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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 16  |  Issue : 3  |  Page : 191-195

Acute presentation of metastatic testicular seminoma as chronic subdural hematoma with extra-axial brain lesion with severe mass effect: A case report and brief review of literature


1 Department of Neurosurgery, Maharishi Markandeshwar Institute of Medical Science and Research, Ambala, Haryana, India
2 Department of Neurosurgery, Anaesthesia, Maharishi Markandeshwar Institute of Medical Science and Research, Ambala, Haryana, India

Date of Submission18-Oct-2018
Date of Acceptance17-Jul-2019
Date of Web Publication11-Sep-2019

Correspondence Address:
Arvinpreet Kour
Assistant Professor, Department of Anaesthesia, I Block, Flat No 22, Maharishi Markandeshwar University Campus, Mullana, Ambala, 133 207, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_81_18

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  Abstract 


We present an unusual case of a 33-year-old male, who has been diagnosed with seminoma testes with retroperitoneal lymph nodes involvement 1 year back, the patient had undergone four cycles of the chemotherapy and had undergone left orchidectomy for the same. Past 1 year was uneventful and the patient was living a normal healthy life, with no evidence of any diseases and no symptoms. For the last 1 month, the patient complained of headache with no other symptoms, and on 1 day, the patient had sudden loss of consciousness. Noncontrast computed tomography (CT) head was done, which revealed a large chronic subdural collection with an extra-axial mass attached with the dura on the right parasagittal region. The patient at the time of presentation had a Glasgow Coma Scale of 5/15 with irregular respiration, and the right pupil was fixed nonreacting to the light. Urgent surgery was done, and the patient recovered fully with no deficit and was discharged. The patient will be considered for chemotherapy.

Keywords: Brain metastasis, chronic subdural hematoma, seminoma


How to cite this article:
Singh A, Kour A, Bindra G S, Gehlot AK. Acute presentation of metastatic testicular seminoma as chronic subdural hematoma with extra-axial brain lesion with severe mass effect: A case report and brief review of literature. Apollo Med 2019;16:191-5

How to cite this URL:
Singh A, Kour A, Bindra G S, Gehlot AK. Acute presentation of metastatic testicular seminoma as chronic subdural hematoma with extra-axial brain lesion with severe mass effect: A case report and brief review of literature. Apollo Med [serial online] 2019 [cited 2019 Nov 21];16:191-5. Available from: http://www.apollomedicine.org/text.asp?2019/16/3/191/266790




  Introduction Top


Testicular germ-cell tumors (GCTs) are rare, representing <1% of all malignancies in males.[1] International patterns and trends in testis cancer incidence. Earlier, it was that these tumors represent the most common malignancy in men aged 15–35 years, now there is evidence that globally, there has been an increase in the incidence of testicular cancer, with studies reporting almost doubling of its incidence in the past 40 years.[2] Seminoma is the most common type of tumor arising from the testis with pure seminoma, accounting for 40%. Treatment options after orchiectomy in Stage I seminoma are chemotherapy with carboplatin, radiotherapy, or surveillance. Age-standardized incidence rates are highest in New Zealand (7.8), the UK (6.3), Australia (6.1), Sweden (5.6), the USA (5.2), Poland (4.9), and Spain (3.8)/100,000 men. India, China, and Colombia have the lowest incidence of 0.5, 1.3, and 2.2/100,000 men, respectively. India has the lowest overall testicular cancer incidence of 1.7% (2.5; 0.8).[3]

GCT is classified into several subtypes, including seminoma (40%), embryonal carcinoma (25%), teratocarcinoma (25%), teratoma (5%), and pure choriocarcinoma (1%). Testicular GCTs are often metastatic to distant sites including the retroperitoneal lymph nodes, lungs, and liver. Clinically apparent gastrointestinal involvement from metastatic testicular cancer occurs in <5% of cases and is more commonly associated with nonseminomatous GCTs than with seminomas.[4],[5],[6],[7],[8],[9],[10],[11] However, in a postmortem study, gastrointestinal metastases were found in 27% of cases.[7] Patients with intestinal metastases can present with perforation, obstruction, and bleeding at diagnosis or during treatment. The patient can present with life-threatening bleeding from highly vascular metastatic lesions as initial presentation, and a successful management depends on the treatment of underlying malignancy in addition to resuscitative measures. It is rare to present as brain metastasis.


