Severe Complications in Testicular Germ Cell Tumors: The Choriocarcinoma Syndrome

Choriocarcinoma Syndrome: A Rare Complication's Impact on Metastatic Germ Cell Tumor Outcomes

Choriocarcinoma syndrome is a rare form of tumor lysis syndrome that predominantly occurs in patients with metastatic germ cell tumors, particularly those presenting with extensive lung metastases. We report a case of a previously healthy 37-year-old male who presented with a painless left-sided neck lump and nipples with an increased sensitivity to light touch. Workup revealed a significantly elevated beta-human chorionic gonadotropin, a testicular mass, and innumerable pulmonary metastases, suggesting metastatic non-seminomatous germ cell tumor. Following the initiation of chemotherapy with etoposide, ifosfamide, and cisplatin (VIP), the patient experienced a rapid decline in respiratory function, culminating in acute respiratory distress syndrome and subsequent death from respiratory failure six weeks after starting treatment. This case emphasizes the importance of early detection and intervention in managing non-seminomatous germ cell tumors and highlights the critical need for awareness of choriocarcinoma syndrome's risks, the challenges of treatment delays for fertility preservation, and the exploration of alternative therapeutic strategies to improve outcomes in this high-risk patient population.

A poor prognostic male choriocarcinoma with multiple systemic metastases: a case report and the literature review

Background

Non-gestational choriocarcinoma, also known as primary choriocarcinoma, is extremely rare in men, manifesting with specific signs such as breast feminization, testicular atrophy, and loss of libido. The presentation typically includes elevated serum β-hCG levels, widespread metastatic disease, and a rapid progression of the condition.

Case report

We present a rare case of a 41-year-old man diagnosed with choriocarcinoma, exhibiting a unique combination of multiple metastases, including lung, brain, bone, and retroperitoneal lymph node metastases, as confirmed by 18F-FDG PET/CT imaging. The patient was treated with aggressive chemotherapy and pembrolizumab, and the prognosis remained poor. The patient's overall survival was a mere 5 months following diagnosis.

Conclusion

Non-gestational choriocarcinoma represents a rare entity in clinical practice and should be considered in young men presenting with gynaecomastia and elevated β-hCG levels alongside normal gonads. Thus, we advocate for a more comprehensive inquiry into medical history and a systematic examination. The 18F-FDG PET/CT examination not only visually delineates the lesion's location and extent but also serves as a cornerstone for clinical tumor staging, providing valuable support for treatment monitoring and subsequent follow-up.

Pure testicular choriocarcinoma, a rare and highly malignant subtype with challenging treatment: A case report and review of the literature

Testicular choriocarcinoma (CC) is the rarest subtype of germ cell tumours (GCTs) of the testis, with a high malignant potential and early haematogenous metastasis. Radical surgical resection should be performed primarily for histological diagnosis, while chemotherapy remains the mainstay of therapy for advanced disease. In the present study, the case of a 65-year-old male patient diagnosed with metastatic testicular CC, who did not fully respond to chemotherapy is reported. This patient underwent surgical removal of the testicular tumour, chemotherapy with etoposide and cisplatin, and radiotherapy of the intracranial lesions. Although the serum human chorionic gonadotropin (HCG) levels of the patient and most of the metastases continued decreasing during chemotherapy, complete response was not achieved after six cycles of chemotherapy. The patient refused high-dose chemotherapy and autologous stem cell transplantation due to severe side effects, and eventually developed respiratory failure on maintenance therapy with oral etoposide. A literature review was then performed, aiming to summarize the characteristics and therapeutic principles of testicular CC. In addition, the emerging therapeutic agents that could be used in maintenance therapy for GCTs, particularly for testicular CC, were also discussed. The limited clinical trials of targeted treatments showed potential benefit for long survival of patients with selected GCTs with fewer side effects. In particular, immunotherapy showed unique potential for testicular CC in preclinical studies, offering new approaches of maintenance therapy for advanced disease. Further studies should shed light on the identification of prognostic factors that predict the response to immune-based therapy in GCTs.

A decade in focus: mixed germ cell tumors with choriocarcinoma components

Introduction

This 10-year registry review aimed to investigate the clinical behaviour and outcomes of mixed germ cell tumours with choriocarcinoma components, a rare and aggressive subtype of testicular cancer, in Saudi Arabia. The study explores the demographic characteristics of affected patients, tumour profiles, and the mortality rate associated with this malignancy.

Methods

Utilizing data from the Saudi Cancer Registry, the authors identified 33 cases of mixed germ cell tumours with choriocarcinoma components among 1001 testicular cancer cases recorded between 2008 and 2017. Demographic information, including age, marital status, region of residency, year of diagnosis, and 10-year survival status, were collected. Tumour factors, such as the basis of diagnosis, origin site, behaviour, grade, extension, and laterality, were also analyzed.

