Primary carcinoid of the testis associated with carcinoid syndrome

Complete remission of Cdx-2 positive primary testicular carcinoid tumor: 10-years follow-up and literature review

BACKGROUND

The neuroendocrine cells can cause a variety of malignancies throughout the human body known as the neuroendocrine tumors (NETs) or carcinoid tumors. The primary testicular carcinoid tumor (PTCT) accounts for less than 1% of the testicular neoplasms and for only 0.2% of all carcinoid tumors representing already a very rare neoplastic entity. Here, we present a patient with a history of an exceptionally rare primary testicular carcinoid tumor, staining positive for Cdx-2 along with a literature review.

CASE PRESENTATION

A 44-year old patient without significant past medical history was diagnosed in September 2009 with primary testicular carcinoid tumor, which was surprisingly staining positively for Cdx-2, too. At the time of the initial diagnosis the tumor was already showing histopathological infiltration of veins. DOTA-TATE-PET/CT imaging and endoscopy studies did not show any signs of distant metastases and in particular no gastrointestinal manifestation following no further medical indication for systemic chemotherapy. The continuous and close follow-up of the patient has reached a total of over 10 years at the time of publication remaining in complete remission.

CONCLUSION

The diagnosis of primary testicular carcinoid is based on histopathology. The detailed histopathologic assessment of biomarkers based on immunohistochemistry is very important for the classification and the prognosis of the primary testicular carcinoid tumor. Primary testicular carcinoid tumor with Cdx-2 positive stain outlines an exceptionally rare neoplastic entity without a consensus about general follow-up guidelines, requiring close clinical and imaging aftercare and consideration in Cdx-2 positive metastatic tumor of unknown origin.

Carcinoid tumor masquerading as testicular tumor

Level of evidence: 3

Carcinoid-syndrome: recent advances, current status and controversies

PURPOSE OF REVIEW

To review recent advances and controversies in all aspects of carcinoid-syndrome.

RECENT FINDINGS

Over the last few years there have been a number of advances in all aspects of carcinoid syndrome as well as new therapies. These include new studies on its epidemiology which demonstrate it is increasing in frequency; increasing insights into the pathogenesis of its various clinical manifestations and into its natural history: definition of prognostic factors; new methods to verify its presence; the development of new drugs to treat its various manifestations, both initially and in somatostatin-refractory cases; and an increased understanding of the pathogenesis, natural history and management of carcinoid heart disease. These advances have generated several controversies and these are also reviewed.

SUMMARY

There have been numerous advances in all aspects of the carcinoid-syndrome, which is the most common functional syndrome neuroendocrine tumors produce. These advances are leading to new approaches to the management of these patients and in some cases to new controversies.

Neuroendocrine Testicular Tumors: A Systematic Review and Meta-Analysis

PURPOSE

The purpose of this study is to study the main epidemiological, clinical, para clinical, pathological, therapeutic, and evolutionary features of patients with testicular neuroendocrine tumors (TNET).

MATERIALS AND METHODS

Nine case series and sixteen case reports were identified by searching PubMed database and qualified for inclusion in this study. We added the data of one case treated in the department of urology in Habib Bourguiba Hospital in Sfax, to the published cases.

RESULTS

A total of 132 cases were collected. Median age at diagnosis was 39 years old (range 10- 83 years). The most common presenting symptom was either a testicular mass or a swelling in 38.46% of cases. Carcinoid syndrome was documented in 10.60% of patients. The clinical examination revealed a palpable mass in 44.70% of patients. This mass was painless and firm in most cases. Serum tumor markers (β-gonadotrophine chorionique humaine, α-feto protein, and lactate dehydrogenase) were within normal limits in all patients except in one case. Most testicular neuroendocrine tumors (76.52%) were primary and pure. The tumors were positive for chromogranin (100%), synaptophysin (100%) and cytokeratin (93.10%). Metastases were detected at time of diagnosis in eight cases (6.06%). The main treatment was radical orchiectomy performed in 127 patients (96.21%). The 5-year overall survival rate was 78.70% and the 5-year specific survival rate was 84.30%.

CONCLUSION

The diagnosis of testicular carcinoids is based on the immunohistochemistry study. The treatment of choice for these tumors is radical orchiectomy. Somatostatin analogues were reported to be effective in patients with carcinoid syndrome.

Intratubular Germ Cell Neoplasia of the Testis, Bilateral Testicular Cancer, and Aberrant Histologies

Intratubular germ cell neoplasia (ITGCN) is a precursor lesion for testicular germ cell tumors, most of which are early stage. ITGCN is also associated with testicular cancer or ITGCN in the contralateral testis, leading to a risk of bilateral testicular malignancy. Testicular biopsy detects most cases, and orchiectomy is the treatment of choice in patients with unilateral ITGCN. Low-dose radiation therapy is recommended in patients with bilateral ITGCN or ITGCN in the solitary testis, but the long-term risks of infertility and hypogonadism need to be discussed with the patient. Rare histologies of primary testicular cancer are also discussed.