  Case Report Top


A 33-year-old male who was brought to the hospital in critical condition, had been previously diagnosed with seminoma testes [Histopathology – [Figure 1], [Figure 2], [Figure 3]] with retroperitoneal lymph nodes on CT scan abdomen [Figure 4] involvement 1 year back, and he had undergone left orchidectomy followed by four cycles of the chemotherapy for the same.
Figure 1: Pathological slides of seminoma from the brain (synaptophysin staining)

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Figure 2: Pathological slides of seminoma from the brain (oct3/4 C10 staining)

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Figure 3: Pathological slides of seminoma from the brain (Pancytokeratin AE1/AE3 staining)

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Figure 4: Computed tomography scan abdomen of the patient showing retroperitoneal lymph nodes involvement

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Past 1 year was uneventful and the patient was living a normal healthy life, with no evidence of any symptoms and diseases. For the last 1 month, the patient started complaints of minimum headache which was more in the morning and was relieved with taking mild antipyretics, the patient complained of headache with no other symptoms, and on day 1, the patient had sudden loss of consciousness.

The patient was brought into the Emergency Department of the Medical College (Maharashi Markendeshwar Institute of Medical Science and Research), was initially, urgently managed by general surgery department, initial investigation were done, urgent noncontrast computed tomography head [Figure 5] and [Figure 6] revealed a large right frontotemporoparietal chronic subdural hematoma with an extra-axial mass attached with the dura with its blood circulation from the sagittal sinus on the right parasagittal region. The patient at the time of presentation had a Glasgow Coma Scale (GCS) of 3/15 with irregular respiration, bilateral; pupils fixed nonreacting to the light with anisocoria, right pupil 4 mm nonreacting, and left 2 mm fixed nonreacting to the light. He was immediately intubated and was taken for the emergency craniotomy, postoperatively, the patient was continued on ventilatory support being sedated and paralyzed, and on the next day, postoperative plain [Figure 7] and contrast CT [Figure 8] head was done which were grossly normal with postoperative changes, the patient was extubated, and on subsequent day, the patient was shifted to the ward. The patient recovered fully with no deficit and was discharged. On review after 10 days, the patient was considered for chemotherapy.
Figure 5: Preoperative noncontrast computed tomography head axial sections showing extra-axial mass with chronic subdural with mass effect

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Figure 6: Preoperative noncontrast computed tomography head coronal sections showing extra-axial mass with chronic subdural with mass effect

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Figure 7: Postoperative noncontrast computed tomography head axial sections showing the complete removal of extra-axial mass and chronic subdural with no mass effect

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Figure 8: Postoperative contrast-enhanced computed tomography head coronal sections showing the complete removal of extra-axial mass and chronic subdural with no mass effect

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  Discussion Top


Abdominopelvic CT scanning is used to assess the retroperitoneal nodes. Chest X-ray is indicated in all the patients having retroperitoneal lymphadenopathy to rule out the pulmonary metastasis. Elevated values of beta-human chorionic gonadotropin (HCG), lactic dehydrogenase (LDH), or alpha-fetoprotein (AFP) should be followed with repeated tests. Serum concentrations of beta-HCG and LDH may be elevated in patients with seminoma. Our patient had undergone positron emission tomography scan and only found to have retropharyngeal lymph node. Orchiectomy is both diagnostic and therapeutic. Our patient after undergoing orchidectomy and chemotherapy was followed; levels of the beta-HCG and AFP were repeated after chemotherapy and were normal. (1.5 mlU/ml and 3.61 ng/ml), in spite of all those the patient had metastasis in the brain. Patients with seminoma arising from an extragonadal site, such as the mediastinum, are treated with standard chemotherapy regimens according to risk.