Results

The majority of cases (78.8%) occurred in the young age group (18-45 years), and most tumours (97%) originated in normally descended testes. Grade IV (undifferentiated anaplastic) tumours and distant metastasis were present in 45.5% of patients. All cases exhibited malignant tumour behaviour. The overall mortality rate was 15%, with a mean time from diagnosis to death of 7.72 months (range: 0.5-21.5 months).

Conclusion

Mixed germ cell tumours with choriocarcinoma components are rare and tend to affect younger populations. These tumours demonstrate aggressive clinical behaviour, with a significant proportion presenting with high-grade lesions and metastasis at diagnosis. The observed mortality rate underscores the poor prognosis associated with this malignancy. Our study provides essential insights into the clinical characteristics of this rare tumour subtype in the Saudi Arabian population, emphasizing the need for further research to identify prognostic factors and optimize management strategies for affected patients.

A remarkable response to combination chemotherapy with nivolumab and ipilimumab in a patient with primary pulmonary choriocarcinoma: a case report

Background

Primary pulmonary choriocarcinoma (PPC) is a rare malignancy, and only 41 PPC cases have been reported in males up to 2021. Due to its rarity, no standardized treatments for PPC have been established. Cytotoxic chemotherapy has limited efficacy, and the prognosis of advanced PPC is notably poor. Immune checkpoint inhibitors (ICIs) are expected to provide long-term survival for PPC patients, but only a few cases have been reported. The optimal treatment for PPC has not been determined.

Case Description

Here, we report a 72-year-old male with post-surgery relapsed PPC, presenting with multiple pulmonary nodules and an intracardiac mass. The OncomineTM Dx target test showed no mutation of cancer-relevant genes, and programmed death-ligand 1 (PD-L1) expression was negative (0%) in the 22C3 assay. He received a combination of carboplatin, paclitaxel, nivolumab, and ipilimumab which is widely used as a first-line treatment for advanced non-small-cell lung cancer (NSCLC). Two months after treatment began, computed tomography (CT) showed multiple lung nodules and an intracardiac mass reduction, which has been sustained for 12 months. Grade 3 febrile neutropenia and grade 2 rash were observed, however, these adverse events were manageable.

Conclusions

This is the first case of postoperative relapse PPC that has been successfully treated with the combination of chemotherapy, nivolumab, and ipilimumab. This therapy may be a promising option for advanced PPC.

Medical Literature Writing With ChatGPT: A Rare Case of Choriocarcinoma Syndrome With Hemorrhagic Brain Metastases Due to Burned Out Metastatic Mixed Testicular Cancer

Testicular tumors are one of the most commonly observed malignancies among men. An aggressive and rare subtype of the disease, testicular choriocarcinoma, has a worse prognosis due to the tendency of early hematogenous spread to multiple organs and advanced symptoms at presentation time. Characteristic features of choriocarcinoma include elevated beta human chorionic gonadotropin (β-hCG) in a young male with testicular mass. However, when the primary testicular tumor overutilizes its blood supply and spontaneously regresses, it is presumed to have been "burnt out" with remnants evident by metastatic retroperitoneal lymphadenopathy, scarred tissue, and calcifications. Treatment of advanced testicular cancer may be complicated by a rare entity known as choriocarcinoma syndrome, distinguished by rapid and fatal hemorrhaging of metastatic tumor sites. Prior described cases of choriocarcinoma syndrome involve pulmonary and gastrointestinal hemorrhages. We present an uncommon case of a 34-year-old male with a "burnt out" metastatic mixed testicular cancer who presented with choriocarcinoma syndrome (CS) treated with chemotherapy but developed deadly hemorrhaging of brain metastases. In addition, with the assistance of ChatGPT, we report our experience with this OpenAI tool and its potential uses in medical literature writing.

Successful surgical management of massive hemoretroperitoneum caused by spontaneous rupture of retroperitoneal lymph node metastases in a patient with advanced mixed germ cell tumor: a COVID-19 pandemic-related surgical challenge

BACKGROUND

Spontaneous rapture of a germ cell tumor (GCT) metastases causing massive hemoretroperitoneum in a patient without choriocarcinoma component who has not received previous systemic chemotherapy is an exceedingly rare event. In such a devastating case scenario, a high index of clinical suspicion for early diagnosis and appropriate management is crucial.

