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E-JCRT CORRESPONDENCE
Year : 2015  |  Volume : 11  |  Issue : 4  |  Page : 1035

Cytomorphology of lung metastasis of pure choriocarcinoma of testis in a 58-year-old male


1 Lab Head, SRL Ltd, Shimla, Himachal Pradesh, India
2 Department of Pathology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India

Date of Web Publication15-Feb-2016

Correspondence Address:
Shailja Puri
Lab Head, SRL Ltd, Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.154010

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 > Abstract 


Choriocarcinoma is malignancy arising from the trophoblastic tissue. Pure choriocarcinoma is rare in testis. Choriocarcinoma of testis is more commonly associated with other germ cell tumors. The usual age of presentation is 2nd–3rd decade. Distant metastasis is known to occur in choriocarcinoma. We present a rare case of testicular pure choriocarcinoma in a male patient. The patient was treated with orchidectomy, lymphadenectomy, and chemotherapy. Three months later the patient presented with hemoptysis and a lung mass. The aspiration cytology of the lung mass revealed metastatic deposits of syncytiotrophoblastic and cytiotrophoblastic cells. We are reporting this case due to its rarity, rare age of presentation, and characteristic cytology at metastatic focus.

Keywords: Choriocarcinoma, testis, trophoblastic tissue


How to cite this article:
Puri S, Sood S, Mohindroo S, Kaushal V. Cytomorphology of lung metastasis of pure choriocarcinoma of testis in a 58-year-old male. J Can Res Ther 2015;11:1035

How to cite this URL:
Puri S, Sood S, Mohindroo S, Kaushal V. Cytomorphology of lung metastasis of pure choriocarcinoma of testis in a 58-year-old male. J Can Res Ther [serial online] 2015 [cited 2017 Dec 11];11:1035. Available from: http://www.cancerjournal.net/text.asp?2015/11/4/1035/154010




 > Introduction Top


Pure choriocarcinoma of testes is very rare. Most of them are associated with other germ cell tumors. Pure choriocarcinoma is associated with poor prognosis owing to its early hematogenous spread. Distant site metastasis can be the presenting feature of choriocarcinoma. We present a case of a 58-year-old male presenting as testicular mass, which came out to be pure choriocarcinoma on histopathology and immunohistochemistry. Within next 3 months, the patient presented with hemoptysis and lung mass. The cytology of the lesion turned out to be metastasis from the testicular tumor. The case emphasized the rapid progression of choriocarcinoma and characteristic cytological features.


 > Case report Top


A 58-year-old male presented with rapidly increasing scrotal mass for 6 months. General physical examination revealed gynecomastia. Ultrasonography of the scrotal mass revealed 7 × 6 × 4 cm sized enlarged testis, heterogeneous in texture with areas of cystic change. Right testis was unremarkable. Serum β-human chorionic gonadotropin (β-HCG) level was markedly elevated (184,624.28 mIU/ml). A left orchidectomy was performed. Grossly, the tumor measured 8 × 6 × 3 cm. The cut surface of the testis was completely replaced by a variegated gray-white growth with extensive areas of hemorrhage and necrosis [Figure 1]a. The histopathologic examination revealed intimate admixture of multinucleated syncytiotrophoblastic cells with cytotrophoblastic cells in a biphasic plexiform pattern [Figure 1]b. The cytotrophoblastic cells were mononuclear with mildly pleomorphic round nuclei, and pale cytoplasm. The syncytiotrophoblastic cells were multinucleated with large pleomorphic nuclei and abundant eosinophilic cytoplasm. Extensive sampling was performed to look for any other component of germ cell tumor. There was evidence of capsular invasion. Spermatic cord was free from tumor invasion. The syncytiotrophoblasts were immunoreactive for β-HCG [Figure 1]b and cytotrophoblasts was immunoreactive for keratin. A final diagnosis of nonseminomatous germ cell tumor, pure choriocarcinoma of testis was given. Three months later, the patient presented to pulmonary outpatient department with hemoptysis. Computed tomography chest revealed a heterogeneous mass in the right cardiophrenic angle measuring 6 × 4.5 cm [Figure 1]c suggestive of metastasis. Ultrasound-guided fine-needle aspiration smear of the lung mass was done. The cytology smears were hemorrhagic showing groups of predominantly isolated large tumor cells showing high nucleocytoplasmic ratio; large hyperchromatic pleomorphic to bizarre nuclei coarse irregular/reticular chromatin; conspicuous nucleoli; and moderate amount of basophilic cytoplasm showing finely vacuolated, binucleated, and multinucleated cells [Figure 1]d. On the basis of previous history of pure choriocarcinoma of testis, a diagnosis of metastasis from pure choriocarcinoma of testis to lung was given. The patient was referred to regional cancer institute for chemotherapy.
Figure 1: (a) The cut surface of the testis was completely replaced by a variegated gray-white growth with extensive areas of hemorrhage and necrosis. (b) The histopathologic examination revealed intimate admixture of multinucleated syncytiotrophoblastic cells with cytiotrophoblastic cells in a biphasic plexiform pattern (hematoxylin and eosin, ×10). The syncytiotrophoblastic cells immunoreactive for β-human chorionic gonadotropin (HCG). (c) The computed tomography chest revealed a heterogeneous mass in the right cardiophrenic angle. (d) The cytology smears from lung mass revealed malignant multinucleated synctiotrophoblastic cells (Giemsa, ×40)