As per the literature, the involvement of the brain is rare, the patients of seminoma have a good prognosis, and they usually respond well to the chemotherapy and radiotherapy; it is very rare that the patient needed surgery. Whereas, our patient presented as acute episode with life-threatening complication with herniation of the brain, surgery was utmost required to save the life, otherwise if the patient had presented with good GCS, we would have been opted for chemotherapy/radiotherapy. Even after the patient had metastasized to the brain, they had excellent prognosis.

The general principles of treatment of seminoma according to the National Compressive Cancer Network guidelines of 2016 are.

Radiotherapy

Smaller fields require lower doses of radiations.

Adapted to the tumors with size more than 4 cm.[12],[13]

  • Linear accelerators with >6 MV photons were used [14]
  • The mean was reduced to 50%
  • Radiotherapy should start once the orchiectomy wound has fully healed
  • Patients should be treated 5 days/week.


The chemotherapy had excellent results for the treatment of the seminoma.

The primary regimens include

  1. Etoposide and Cisplatin


    • Etoposide 100 mg/m 2 intravenous (IV) on days 1–5 cisplatin 20 mg/m 2 IV on days 1–5
    • To be repeated every 21 days.


  2. Bleomycin, Etopside and Cisplatin


    • Etoposide 100 mg/m 2 IV on days 1–5 cisplatin 20 mg/m 2 IV on days 1–5
    • Bleomycin 30 units IV weekly on days 1, 8, and 15 or days 2, 9, and 16
    • Repeat every 21 days.


  3. Etopside, Ifosfamide and Cisplatin


    • Etoposide 75 mg/m 2 IV on days 1–5 mesna 120 mg/m 2 slow IV push before ifosfamide on day 1, then mesna 1200 mg/m 2 IV continuous infusion on days 1–5 ifosfamide 1200 mg/m 2 on days 1–5, cisplatin 20 mg/m 2 IV on days 1–5
    • Repeat every 21 days.[15],[16],[17]


Second-line chemotherapy regimens for metastatic germ cell tumors

  1. Vinblastin sulphate, ifosfamide and cisplastin


    • Vinblastine 0.11 mg/kg IV push on days 1–2, mesna 400 mg/m 2 IV every 8 h on days 1–5 ifosfamide 1200 mg/m 2 IV on days 1–5, and cisplatin 20 mg/m 2 IV on days 1–5
    • Repeat every 21 days.


  2. Taxol [Paclitaxel] ifosfamide and carboplatin
  3. Paclitaxel 250 mg/m 2 IV on day 1, ifosfamide 1500 mg/m 2 IV on days 2–5, mesna 500 mg/m 2 IV before ifosfamide, and then 4 and 8 h after each ifosfamide dose on days 2–5, cisplatin 25 mg/m 2 IV on days 2–5 repeat every 21 days, carboplatin 700 mg/m 2 IV etoposide 750 mg/m 2 IV. Administer 5, 4, and 3 days be for peripheral blood stem cell infusion for two cycles. Paclitaxel 200 mg/m 2 IV over 24 h on day 1, ifosfamide 2000 mg/m 2 over 4 h with mesna, protection on days 2–4, repeat every 14 days for two cycles followed by carboplatin AUC 7–8 IV over 60 min days 1–3, etoposide 400 mg/m 2 IV days 1–3. Administer with peripheral blood stem cell support at 14–21-day intervals for three cycles.


Subsequent chemotherapy regimens for metastatic germ cell tumors

  • Gemcitabine/oxaliplatin
  • Gemcitabine/paclitaxel
  • Gemcitabine/paclitaxel/oxaliplatin
  • Etoposide (oral).