CASE PRESENTATION

We report on a 25-year-old male patient with a 4-month history of orchiectomy for testicular GCT (tGCT), who presented in the emergency department with acute abdomen and hemodynamic instability. Urgent computed tomography scan depicted a retroperitoneal mass measuring approximately 13 × 11.4 × 15 cm and massive intraperitoneal hemorrhage. Hemoperitoneum caused by spontaneous rapture of the metastatic retroperitoneal mass was suspected. COVID-19 pandemic-related deviation from the oncologic surveillance standards combined with COVID-19-related patient's emotional distress and self-neglect had led to loss of opportunity for appropriate adjuvant chemotherapy, obviously leading to the development of this devastating complication. An emergency, surgical exploration was decided. The bleeding mass was adequately exposed following a Cattell-Braasch maneuver and active bleeding was controlled by a challenging resection of approximately 80% of the lymph node mass volume. Pathological evaluation of the specimen revealed teratoma with low volume of yolk sac tumor component and extensive necrosis, findings compatible with the patient's history. Postoperative recovery was uneventful, followed by early start of adjuvant chemotherapy. Two years after the operation the patient is doing well with no evidence of recurrent disease.

CONCLUSIONS

Massive hemoperitoneum is a devastating event that exceedingly rarely can complicate the clinical course of patients with advanced tGCT. Emergency surgical intervention is usually necessary however, sound judgement and careful surgical techniques are required for a positive and uneventful outcome. During COVID-19 pandemic, first-line medical personnel push their limits further not only to ensure health care services standards but also, to manage unpredictable, life-threatening cancer-related complications, associated with COVID-19-related deviation from appropriate oncologic surveillance and care.

Inflammatory Biomarkers for Outcome Prediction in Patients With Metastatic Testicular Cancer

Germ cell tumors are the most common malignant tumors in male young adults. Platinum-based chemotherapy has dramatically improved the outcome of metastatic germ cell tumor patients and overall cure rates now exceed 80%. The choice of medical treatment can be guided by the prognosis estimation which is an important step during the decision-making process. IGCCCG classification plays a pivotal role in the management of advanced disease. However, histological and clinical parameters are the available factors that condition the prognosis, but they do not reflect the tumor's molecular and pathological features and do not predict who will respond to chemotherapy. After first-line chemotherapy 20%-30% of patients relapse and for these patients, the issue of prognostic factors is far more complex. Validated biomarkers and a molecular selection of patients that reflect the pathogenesis are highly needed. The association between cancer-related systemic inflammation, tumorigenesis, and cancer progression has been demonstrated. In the last years, several studies have shown the prognostic utility of immune-inflammation indexes in different tumor types. This review analyzed the prognostic impact of inflammatory markers retrieved from routine blood draws in GCT patients.

Factors Associated With Choriocarcinoma Syndrome Development in Poor-Risk Patients With Germ Cell Tumors

Background

Germ cell tumors (GCTs) represent a highly curable cancer. However, a small proportion of poor-risk patients can develop choriocarcinoma syndrome (CS) connected with acute respiratory distress syndrome (ARDS) with a high mortality rate. Our retrospective study aimed to determine the risk factors of poor-risk GCTs susceptible to CS development.

Patients and Methods

Using a computerized database and a systematic chart review, we identified the records of 532 patients with GCTs treated at the National Cancer Institute from 2000 to 2018. Ninety eligible patients with poor-risk GCTs based on IGCCCG classification were identified. All patients were treated with platinum-based induction chemotherapy. Clinicopathological variables were collected and analyzed in correlation with CS development.

Results

Nine (10%) of 90 patients developed CS in a median of 1 day (1–9 days) after chemotherapy administration. All patients died shortly after the chemotherapy start with a median of 4 days (3–35 days) due to ARDS development. In univariate analysis, metastatic lung involvement ≥50% of lung parenchyma, choriocarcinoma elements in histology specimen, dyspnea, cough, hemoptysis, ECOG PS ≥2, weight loss, hemoglobin ≤100 g/l, and NLR ≥3.3 at the time of presentation were associated with CS development. In multivariate analysis, ECOG PS ≥2 and metastatic lung involvement ≥50% were independently associated with CS. All patients with these two characteristics developed CS, compared to 0% with zero or one of these factors (p < 0.000001).

Conclusions

In our study, we identified factors associated with CS development. These factors might improve the risk stratification of the patients susceptible to CS and improve their outcome.

Pretreatment of choriocarcinoma syndrome: a rare complication of metastatic germ cell tumours

A 27-year-old man newly diagnosed with metastatic testicular choriocarcinoma developed a large right perinephric haematoma secondary to a metastatic deposit in his right kidney. His presentation was also complicated by bilateral iliac venous thrombosis and pulmonary embolism identified prior to initiation of chemotherapy. He underwent multiple attempts at angioembolisation of the bleeding vessels and ultimately angioembolisation of the main renal artery had to be performed to control the bleeding. Following resolution and commencement of chemotherapy, the patient also developed spontaneous intracranial haemorrhage requiring craniotomy.

