lymphocytes throughout the stroma of the tumor. Zones of necrosis were evident (fig. 4). The metastases were of similar histologic structure. The atrophic portion of the cord contained demyelinization and edematous ml;llacia of the white matter and
Fm. 4. Photomicrograph of testicular seminoma. Sheets of cells with definite cell membranes, cle~r cytoplasm and vesicular nuclei. Note lymphocyt1c infiltration of stroma. H & E X 400. swelling and chromatolysis of the anterior horn cells. The gastric lesions were benign peptic ulcerations. Final diagnoses. Sern.inoma of the right testicle with extensive iliac and para-aortic nodal metastases; paraplegia (clinical) due to spinal c01:d compression and atrophy secondary to metastatic epidural seminorn.a; thrombosis of the left subclavian inferior vena cava and both iliac veins; rn.ultipl~ peptic ulcerations of the stomach with perforation of one, and early peritonitis; and multiple pulmonary ern.boli. COMMENT
The pathology of sern.inoma, including its pattern of metastasis has been comprehensively described by Dixon and Moore. 6 There does not seem to be any correlation between the size of the primary lesion and the bulk of the metastases. Voluminous para-aortic nodal involvement and retroperitoneal tumor secondary to an inapparent testicular turn.or have been previously described • Dixon, F. J. and Moore, R. A.: Tumors of the Male Sex Organs. In: Atlas of _Tumor Pathology. Washington: Armed Force Institute of Pathology, sec. 8, fasc. 31b and 32, pp. 57-72, 1952.
TESTICULAR SEMINOMA AS CAUSE OF PARAPLEGIA
by Auvert, 7 by Grimoud8 and by Slater. 9 This phenomenon occurs in the natural history of this tumor and must be always considered when confronted with these clinical situations. The rapid development of paraplegia as described here has been recognized as characteristic of metastatic epidural neoplasm in contrast to slow progression of symptoms due to compression by benign primary tumors. Barron stated that 7 Auvert, J.: A case of para-aortic lymph node metastases of an undiscovered seminoma at the level of the testes. J. Urol. Med. Chir., 66: 800-809, 1960.
8 Grimoud, M., Lapeyrere, J., Moreau, G., Sue, J.M. and Utheza, G.: Voluminous retroperitoneal abdominal tumor revealing an inapparent testicular seminoma. Toulouse Med., 61: 518-520, 1960. 9 Slater, G. S., Schultz, H. and Kreutzmann, W. B.: Occult testicular tumor. J.A.M.A., 157: 911-
912, 1955.
73
30 per cent of the patients in his series were paraplegic within a week and in some cases this could be measured in terms of hours or days. 5 SUMMARY
The case of a 63-year-old man with rapid onset of paraplegia secondary to metastatic epidural neoplasm has been described. The more common tumors causing this phenomenon have been reported as lymphoma, lung and breast malignancies. In this case, as has been described elsewhere, voluminous metastases from a seminoma have precipitated symptoms and the seminoma remained undetected, in its primary site, until necrospy. Testicular seminoma should always be considered in certain clinical situations.
THE JOURNAL OF UROLOGY
Copyright © 1966 by The Williams & Wilkins Co.
TESTICULAR SEMINOMA AS A CAUSE OF PARAPLEGIA: A CASE REPORT JOHN W. NELSON
AND
EUGENE H. RUFFOLO
From the Department of Pathology, Tampa General Hospital, Tampa, Florida
The differential diagnosis of paraplegia includes metastatic extradural neoplasm. Investigators of this phenomenon have designated malignant lymphoma, lung and breast as the most common sites of the primary tumor. 1- 4 Testicular seminoma does not appear in the tabulation of primary sites in these reviews, which include 174 cases of metastatic extradural neoplasm. Barron presented an analysis of 127 necropsies performed on subjects having symptomatic involvement of the cord and cauda equina and listed 1 seminoma as the primary neoplasm. 5 Our case report describes a seminoma, previously undiagnosed, which initially presented as rapidly developing paraplegia.