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Purdue MP, Devesa SS, Sigurdson AJ, McGlynn KA. International patterns and trends in testis cancer incidence. Int J Cancer 2005;115:822-7.  Back to cited text no. 1
    
2.
Huyghe E, Matsuda T, Thonneau P. Increasing incidence of testicular cancer worldwide: A review. J Urol 2003;170:5-11.  Back to cited text no. 2
    
3.
Shanmugalingam T, Soultati A, Chowdhury S, Rudman S, Van Hemelrijck M. Global incidence and outcome of testicular cancer. Clin Epidemiol 2013;5:417-27.  Back to cited text no. 3
    
4.
Cicin I, Ozyilmaz F, Karagol H, Yalcin F, Uzunoglu S, Kaplan M. Massive upper gastrointestinal bleeding from pure metastatic choriocarcinoma in patient with mixed germ cell tumor with subclinical intestinal metastasis. Urology 2009;73:443.e15-7.  Back to cited text no. 4
    
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Harikumar R, Harish K, Aravindan KP, Thomas V. Testicular choriocarcinoma with gastric metastasis presenting as hematemesis. Indian J Gastroenterol 2004;23:223-4.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Plukker JT, Schraffordt Koops H, Sleijfer DT, Oosterhuis JW, van der Jagt E. Intestinal hemorrhages in patients with a nonseminomatous testicular tumor. Cancer 1991;68:2630-2.  Back to cited text no. 6
    
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Bredael JJ, Vugrin D, Whitmore WF Jr. Autopsy findings in 154 patients with germ cell tumors of the testis. Cancer 1982;50:548-51.  Back to cited text no. 7
    
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Nord C, Fosså SD, Giercksky KE. Gastrointestinal presentation of germ cell malignancy. Eur Urol 2000;38:721-4.  Back to cited text no. 8
    
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Shariat SF, Duchene D, Kabbani W, Mucher Z, Lotan Y. Gastrointestinal hemorrhage as first manifestation of metastatic testicular tumor. Urology 2005;66:1319.  Back to cited text no. 9
    
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Varadarajulu S, Ramsey WH. Hematemesis as the initial presentation of testicular cancer. Am J Gastroenterol 2000;95:3678-9.  Back to cited text no. 10
    
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Nakamura A, Ikeda Y, Morishita S, Sato Y, Matsumoto M, Inomoto T, et al. Upper gastrointestinal bleeding arising from metastatic testicular tumor. J Gastroenterol 1997;32:650-3.  Back to cited text no. 11
    
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Chung P, Warde P. Stage I seminoma: Adjuvant treatment is effective but is it necessary? J Natl Cancer Inst 2011;103:194-6.  Back to cited text no. 12
    
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Chung P. Prognostic factors for relapse in stage I seminoma: A validation study [abstract]. J Clin Oncol 2010;28:4535.  Back to cited text no. 13
    
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Zilli T, Boudreau C, Doucet R, Alizadeh M, Lambert C, van Nguyen T, et al. Bone marrow-sparing intensity-modulated radiation therapy for stage I seminoma. Acta Oncol 2011;50:555-62.  Back to cited text no. 14
    
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Xiao H, Mazumdar M, Bajorin DF, Sarosdy M, Vlamis V, Spicer J, et al. Long-term follow-up of patients with goo d-risk germ cell tumors treated with etoposide and cisplatin. J Clin Oncol 1997;15:2553-8.  Back to cited text no. 15
    
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Saxman SB, Finch D, Gonin R, Einhorn LH. Long-term follow-up of a phase III study of three versus four cycles of bleomycin, etoposide, and cisplatin in favorable-prognosis germ-cell tumors: The Indian University experience. J Clin Oncol 1998;16:702-6.  Back to cited text no. 16
    
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Nichols CR, Catalano PJ, Crawford ED, Vogelzang NJ, Einhorn LH, Loehrer PJ, et al. Randomized comparison of cisplatin and etoposide and either bleomycin or ifosfamide in treatment of advanced disseminated germ cell tumors: An Eastern Cooperative Oncology Group, Southwest Oncology Group, and Cancer and Leukemia Group B study. J Clin Oncol 1998;16:1287-93.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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