Therapeutical interference with the epigenetic landscape of germ cell tumors: a comparative drug study and new mechanistical insights

Background

Type II germ cell tumors (GCT) are the most common solid cancers in males of age 15 to 35 years. Treatment of these tumors includes cisplatin-based therapy achieving high cure rates, but also leading to late toxicities. As mainly young men are suffering from GCTs, late toxicities play a major role regarding life expectancy, and the development of therapy resistance emphasizes the need for alternative therapeutic options. GCTs are highly susceptible to interference with the epigenetic landscape; therefore, this study focuses on screening of drugs against epigenetic factors as a treatment option for GCTs.

Results

We present seven different epigenetic inhibitors efficiently decreasing cell viability in GCT cell lines including cisplatin-resistant subclones at low concentrations by targeting epigenetic modifiers and interactors, like histone deacetylases (Quisinostat), histone demethylases (JIB-04), histone methyltransferases (Chaetocin), epigenetic readers (MZ-1, LP99) and polycomb-repressive complexes (PRT4165, GSK343). Mass spectrometry-based analyses of the histone modification landscape revealed effects beyond the expected mode-of-action of each drug, suggesting a wider spectrum of activity than initially assumed. Moreover, we characterized the effects of each drug on the transcriptome of GCT cells by RNA sequencing and found common deregulations in gene expression of ion transporters and DNA-binding factors. A kinase array revealed deregulations of signaling pathways, like cAMP, JAK-STAT and WNT.

Conclusion

Our study identified seven drugs against epigenetic modifiers to treat cisplatin-resistant GCTs. Further, we extensively analyzed off-target effects and modes-of-action, which are important for risk assessment of the individual drugs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13148-021-01223-1.

Case report: Challenges, treatment, prognosis and outcome of a patient with partially treated seminomatous testicular carcinoma

Background

Testicular carcinoma is a rare malignancy in men. It is ranked the 18th most common male cancer in Malaysia with seminoma representing 40% of the primary testicular neoplasms. Early detection of the tumour and the immediate initiation of treatment and disease management provide high possibilities of positive outcomes for patients.

Case presentation

A 36-year-old male was initially diagnosed with a left cryptorchidism and metastatic testicular seminoma. However, due to socioeconomic circumstances and the Coronavirus-19 (COVID-19) pandemic, he defaulted on his chemoradiotherapy follow-up treatments. He returned to us four years later with a progressively enlarging testicular mass with normal tumour marker values and subsequently underwent a successful radical left orchidectomy. Histopathological examination revealed features of regressed germ cell tumour (GCT). He successfully underwent chemoradiotherapy treatment and surveillance follow-ups did not show tumor recurrences.

Discussion

Seminoma is the commonest type of testicular carcinoma with good prognosis among young patients. In huge masses, as seen in our patient, early chemoradiotherapy with the intention to reduce tumor bulk and invasiveness after which will be followed by radical orchidectomy. Residual mass post chemotherapy for patients with seminomas should be properly assessed for viability of tumor cells within it.

Conclusion

Undescended testis and cryptorchidism present key risk factors for developing testicular carcinomas which are uncommon among men. Early detection, surgery and chemoradiotherapy on seminomas would usually lead to positive outcomes. The remarkable chemosensitivity of a seminomatous type tumour towards a platinum-based regiment in combination with radical resection entails good prognosis and effective local disease control.

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Testicular carcinoma is an extremely rare malignancy among men which affects the young age groups.

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Ectopic testis should be surgically corrected prior to puberty to hinder germ cell insult.

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Extensive metastatic disease requires urgent chemotherapy initiation followed by orchidectomy later.

Paclitaxel, Ifosfamide, and Cisplatin in Patients with Poor-prognosis Disseminated Nonseminomatous Germ Cell Tumors with Unfavorable Serum Tumor Marker Decline After First Cycle of Chemotherapy. The GCT-SK-003 Phase II Trial

Background

Germ cell tumors represent highly curable disease even in metastatic stage. However, poor-risk patients with an unfavorable serum tumor marker (STM) decline after the first cycle of chemotherapy represent a subgroup with dismal prognosis, with approximately 50% cure rate using bleomycin, etoposide, and cisplatin (BEP).

Objective

The aim of this study was to determine the efficacy and safety of paclitaxel, ifosfamide, and cisplatin (TIP) in this patient population.

Design, setting, and participants

This was an open-labeled, nonrandomized, single-center phase II trial to study the efficacy and toxicity of TIP in the first-line treatment of germ cell tumor patients with an unfavorable decline of STMs. Nineteen patients with a poor prognosis according to the International Germ Cell Cancer Collaboration Group classification and an unfavorable STM decline after the first cycle of chemotherapy were included in this phase II study (NCT02414685). The treatment regimen consisted of paclitaxel 250 mg/m² on day 1, ifosfamide 1200 mg/m² on days 1–5, and cisplatin 20 mg/m² on days 1–5, totally for four cycles.