the umbilicus bilaterally. Position and vibratory senses were absent as was the cremasteric reflex. Urinalysis revealed a specific gravity of 1.020; sugar, negative; albumin, 10 mg. per cent; 85 to 90 white and 5 to 8 red blood cells per high power field and bacteria (Pseudomonas aeruginosa). Other laboratory reports including serology were non-contributory. Roentgenologic examination of the chest revealed increased parenchymal density in the right upper lobe and lobular masses in the medisastinum on either side of the ninth through tenth thoracic vertebrae. Laminography of this region suggested that the masses were most likely mediastinal nodes. No convincing roentgen involvement of bone was present. A complete obstruction of cephalad flow of the opaque medium in the region of the midcentrum of Tll was evident in the thoracic myelogram. This was interpreted as most likely due to a regional extension of a neoplastic process previously observed in the mediastinum. A malignancy in the right upper lobe of the lung was considered the most probable site of the primary growth. Bilateral abdominal pain had been experienced a few days previously but was not present at the time of examination. A decompression laminectomy was performed. Infiltrating tumor was encountered in the paravertebral muscles on either side of T9 to TlO. A frozen section was reported as metastatic grade 4 adenocarcinoma. Laminectomy revealed the epidural tumor which had encircled the dural sac. After the operation, the patient continued to have urinary tract infection and his general condition deteriorated. He died 12 days postoperatively.
CASE REPORT
A 63-year-old white man was hospitalized for psychiatric observation and evaluation. The physical examination and complete review of symptoms were negative. A diagnosis of paranoid psychosis and involutional psychotic reaction was established and the patient was discharged after 14 days. Ataxia had been noted for a few days prior to discharge and attributed to librium therapy. The day following discharge the patient was readmitted because of difficulty in voiding and gradual weakening of the legs. Neurologic signs developed rapidly and within 3 days flaccid paralysis was complete. Examination revealed absent deep tendon reflexes and hypesthesia to Accepted for publication March 15, 1965. 1 Kennedy, J. C. and Stern, W. E.: Metastatic neoplasms of the vertebral column producing compression of the spinal cord. Amer. J. Surg., 104: 155-168, 1962.
2 Mullan, J. and Evans, J.P.: Neoplastic disease of the spinal extradural space. Arch. Surg.,
AUTOPSY
74: 900-907, 1957. 3 Perese, D. JVI.: Treatment of metastatic extra-
Gross examination. The abdominal cavity contained a greenish serous fluid which filled the pelvis. The fluid was emanating from a perforated ulcer on the lesser curvature of the stomach. The peritoneum was covered by fine fibrinous exudate. The opened stomach revealed 4 other well demarcated ulcerations along the lesser curvature. No tumor was found in either the main stem
dural spinal cord tumors. A series of 30 cases. Cancer, 11: 214-221, 1958. 4 Rowbotham, G. F.: Early diagnosis of compression of the spinal cord by neoplasms. Lancet,
2: 1220-1222, 1955.
5 Barron, K. D., Hirano, A., Araki, S. and Terry, R. D.: Experiences with metastatic neoplasms involving the spinal cord. Neurology, 9:
91-106, 1959. 70
TESTICULAR SEMIN01YIA AS CAUSE OF PARAPLEGIA
.J
J ,f
s r'
1j I4'
r
71
1111 m, 1111 ,111 111111m,1 1111111111111um,11111wn11111-11111111ll1111111111111111111111111111111111U1.11111001111111111111ll111lllllllu 1g:1r111111111flillllllll!llllllllllljlllllll~oumu111111111,w11 ··,, I ,o/ I !JI T jl() ,!1 ,fl r·,f, r· !1• 1I 15 1IE !, $F I I rz () l"1fi-l"i.,J2 •. !h 21• I ?15 I >k I 1 , r·,i.··1 iisT;lil
Fm. l. Bulk of metastatic nodal masses in relation to spinal cord and vertebrae. Notice osseous involvement.