Primary pure carcinoid tumors of the testis: Clinicopathological and immunophenotypical characteristics of 11 cases

Primary pure carcinoid tumors of the testis (pPCTT) are rare, and there are only a limited number of studies available. In the present study we described the clinicopathological and immunophenotypical characteristics of 11 cases from our institution between 1978 and 2014, and reported our experiences of the diagnosis and treatment of these patients. The patients ranged in age from 26 to 68 years old, with a median age of 48 years. One patient (9%) was classified as pT2 and 10 (91%) were pT1. Histologically, 7 cases were diagnosed as classical carcinoid tumors, while the other 4 cases were identified as atypical carcinoid tumors. The most common growth pattern was a mixed insular, acinar, rosetted, solid and trabecular pattern. Immunohistochemical staining revealed positive expression of neuron-specific enolase in all cases, and CgA, Syn and CD56 markers in 8 (72.7%), 10 (90.9%) and 9 cases (81.7%), respectively. In addition to radical orchiectomy, 9 patients (81.7%) received a combined modality of treatment. Follow-up data were available for 8 patients. Seven were alive at the last follow-up without recurrence, and one patient succumbed to cerebral hemorrhage 7 years after surgery. In summary, localized pPCTT is a rare disease with an indolent clinical course. When a testicular carcinoid tumor is identified, a metastasis or an intestinal primary tumor should be excluded, particularly when the testicular tumor is large. A tumor size ≤6.0 cm and the histological appearance had little relation with metastatic behavior.

Primary carcinoid tumor of the testis

Primary carcinoid tumors of the testis are a rare entity comprising less than 1% of all testicular neoplasms. Their presence should be considered particularly when evaluating a testicular lesion in an older male patient. Immunohistochemical studies may aid in diagnosis and radiographic evaluation is important to rule out metastatic origin. Primary carcinoid tumors of the testis are associated with an excellent prognosis; however, surveillance is important given rare reports of delayed metastases.

Primary Testicular Carcinoid Tumor presenting as Carcinoid Heart Disease

Primary carcinoid tumors of the testis are very rare, and they seldom present with carcinoid syndrome. We report a hereto unreported instance, where a patient with a long-standing testicular mass presented with carcinoid heart disease, an uncommon form of carcinoid syndrome. He presented with symptoms of right heart failure, episodic facial flushing and was found to have severe right-sided valvular heart disease. His urinary 5-hydroxy indole acetic acid level was elevated. He underwent orchidectomy and the histopathology confirmed a testicular carcinoid tumor.

Primary neuroendocrine tumor of the testis and osseous, cardiac, and lymph node metastases in a young patient

A 19-year-old patient was diagnosed with a neuroendocrine tumor (NET) of the testis and suffered from testicular pain and swelling after orchiectomy. After a comprehensive diagnosis, this tumor was shown to be a primary, metastasizing NET of the testis. Primary NETs of the testis are very rare; in the literature, only approximately 60 patients of all ages are mentioned. Less than 20% of the patients show a metastatic spread. In our patient, lymph node, cardiac, and osseous metastases have been found. It was possible to remove the lymph node metastases through surgery, and the osseous metastases were treated by means of radiation. The exploratory thoracotomy revealed a cardiac metastatic spread; however, it was so extended that a radical resection was not possible. Thereafter, the patient received palliative antiproliferative therapy with the somatostatin analogue lanreotide in the form of monthly subcutaneous injections. This treatment resulted in a stable disease situation.

RESULT

It is possible to administer lanreotide autogel in order to control the growth of the tumor in a young patient with a metastasizing primary NET of the testis with an impossible curative resection of the metastases.

Primary testicular carcinoid tumour with mature teratoma in undescended testis metastatic to lymph nodes

We report a case of primary testicular carcinoid tumour with mature teratoma metastatic to the para-aortic lymph node and the lymph node around the left gonadal vein, which was treated with radical orchiectomy, bleomycin, etoposide, and cisplatin chemotherapy, and modified retroperitoneal lymph node dissection. Three days after modified retroperitoneal lymph node dissection, bleomycin induced pneumonitis occurred, which was resolved with steroid administration. The patient is alive without recurrence 31 months after radical orchiectomy.

Primary neuroendocrine tumor of the testis

Testicular neuroendocrine tumor is rare. It accounts for less than 1% of all testicular neoplasms. More than 60 cases have been published in the literature. A 27-year-old man presented with left testicular mass and underwent radical orchidectomy. Histological examination showed neuroendocrine tumor, confirmed by immunohistochemistry and electron microscopy. The patient showed no evidence of metastasis over 1-year follow-up post-orchidectomy in spite of extensive tumor necrosis.

[Carcinoid tumor of the testis]

A 69-year-old man presented with a 2.4 cm painless mass in his right testis. Inguinal orchiectomy was performed. Histologically a carcinoid tumor of the testis was diagnosed. These neuroendocrine, noninvasive tumors are very rare, representing 0.23% of all testicular neoplasms. In 10% these tumors are associated with carcinoid syndrome and in 20% with metastatic disease.