Outcome measurements and statistical analysis

The primary endpoint was complete response (CR) rate. An optimal Simon two-stage design was used with a type I error of 5% and study power of 80%. If fewer than six CRs to study therapy have been observed among the first 19 patients, the study was to be terminated.

Results and limitations

A CR was achieved in four (21.1%) patients; therefore, the study was terminated in the first stage. A favorable response rate (CR or partial remission with negative tumor markers) was observed in 14 (78.9%) patients. At a median follow-up period of 35.2 mo (range, 5.6–62.1 mo), ten (52.6%) patients experienced disease progression and eight patients (42.1%) died. The 2-yr progression-free and overall survival was 41.2% (95% confidence interval [CI] 16.8–65.7) and 72.7% (95% CI 48.9–96.4), respectively. TIP was well tolerated, and no unexpected toxicity was observed. No informative biomarkers, including miR-371a-3p was identified.

Conclusions

Treatment modification from the BEP to the TIP regimen in patients with an unfavorable STM decline after the first cycle of chemotherapy was not associated with improved outcome, and four cycles of BEP remain the standard treatment option in this patient population.

Patient summary

Poor-risk patients with an unfavorable serum tumor marker decline after the first cycle of chemotherapy represent a subgroup with dismal prognosis, with an approximately 50% cure rate using bleomycin, etoposide, and cisplatin (BEP). Treatment modification from the BEP regimen to the paclitaxel, ifosfamide, and cisplatin regimen in patients with an unfavorable serum tumor marker decline after the first cycle of chemotherapy was not associated with improved outcome, and four cycles of BEP remain the standard treatment option in this patient population.

Metastatic choriocarcinoma with hemorrhagic complications and spontaneous ovarian hyperstimulation syndrome: A case report

Gestational choriocarcinoma is a malignant trophoblastic tumor arising from any gestational event, even with a long latency period, generally in the reproductive female. It is associated with a high level of beta-human chorionic gonadotropin. Its primary site is usually the uterus but not all patients have a detectable lesion in this site. Regression of the primary tumor after it has metastasized is not uncommon, and one-third of cases manifest as complications of metastatic disease. In this report we present an uncommon case of gestational choriocarcinoma with lung, liver and jejunal metastases at the time of diagnosis without evidence of pelvic disease, in 34-year-old woman. The main points of interest of our case were the development of the ovarian hyperstimulation syndrome with massive multicystic ovarian enlargement induced by high level of beta-human chorionic gonadotropin and the bleeding of jejunal and liver metastases, due to the high vascularity of the tumor tissue, a condition known as "Choriocarcinoma Syndrome". We will focus on the radiological findings of metastases, bleeding complications and ovarian hyperstimulation syndrome.

Prophylaxis Against Thromboembolic Events During Chemotherapy for Germ Cell Cancer

INTRODUCTION

Patients with advanced germ cell tumors (GCT) receiving cisplatin-based chemotherapy have high rates of thromboembolic events (TEE) which can negatively affect their overall survival. While primary TEE prophylaxis during chemotherapy may prevent these events, it is unclear which patients will benefit in this setting.

MATERIALS AND METHODS

A review of PubMed/Medline was conducted in December 2020 and all pertinent articles were evaluated for relevancy and quality of data for inclusion in the review.

RESULTS

Studies on patients receiving initial cisplatin-based chemotherapy for advanced GCT have reported up to a 19% rate of TEE. This high rate may be associated with multiple factors including retroperitoneal lymphadenopathy, advanced clinical stage, high risk Khorana scores and presence of a central line. Large phase III clinical trials have demonstrated the benefit of low-molecular-weight-heparin and direct oral anticoagulants for primary prophylaxis and against recurrent TEE. However, primary prophylaxis is currently underutilized with GCT patients starting chemotherapy.

CONCLUSION

Precise models to predict TEE risk and consideration of anticoagulation are difficult to develop owing to the relatively uncommon nature of GCT and lack of representation in primary TEE prophylaxis clinical trials. Despite these limitations, we believe that the benefits of prophylactic anticoagulation outweigh the risk of major bleeding in select GCT patients with higher risk of TEE. We have developed a simple algorithm to help guide TEE prophylaxis selection based on patient factors and route of chemotherapy administration. Given the high rate of TEE in GCT patients, we believe better utilization of primary prophylaxis in patient starting cisplatin-based chemotherapy will have clinical benefit.

Clinical Experience of Male Primary Choriocarcinoma at the Samsung Medical Center

PURPOSE

The objective of this study was to describe and analyze the clinicopathological features of primary choriocarcinoma (PCC) observed in male patients treated at the Samsung Medical Center between 1996 and 2020.

