Extragonadal germ cell tumor in the retrovesical region associated with Klinefelter's syndrome: a case report and review of the literature

Oncologic manifestations of Klinefelter syndrome

Klinefelter syndrome (47,XXY) has a prevalence of approximately 1 in 500 males. It is a condition characterized by an extra X chromosome and is an underdiagnosed clinical entity. Inactivation of genes enables their escape from regulatory mechanisms, which can result in such classic physical manifestations as hypogonadism, gynecomastia, infertility, and various hormonal and physical abnormalities. While the endocrine manifestations of 47,XXY are well-known, the oncologic manifestations have received less attention. An association between cancer and 47,XXY has not as yet been clearly defined, with variability noted in the prevalence of different malignancies in 47,XXY patients. The mechanisms underlying these altered oncologic risks are still under debate. Some of the proposed explanations include hormone imbalance, developmental malfunctions, and failed DNA repair mechanisms. However, the recognition of the oncological associations linked to 47,XXY could be helpful. Screening measures in certain malignancies may enable an earlier diagnosis of 47,XXY and the implementation of more customized care in 47,XXY and the mosaic variants.. The data for this review was compiled from relevant PubMed articles published within the last three decades and organized based on cancer type.

Nonepithelial Tumors and Tumor-Like Lesions of the Prostate Gland

Many significant benign and malignant nonepithelial tumors and stromal tumor-like lesions arise in the prostate gland. Although such lesions are rare, their recognition by the pathologist is essential because their treatment and prognosis are quite variable. In this review, lesions of the specialized prostatic stroma, that is, lesions that can be seen in the stroma of the prostate but not in that of other organs, except for the phyllodes type of lesions, are discussed. Benign and malignant lesions of the soft tissues that occur in the stroma of other organs and are seen with some frequency in the prostate are also discussed. Few of the rarer soft tissue lesions are mentioned. Lesions and tumors with melanocytic differentiation, hematopoietic derivation, and germ cell tumors are described. It is hoped that this review will serve as a useful reference when encountering some of these lesions, all of which are referenced to their original and subsequent reports. Some non-English language references are also cited to reflect the international recognition of these lesions or to give credit to the author who first described the entity.

Retroperitoneal extragonadal germ cell tumor in a patient with Klinefelter's syndrome

A 22-year-old man was diagnosed with retroperitoneal seminoma associated with Klinefelter's syndrome. The tumor was 14 x 12 cm in size and surrounded the superior mesenteric artery. He received induction chemotherapy with bleomycin, etoposide and cisplatin (BEP) followed by salvage chemotherapy with paclitaxel, ifosfamide and cisplatin (TIP). The tumor considerably decreased in size and remains as a poorly defined plaque. At the time of writing, he is being followed closely and is free from progression.

Primary intrapelvic seminoma in Klinefelter's syndrome

Seminoma arising in patients with Klinefelter's syndrome is extremely rare; to our knowledge, only three cases have been reported in the English language literature. We report a case of intrapelvic seminoma in a 39-year-old man with Klinefelter's syndrome. Gross examination revealed that the tumor was a solid and irregular mass measuring 90 mm in diameter. The cut surfaces of this ill-defined tumor were yellow-white with necrotic foci. Histologically, the tumor cells were separated into lobules by branching, fibrous septa containing lymphocytes. In some parts of the tumor, a cord-like arrangement of tumor cells was present. Immunohistochemically, the tumor cells were strongly and diffusely positive for antiplacental alkaline phosphatase antibody along their cytoplasmic membranes, but negative for both chorionic gonadotrophin and alpha-fetoprotein. Based on these findings, we diagnosed this tumor as a seminoma. The testes when examined were found to be atrophic bilaterally, but with no tumor lesions. Chromosomal analysis yielded a 47XXY karyotype, compatible with Klinefelter's syndrome. These findings indicate a case of primary intrapelvic seminoma in Klinefelter's syndrome. The patient underwent intensive radiation therapy postoperatively, and he demonstrated no evidence of recurrence or metastasis during the 13-month period following surgery.

Diagnostic difficulties before definitive treatment of an extragonadal retroperitoneal germ cell tumor

A primary extragonadal germ cell tumor of the retroperitoneum was diagnosed in a 47-year-old man without elevated serum alpha-fetoprotein, human chorionic gonadotropin, or lactate dehydrogenase levels. The diagnosis was made by histologic analysis after resection. The patient responded well to a combination of cisplatin, etoposide, and ifosfamide, achieving a partial response with four cycles. Residual tumor resection revealed necrotic tissue only. The patient was alive and disease free 24 months after diagnosis. The diagnostic difficulties of this particular situation are discussed.