-I
""l""l""l'ml ""l'"'I 1111111111111111111 f111111111 p11111111 I111111111 I111111111I111111111I11111111111111111111u 1111111 t , 1 o 1 1 1 2 1 l 1 ,. t 5 1 6 117 1 a 1 9 2 o 2 1 B
Fm. 2. A, epidural metastasis. B, obvious atrophy of removed cord
72
NELSON AND RUFFOLO
1JIIHjlllljllillll! 1111111111111111111111111111111
' 8
9)
10
1'1
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Frn. 3. Cut surfaces of testes reveal primary seminoma within right testicle. bronchi or within the pulmonary parenchyma. Multiple emboli were found adherent to the walls of the secondary pulmonary arteries. The para-aortic nodes from the level of the aortic arch down into the pelvis (iliac nodes) were bilaterally enlarged to 8 cm. in diameter. One node beneath the medial end of the left clavicle obstructed the subclavian vein and caused distal thrombosis of the subclavian-axillary venous system. The nodes at the level of L4 to 5 displaced the inferior vena cava anteriorly causing distal thrombosis of the iliac venous system bilaterally. The cut surface of these nodes r~vealed complete replacement by soft, white, partially necrotic tumor (fig. 1). Tumor extended through the nodes, through adjacent paravertebral muscles and through the vertebrae causing extradural compression atrophy of the cord at the level of T9 to 12 (fig. 2). Examination of the genitalia revealed both testes to be equal in size (4 cm. diameter) and cut surfaces revealed a soft grey-white 2 cm. nodule in the right testicle (fig. 3). The cranium was opened and examination of the brain was not remarkable. Microscopic examination. The testicular tumor was composed of sheets of large cells with definite cell membranes, clear cytoplasm and vesicular nuclei. There was a sprinkling of lymphocytes throughout the stroma of the tumor. Zones of necrosis were evident (fig. 4). The metastases were of similar histologic structure. The atrophic portion of the cord contained demyelinization and edematous ml;llacia of the white matter and
Fm. 4. Photomicrograph of testicular seminoma. Sheets of cells with definite cell membranes, cle~r cytoplasm and vesicular nuclei. Note lymphocyt1c infiltration of stroma. H & E X 400. swelling and chromatolysis of the anterior horn cells. The gastric lesions were benign peptic ulcerations. Final diagnoses. Sern.inoma of the right testicle with extensive iliac and para-aortic nodal metastases; paraplegia (clinical) due to spinal c01:d compression and atrophy secondary to metastatic epidural seminorn.a; thrombosis of the left subclavian inferior vena cava and both iliac veins; rn.ultipl~ peptic ulcerations of the stomach with perforation of one, and early peritonitis; and multiple pulmonary ern.boli. COMMENT
The pathology of sern.inoma, including its pattern of metastasis has been comprehensively described by Dixon and Moore. 6 There does not seem to be any correlation between the size of the primary lesion and the bulk of the metastases. Voluminous para-aortic nodal involvement and retroperitoneal tumor secondary to an inapparent testicular turn.or have been previously described • Dixon, F. J. and Moore, R. A.: Tumors of the Male Sex Organs. In: Atlas of _Tumor Pathology. Washington: Armed Force Institute of Pathology, sec. 8, fasc. 31b and 32, pp. 57-72, 1952.
TESTICULAR SEMINOMA AS CAUSE OF PARAPLEGIA
by Auvert, 7 by Grimoud8 and by Slater. 9 This phenomenon occurs in the natural history of this tumor and must be always considered when confronted with these clinical situations. The rapid development of paraplegia as described here has been recognized as characteristic of metastatic epidural neoplasm in contrast to slow progression of symptoms due to compression by benign primary tumors. Barron stated that 7 Auvert, J.: A case of para-aortic lymph node metastases of an undiscovered seminoma at the level of the testes. J. Urol. Med. Chir., 66: 800-809, 1960.
8 Grimoud, M., Lapeyrere, J., Moreau, G., Sue, J.M. and Utheza, G.: Voluminous retroperitoneal abdominal tumor revealing an inapparent testicular seminoma. Toulouse Med., 61: 518-520, 1960. 9 Slater, G. S., Schultz, H. and Kreutzmann, W. B.: Occult testicular tumor. J.A.M.A., 157: 911-
912, 1955.
73
30 per cent of the patients in his series were paraplegic within a week and in some cases this could be measured in terms of hours or days. 5 SUMMARY
The case of a 63-year-old man with rapid onset of paraplegia secondary to metastatic epidural neoplasm has been described. The more common tumors causing this phenomenon have been reported as lymphoma, lung and breast malignancies. In this case, as has been described elsewhere, voluminous metastases from a seminoma have precipitated symptoms and the seminoma remained undetected, in its primary site, until necrospy. Testicular seminoma should always be considered in certain clinical situations.