MATERIALS AND METHODS

We reviewed the clinical records of 14 male patients with PCC retrospectively to assess their demographic, histological, and clinical characteristics at the time of diagnosis as well as identify the treatment outcomes.

RESULTS

The median age of the patients was 33 years. The primary tumor site was the testicles in seven cases (50%), the mediastinum in six cases (43%), and the brain in one case (7%). The most common metastatic site was the lungs (79%), followed by the brain (43%). All patients with PCC received cytotoxic chemotherapy. Twelve patients had records of their response to cytotoxic chemotherapy; of these 12 patients, eight (8/12, 67%) achieved an objective response, and four (4/12, 33%) achieved stable disease response as the best response during chemotherapy.

CONCLUSION

It is known that most male PCC patients eventually develop resistance to cytotoxic chemotherapy and die. Factors such as poor response to chemotherapy, high disease burden, brain metastasis, and hemoptysis at the time of diagnosis are associated with shorter survival time in male PCC patients. Programmed death-1/programmed death-ligand 1 blockade therapy can be a salvage treatment for chemotherapy-resistant male PCC patients.

An Exceptionally Rare Cause of Refractory Gastrointestinal Bleed: Choriocarcinoma Syndrome

Testicular choriocarcinomas comprise less than 1% of all testicular tumors and are often highly vascular with early hematogenous metastasis. Choriocarcinoma syndrome (CS) is a rare entity distinguished by diffuse tumor burden and often fatal bleeding from metastatic sites. Most reported cases describe pulmonary hemorrhage secondary to initiation of chemotherapy. We present a fatal case of a young, previously healthy male with overwhelming gastrointestinal bleeding as the presenting sign of CS. Our case demonstrates that CS should be considered in the differential diagnosis for refractory anemia due to gastrointestinal hemorrhage in a young male with a testicular mass.

Testicular Germ Cell Tumors: Paraneoplastic Syndromes and the Role of Beta-Human Chorionic Gonadotropin

Choriocarcinoma syndrome is a rare phenomenon that occurs in male patients with testicular choriocarcinoma. Male patients who have a testicular non-seminomatous germ cell tumor (TNSGCT) with at least partial choriocarcinoma histology, and metastases to the lungs and/or other extragonadal sites, as well as a markedly elevated beta-human chorionic gonadotropin (HCG), have been prone to pulmonary bleeding, hypoxia, and acute respiratory distress syndrome (ARDS). The respiratory complications occur immediately after chemotherapy is administered or, in some cases, spontaneously. Paraneoplastic hyperthyroidism is another entity described in patients with testicular choriocarcinoma, whereby high levels of HCG (typically >50,000 mIU/ml) induce clinical and laboratory characteristics of hyperthyroidism. We present the case of a male patient diagnosed with TNSGCT and found to have both choriocarcinoma syndrome and paraneoplastic hyperthyroidism in the setting of only mildly elevated HCG levels. We compare our case with similar cases published previously while questioning the quantitative role of HCG.

Pure testicular choriocarcinoma Cannonball metastases as a presenting imaging feature: A case report and a review of literature

Pure testicular choriocarcinoma is an extremely rare subtype of nonseminomatous germ cell tumor, accounting for less than 1% of all germ cell tumors and only 0.19% of all testicular tumors. It is a highly aggressive malignant tumor with early multiorgan metastasis and poor prognosis. We present a case of 23-year-old male presented to the hospital with mild hemoptysis which was thought as a sequela of his past COVID-19 pneumonia infection, however; chest radiograph showed multiple rounded cannonball opacities seen throughout both lungs raising the suspicion of metastatic deposits to the lungs. During physical examination, left testicular painless swelling was noted leading to an ultrasound of the scrotum which revealed a left intratesticular infiltrative, heterogeneous mass. Tumor markers, including beta-human chorionic gonadotropin, lactate dehydrogenase and alpha fetoprotein were extremely high. Computed tomography scan of the brain, chest, abdomen, and pelvis showed hemorrhagic metastatic deposits to the brain, chest, and left para-aortic lymph nodes. The patient underwent radical orchiectomy and histopathology reports confirmed the diagnosis of pure testicular choriocarcinoma.

