-2 :: Case - 13555 ::
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Tx and Followup:
T2N2M1bS3    AJCC Stage IIIC (poor risk, but ~70% respond to initial chemo, with 10-15% eligible for salvage therapy).

Screening abdomen and chest studies show dissemination - but there are no brain metastases.


Orchiectomy with retroperitoneal lymph node dissection, was followed by chemotherapy.

Additional Discussion:
Lymph node drainage from the testicle follows the path of embryonic develoment back to the renal hilus and para-aortic lymph nodes. Staging of testicular cancers includes imaging of the abdomen and chest. Metastatic spread usually follows this cascade: local lymph nodes/veins > renal and para-aortic nodes/veins > lung > system spread. The lung is usually involved before there can be spread to the CNS - unless there is right-to-left shunt.

Discussion Author: Seth D. O'Brien

Of all malignant intratesticular neoplams, mixed germ cell tumors are the second most common. Of these the majority are at least a portion of embryonal cell carcinoma which constitute 20-25% of all primary germ cell malignancies. Unfortunately this subtype of germ cell tumor tend to be more aggressive and will invade the tunica albuginea and/or cause visceral metastases. Although embryonal cell carcinomas have three sub-types: adult, infantile and endodermal sinus tumor, embryonal cell carcinomas tend to be less radio and chemosensitive than seminomatous tumors. Infantile and endodermal sinus types are associated with elevated alpha-fetoprotein which can be used to monitor therapy/recurrence.
Teratomas are a second type of germ cell tumor. Teratoma also has three subtypes: mature, immature, and with malignant transformation. Teratomas must have three germinal layers: endoderm, mesoderm, ectoderm. They constitute 5% of all primary testicular neoplasms. Although approximately 30% will metastasize, the reported 5-year survival is 70%.
Although not seen in this case the other type of non-seminomatous germ cell tumor type is choriocarcinoma which is the rarest and least favorable of the three basic types. Although it rarely occurs in its pure form, it represents 23% of mixed germ cell tumors. These leisons are highly vascular and metastasize early.

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