Benign and Malignant Neoplasms of the Testis and Paratesticular Tissue

Benign and malignant tumors of the testes and paratesticular tissues present an interesting spectrum of diagnostic entities often encountered in routine surgical pathology practice. Germ cell tumors are the most common tumors of the testes and, despite a rising incidence, have excellent prognosis because of their radiosensitivity and/or effective chemotherapeutic agents. The proper classification of these tumors aids in the choice of appropriate treatment options. This article reviews benign and malignant neoplastic entities of the testes and paratesticular tissues and illustrates the classic pathologic characteristics. The differential diagnosis, along with ancillary studies, clinical significance, and presentation are discussed also.

An analysis of rare carcinoid tumors: clarifying these clinical conundrums

Carcinoid tumors are distinct neuroendocrine neoplasms with characteristic histological, clinical, and biological properties. Though commonly associated with the gastrointestinal tract and bronchopulmonary system, a substantial number of these tumors originate in less common anatomical sites and can range from indolent, unrecognized entities to highly active, metastatic secretory tumors. Their presentation within unfamiliar locations often results in clinical confusion, and they persist as unrecognized lesions, subjecting patients to delayed, inappropriate, or ineffective treatment. The authors reviewed 13,715 carcinoid tumors identified by three consecutive registries of the National Cancer Institute (NCI) from 1950 to 1999, focusing on the anatomic sites accounting for less than one percent of all carcinoids. In addition, data from the world's literature published on carcinoid tumors within these particular anatomic locations were then analyzed with respect to incidence, clinical presentation, symptoms, diagnostic evaluation, microscopic and immunohistochemical findings, treatment strategies, and prognosis. The primary organs in which carcinoids are most commonly mistaken for some of the more conspicuous endemic tumors include the esophagus, pancreas, liver, biliary tract, gallbladder, and Meckel's diverticulum, as well as within the pelvic and otolaryngeal organs and the breast. In general, the highest proportion of "rare" carcinoids was identified in the gastrointestinal (GI) tract, with the ovary as the single most affected extra-GI site. Tumors with the worst prognosis were those that involved the pancreas (37.5%: 5-year survival) and those in the cervix (12-33%: 3-year survival). While gastrointestinal carcinoids have become a more recognized entity and thus more amenable to identification, similar lesions are often not considered in other sites and have often either been overlooked or misdiagnosed. Widespread reports of their occurrence in rare locations warrants attention. The diminution of the likelihood of inadvertently neglecting these often benign, indolent neoplasms that are well known to metastasize if unaddressed would represent an important advance. Familiarity with such unusual sites of origin will facilitate appropriate recognition and characterization of such tumors, allowing for timely intervention.

Primary carcinoid tumor of the testis with teratoma metastatic to the para-aortic lymph node

A primary testicular carcinoid tumor with teratoma metastasized to the para-aortic lymph node. After inguinal orchiectomy, serum and urinary levels of 5-hydroxyindoleacetic acid (5-HIAA) were found to be elevated. Chemotherapy consisting of cisplatin, etoposide and bleomycin was not effective on the metastatic lesions. Retroperitoneal lymphadenectomy normalized the levels of 5-HIAA. The patient is alive without recurrence 25 months after the retroperitoneal lymphadenectomy.

Testicular metastasis 10 years after resection of appendiceal carcinoid

Testicular carcinoids are very rare and account for less than 1% of all testicular neoplasms. They may present as primary testicular tumors or secondary tumors from extratesticular sources. We report a case of a secondary testicular carcinoid occurring 10 years after surgical treatment of an appendiceal carcinoid. The patient underwent radical orchiectomy and at 24 months of follow-up had no evidence of metastases elsewhere. Because secondary carcinoids have a worse clinical course and prognosis than primary tumors, metastatic disease should be excluded before the tumor is identified as a primary. Long-term follow-up is necessary for patients with carcinoid tumor owing to its indolent course and the risk of metastasis several years after treatment of the primary.

Primary carcinoid tumor of the testis: Immunohistochemical, ultrastructural and FISH analysis with review of the literature

Primary carcinoid tumor of the testis only accounts for 0.2% of all carcinoid tumors in Japan. The clinicopathological features, including differences between Japanese and Europe/United States (Eur/US) series', which are known in ovarian carcinoids, have not yet been sufficiently recognized. In the present study, five testicular carcinoids from various clinicopathological viewpoints were analyzed, with a review of the literature. All 15 cases in Japan, including 10 previously reported, were insular carcinoids. Three of the 15 cases (20%) were associated with a teratoma. Serotonin production was confirmed in at least 10 cases (five cases in the present study and five cases in previous studies), but carcinoid syndrome was present in only two cases. Three of the 15 cases (20%) showed distant metastases, and the tumors that metastasized were larger than those that did not. These features were almost similar to those observed in the Eur/US series. Three pure carcinoids were also studied for the number of sex chromosomes by fluorescence in situ hybridization (FISH). They did not show a significant numerical abnormality of the X chromosome, which is common in testicular germ cell tumors. Therefore, the genetic background of pure carcinoids might be different from that of common germ cell tumors.