Intricacies of Radiographic Assessment in Testicular Germ Cell Tumors

Testicular germ cell tumors (GCTs) are malignancies with a unique biology, pathology, clinical appearance, and excellent outcomes. A correct radiographic assessment of GCTs is extremely important for the clinical management in several typical scenarios. Advancements in the field of diagnostic medicine bring an increasing number of sophisticated imaging methods to increase the performance of imaging studies. The conventional computed tomography (CT) remains the mainstay of diagnostic imaging in the management of GCTs. While certain improvements in the sensitivity and specificity are suggested with magnetic resonance (MR) imaging with lymphotrophic nanoparticles in evaluating retroperitoneal lymph nodes during the staging procedure, further exploration in larger prospective studies is needed. A common diagnostic dilemma is assessing the post-chemotherapy residual disease in GCTs. Several studies have consistently shown advantages in the utility of positron emission tomography (PET) scanning in post-chemotherapy residual retroperitoneal lymph nodes in patients with seminoma, but not with non-seminoma. Recommendations suggest that seminoma patients with a residual disease in the retroperitoneum larger than 3 cm should be subjected for PET scanning with 18-fluorodeoxyglucose. Relatively high sensitivity, specificity and a negative predictive value (80-95%) may guide clinical decision to spare these patients of high morbidity of an unnecessary surgery. However, a positive predictive value of around 50% renders PET scanning difficult to interpret in the case of positive finding. These patients often require extremely difficult surgical procedures with the high risk of post-operative morbidity. Therefore, seminoma patients with PET positive residual masses larger than 3 cm still remain a serious challenge in the decision making of nuclear medicine specialist, oncologists, and urologic surgeons. In this article, we aim to summarize data on controversial dilemmas in staging procedures, active surveillance, and post-chemotherapy assessment of GCTs based on the available published literature.

Hemorrhage During Induction Chemotherapy in Neuroblastoma: Additional Risk Factors in High-Risk Patients

Background: Neuroblastoma is the most common solid extracranial tumor in children. Patients affected by neuroblastoma are stratified into low, intermediate, and high risk in terms of event-free and overall survival. Some high-risk patients have an additional risk of acute hemorrhagic complications during induction chemotherapy. Aim: To find easily and rapidly assessed parameters that help clinicians identify those patients affected by high-risk neuroblastoma who have an additional risk of hemorrhagic complications. Methods: The clinical notes of patients diagnosed with high-risk neuroblastoma from January 2013 until February 2021 were retrospectively reviewed. Clinical, demographic and laboratory data, biological characteristics of the tumor, and information about treatment and hospital stay were identified. Results: In the examined period, 44 patients were diagnosed with high-risk neuroblastoma. Four of these patients had hemorrhagic complications within 2-7 days after the initiation of induction chemotherapy; two patients had hemothorax, one patient had hemoperitoneum and one patient had hemothorax and hemoperitoneum. The patient with isolated hemoperitoneum was treated with blood components transfusions, clotting factors and colloids infusions; the three patients with hemothorax underwent thoracostomy tube placement and respiratory support. At initial presentation, patients who suffered from hemorrhagic complications had a higher degree of hypertension (stage 2, p = 0.0003), higher levels of LDH (median 3,745 U/L, p = 0.009) and lower levels of hemoglobin (mean 7.6 gr/dl, p = 0.0007) compared to other high-risk patients. Conclusions: A subgroup of "additional" high-risk patients can be identified within the high-risk neuroblastoma patients based on mean arterial pressure, LDH levels and hemoglobin levels at presentation. Further studies to define cut-off values and optimal management strategies for these patients are needed.

Burned-Out Testicular Tumors in Adolescents: Clinical Aspects and Outcome

Purpose: Testicular germ cell tumors are the fourth most common neoplasm in adolescents, accounting for 8% of all tumors in the age group 15-19 years. On rare instances, the primary testicular lesion is not clinically or radiologically evident while nodal or visceral metastases represent the clinical manifestations of the disease. This phenomenon is described as "burned-out testicular tumor." In this paper, the authors report a single-institution experience with burned-out testicular tumors in adolescents and discuss their clinical implications. Patients and Methods: All the patients diagnosed with metastatic testicular germ cell tumors at Bambino Gesù Children Hospital between January 1, 2010, and June 30, 2020, were included in the study. Patients were categorized into two groups: "primary testicular" and "burned out." All the patients were staged and treated according to the AIEOP-TCGM 2004 protocol. Results: Eleven patients were classified as "primary testicular," and five patients were classified as "burned out." "Burned-out" tumors were associated with the presence of systemic symptoms compared to "primary testicular" tumors (80 vs. 0%; p = 0.0027) and higher aFP, hCG, and LDH levels (p < 0.00001). The "burned-out" population had a statistically significant higher incidence of relevant toxicity than the "primary testicular" population (80 vs. 18%; p = 0.0357) and a worse outcome in terms of both mean overall survival (15 vs. 43 months; p = 0.0299) and mean event-free survival (12 vs. 38 months; p = 0.0164). Conclusion: "Burned-out" testicular tumors seem to be a well-distinct clinical entity with a high treatment-related toxicity and poor prognosis. Further studies are needed to clarify the "burned-out phenomenon" and to identify more effective therapeutic strategies for these patients.