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 > Discussion Top


The first case of pure choriocarcinoma of the testis was described by Tsuchiya et al., in 1980.[1] Choriocarcinoma is a germinal cell tumor arising from testicular cells in males and fetal trophoblast tissue in females. Pure choriocarcinoma in the testes is very rare, representing less than 1% (0.19%) of testicular germ cell tumors; however, it is admixed with other germ cell tumor elements in 8% of testicular germ cell tumors.[2] Testicular germ cell tumors usually present with testicular enlargement and pain. Tumors with unfavorable histology like choriocarcinoma present with early and widespread metastasis. Choriocarcinoma is unique as it represents a malignant transformation of tissue, trophoblast that inherently has the property of invasion and metastasis.[3] The usual age for presentation for choriocarcinoma in males is 2nd and 3rd decade. The patient may present with hormonal features, for example, gynecomastia, symptoms of distant metastasis, and elevated β-HCG levels.[4] In our case, the patient was 58-year-old and presented with gynecomastia. It is unusual to see choriocarcinoma at this age. Distant metastasis has been reported in lung, liver, brain, and some unusual sites like skin,[5] stomach,[6] and choroid.[7] These cases thus presented with a skin nodule,[5] hemetemesis,[6] and ocular mass.[7]

Grossly, the testis may be enlarged, normal sized, or smaller in size. The cut surface shows extensive areas of hemorrhage and necrosis with little gray-white viable tissue at the periphery.[4] Microscopically, the tumor is composed of admixture of syncytiotrophoblast and cytotrophoblast arranged in solid nests and sheets. The syncytiotrophoblastic cells cap the cytotrophoblast resulting in villous configuration. The syncytiotrophoblast is immunoreactive for β-HCG and human placental lactogen (HPL) and cytotrophoblast is immunoreactive for cytokeratin.[4]

The differential diagnosis of choriocarcinoma of testis includes seminoma and embryonal carcinoma with syncytiotrophoblastic giant cells. Five percent of seminomas contain varying number of syncytiotrophoblast cells which may secrete HCG. Grossly, the tumor may be hemorrhagic, but by definition lack association with cytotrophoblast. Occasionally, the seminomas may undergo hemorrhagic infarction and this is massive so that no nonnecrotic tissue is left. This usually leads to misdiagnosis with choriocarcinoma. However on close examination of the outlines of seminoma cells, septa with lymphocytes can still be seen. These features help to make a confident diagnosis of seminoma despite necrosis. Embryonal germ cell tumors with an appliqué pattern are confused with choriocarcinoma. In this pattern, degenerated cells are seen at the periphery of better-preserved cells superficially mimicking the biphasic pattern of choriocarcinoma. Immunohistochemistry with CD 30 is helpful for confirming the diagnosis of choriocarcinoma.[8]

The treatment of choriocarcinoma includes orchidectomy, chemotherapy, and retroperitoneal lymphadenetomy. The prognosis of choriocarcinoma is worse than other testicular tumors due to its early hematogenous spread. Sahraoui et al., reported 14 patients who had a metastasis involution after treatment of whom six died within 3 days–14 months, and 11 were alive after 6–96 months.[3] Distant metastases can be the presenting feature of choriocarcinoma. In metastatic foci from unknown primary, the possibility of primary germ cell tumor of testis should be kept in differential diagnosis in male patients.

In conclusion, this case is rare in being pure choriocarcinoma of testis, accounting for <1% of all testicular tumors in males. The age of presentation is rare, since pure choriocarcinoma occurs in 2nd–4th decade of life. The patient presented with hematogenous spread to lungs within 3 months of first presentation. Distant metastasis is associated with poorer prognosis.

 
 > References Top

1.
Tsuchiya K, Gushiken H, Kamata H. A case of metastatic choriocarcinoma presenting as a hemangioma-like eruption. Rinsho Derma (Tokyo) 1980;22:80-1.  Back to cited text no. 1
    
2.
Sauter G, Epstein JI, Sesterhenn IA. Tumours of the testis and paratesticular tissue. In: Eble JN, Sauter G, Epstein JI, Sesterhenn IA, editors. Tumours of the Urinary System and Male Genital Organs. Lyon: IARC Press; 2004. p. 240-2.  Back to cited text no. 2
    
3.
Sahraoui S, Hassani AT, Ouhtatou F, Acharki A, Benider A, Kahlain A. Pure choriocarcinoma of the testis: Report of a case and review of the literature. Ann Urol 2001;35:125-8.  Back to cited text no. 3
    
4.
RoJ Y, Amin MB, Kim KR, Ayala AG. Tumors of the male genital tract. In: Fletcher C, editor. Diagnostic Histopathology of Tumors. 3rd ed. USA: Elsevier Limited; 2007. p. 827-8.  Back to cited text no. 4
    
5.
Geramizadeh B, Rad H. Cutaneous metastasis of testicular choriocarcinoma, diagnosed by fine-needle aspiration cytology: A rare case report and review of literature. Indian J Pathol Microbiol 2012;55:406-8.  Back to cited text no. 5
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6.
Harikumar R, Harish K, Aravindan KP, Thomas V. Testicular choriocarcinoma with gastric metastasis presenting as hemetemesis. Indian J Gastroenterol 2004;23:223-4.  Back to cited text no. 6
    
7.
Karađinović V, Kozić D, Ostojić J. Metastatic choriocarcinoma of the testis mimicking ocular melanoma. Arch Oncol 2008;17:88.  Back to cited text no. 7
    
8.
Young R. Testicular tumors-some new and a few perennial problems. Arch Pathol Lab Med 2008;132:548-64.  Back to cited text no. 8
    


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