Association of Klinefelter syndrome and abdominal teratoma: a case report

Extragonadal germ cell tumors are rare. The association with Klinefelter syndrome has become observed recently. A case of an 11-month-old infant with Klinefelter syndrome and a retroperitoneal mature teratoma is presented. In the tumor and lymphocytes, a 47,XXY karyotype was found. The association of Klinefelter syndrome with germ cell tumors and its possible explanations are discussed.

A prolactin-secreting tumor in a patient with Klinefelter's syndrome: a case report

We report the case of a patient with Klinefelter's syndrome who developed a prolactin (PRL)-secreting tumor. The patient developed headaches, visual alterations and also symptoms of hypogonadism despite appropriate testosterone (T) replacement therapy. The diagnosis of hyperprolactinemia was then suspected. The laboratory findings confirmed the hypothesis, showing high levels of serum PRL. The patient was initially treated with oral bromocriptine, and afterwards with the injectable form. There was a marked decrease in PRL levels and in tumor size. Although some neoplasms, like breast carcinoma and germ cell tumors, are known to occur more frequently in patients with Klinefelter's syndrome, an association with PRL-secreting tumor has not been reported yet. In conclusion, symptoms of hypogonadism in patients with Klinefelter's syndrome receiving appropriate T replacement therapy can suggest the presence of hyperprolactinemia.

Cancer incidence in men with Klinefelter syndrome

Many case reports have suggested an association between Klinefelter syndrome (KS) and cancer, but studies of the cancer incidence in larger groups of men with KS are lacking. A cohort of 696 men with KS was established from the Danish Cytogenetic Register. Information on the cancer incidence in the cohort was obtained from the Danish Cancer Registry and compared with the expected number calculated from the age, period and site specific cancer rates for Danish men. A total of 39 neoplasms were diagnosed (relative risk = 1.1). Four mediastinal tumours were observed (relative risk = 67); all four were malignant germ cell tumours. No cases of breast cancer or testis cancer were observed. One case of prostate cancer occurred within a previously irradiated field. No excess of leukaemia or lymphoma was found. An increased risk of cancer occurred in the age group 15-30 years (relative risk = 2.7). All six tumours in this group were germ cell tumours or sarcomas. The overall cancer incidence is not increased and no routine cancer screening seems to be justified. A considerably elevated risk of mediastinal germ cell tumours occurs in the period from early adolescence until the age of 30.

Mediastinal teratoma and precocious puberty in a boy with mosaic Klinefelter syndrome

We describe a boy who developed precocious puberty resulting from chorionic gonadotropin produced by a mediastinal germ cell tumor. Following tumor removal he began spontaneous precocious sexual development which was treated and then arrested spontaneously. Investigation of this arrested puberty established that he had Klinefelter syndrome (KS) mosaicism. He represents the first instance of KS mosaicism reported with a mediastinal germ cell tumor, a neoplasm commonly reported in males with a 47,XXY karyotype. We recommend that all males with KS and early sexual development or with "normal" testicular growth be screened with measurement of germ cell tumor markers including beta-subunit of human chorionic gonadotropin and alpha-fetoprotein.

The clonal nature of mediastinal germ cell tumors and acute myelogenous leukemia. A case report and review of the literature

The clonal identity of a mediastinal germ cell malignant tumor and acute myelogenous leukemia is described in an 11-year-old boy in whom both tumors presented simultaneously. The relationship between these two histologically distinct malignancies is discussed in relation to this patient and 34 previously reported patients.

Extragonadal germ cell tumor originating in iliac fossa

Extragonadal germ cell tumors usually originate in midline body structures. We describe the first case of an extragonadal germ cell tumor that arose atypically in the right iliac fossa, a nonmidline pelvic region. Based on this case report and a review of the literature, we suggest a modification of Abell's criteria for the diagnosis of retroperitoneal extragonadal germ cell tumors.

Mediastinal germ cell tumour associated with Klinefelter syndrome. A report of case and review of the literature

A 14-year-old boy with Klinefelter syndrome (KS) and a large mediastinal tumour is presented. Human chorionic gonadotropin and oestradiol were markedly increased. An attempt at radical resection was performed. Histological examination revealed a malignant germ cell tumour of mixed histologic pattern composed of choriocarcinoma and components of mature teratoma. Four courses of cisplatin, bleomycin, and etoposide were given. The patient is without any evidence of tumour recurrence 20 months after diagnosis. A review of the literature revealed another 40 cases of primary mediastinal germ cell tumour (PMGCT) associated with KS. Compiled data from larger series demonstrate that at least 8% of male patients with PMGCT have KS, 50 times the expected frequency. In contrast to PMGCT in patients without KS, all tumours were of nonseminomatous histology, and the average age was considerably lower, Tumours in prepubertal boys were associated with precocious puberty.