Extragonadal Non-gestational Choriocarcinoma with Tonsillar Presentation

Extragonadal non-gestational choriocarcinoma is a rare but well-described phenomenon occurring in patients with midline germ cell tumors. Choriocarcinoma (ChC) is an aggressive neoplasm usually developing in women as a rare complication of pregnancy. In male patients ChC occurs in the testes, usually as a component of mixed germ cell tumors. Very few patients develop extragonadal choriocarcinoma with the tumor occurring in midline locations, such as the mediastinum, retroperitoneum, and central nervous system (mostly pineal gland). Non-midline choriocarcinoma can occur in the lung, gastrointestinal tract, and breast, sometimes blended with another primary malignancy. A midline choriocarcinoma manifesting as a head and neck malignancy is exceptional. During an evaluation of multiple enlarged cervical lymph nodes suspected to be lymphoma in a 72-year-old man, a core biopsy was taken from one of the left neck lymph nodes which histologically showed a necrotic malignancy with strong diffuse pancytokeratin staining. After an initial interpretation of metastatic carcinoma, further samples were taken from both tonsils and from a right level 5 neck lymph node. Histologically, all samples contained the same tumor, showing profound pleomorphism and multinucleated syncytial-type giant cells. A panel of immunohistochemistry studies were performed, including β-human chorionic gonadotropin, with positive findings leading to a diagnosis of extragonadal non-gestational choriocarcinoma.

Circulating microRNAs as biomarkers to assist the management of the malignant germ-cell-tumour subtype choriocarcinoma

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Current biomarkers have limited utility for management of germ-cell-tumours.

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Limitations include secretion restricted to specific subtypes and long half-life.

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Limitations can make interpretation and clinical decision-making challenging.

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Circulating microRNAs show promise for management of these tumours.

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We identify specific circulating microRNAs for the choriocarcinoma subtype.

Germ-cell-tumours (GCTs) are heterogeneous and management is complex. The current conventional biomarkers, alpha-fetoprotein and human-chorionic-gonadotropin (HCG), have limited utility for diagnosis/follow-up as secretion is restricted to specific malignant-GCT subtypes and long half-life can make interpretation and clinical decision-making challenging. We sought to identify circulating microRNAs that reflected choriocarcinoma disease activity more accurately than HCG in a metastatic primary mediastinal nonseminomatous-GCT (PMNSGCT) case with elevated diagnostic serum HCG (>250,000 U/L), consistent with pure choriocarcinoma. We undertook comprehensive microRNA profiling (n = 754 microRNAs) using two 384-well TaqMan Low-Density-Array cards in 16 serum samples; 10 from PMNSGCT diagnosis/follow-up and six controls. Key findings underwent confirmatory qRT-PCR. We identified a serum panel of choriocarcinoma-specific ‘chromosome-19-microRNA-cluster’ (C19MC) microRNAs that were highly elevated at diagnosis but fell rapidly on treatment and normalised before the second full chemotherapy course. We also re-confirmed serum elevation of the previously identified malignant-GCT marker miR-371a-3p at diagnosis. These circulating microRNA markers reflected choriocarcinoma disease activity more accurately than serum HCG and real-time knowledge would have assisted clinical decision-making. With further study, these microRNA markers will facilitate future management of such patients and are likely to result in improved outcomes.

Extracorporeal Membrane Oxygenation Support as a Bridge to Recovery during Chemotherapy in a Young Patient with Metastatic Choriocarcinoma and Severe Acute Respiratory Distress Syndrome

INTRODUCTION

A young woman presented at a local hospital with severe dyspnea directly after childbirth. She was di-agnosed with choriocarcinoma and massive pulmonary metastases. Shortly after administration of polychemotherapy she developed severe acute respiratory distress syndrome (ARDS).

CASE PRESENTATION

The patient was transferred to the intensive care unit (ICU) and extracorporeal membrane oxygenation (ECMO) center of the university hospital. Venovenous ECMO support was implemented for 28 days while enabling continuous chemotherapy. After 49 days in the ICU, she was transferred to the oncology ward in a stable respiratory state.

DISCUSSION/CONCLUSION

Although the survival rates of ARDS in the general ICU population have improved lately due to improved management of ARDS and ECMO support, the data on adult cancer patients receiving ECMO support are very limited. Only few small retrospective studies on ECMO support in adult cancer patients have been conducted. Unfortunately the survival rates of patients after allogenic hematopoietic stem cell transplantation and ECMO support were discouraging. Nevertheless, cancer patients with at least stable disease who are eligible for full-code ICU management may be potential candidates for ECMO in case of severe ARDS. Our case report not only shows that patients suffering from choriocarcinoma with pulmonary metastases may develop severe ARDS in the context of polychemotherapy, but also demonstrates that ECMO support enables chemotherapy continuation and complete remission of the underlying choriocarcinoma.