Small bowel metastases from a testicular choriocarcinoma revealed by gastrointestinal bleeding: a case report
Dassouli1,&, Chama El Manjra1, Adil Ait Errami1, Sofia Oubaha1, Zouhour Samlani1, Khadija Krati1
1Department of Gastroenterology, Mohamed VI University Hospital, Marrakech, Morocco
Cherihane Dassouli, Department of Gastroenterology, Mohamed VI University Hospital, Marrakech, Morocco
Testicular germ cell tumors are the most common cancers in young men. In most cases, patients may present a painless testicular swelling. However, in 10% the presentation is variable and related to site of metastasis and complications. Clinically apparent gastrointestinal involvement was seen in 5% of cases and dominates by gastrointestinal bleeding. We report a case of testicular choriocarcinoma involving the small intestine revealed by melena and complicated by acute intussusception.
Testicular cancers are the most common malignant neoplasm in men
aged 15-35, but only constitute 1% of cancers in males .
Germ cell tumors (GCTs) account for more than 90% of testicular
cancer. Clinically, these tumors are classified as either seminoma
or non-seminoma . In most cases, GCTs present as a painless testicular swelling. However, in
10% of patients, presentation is variable and related to site of
metastasis and complications . These tumors typically metastasize to the retroperitoneal lymph nodes and
less frequently to the lungs, liver and brain , while Gastrointestinal (GI) metastasis is seen in 5% of germ cell tumors and
rare presentation with gastrointestinal bleed have been reported,
with small intestine involvement seen in only 1.4% of cases . We report a case of testicular choriocarcinoma involving the small intestine
revealed by melena and complicated by acute intussusceptions.
Patient and observation
Patient information: a 33-year-old, with no medical history besides 5-pack-year history of tobacco use, has been admitted to our emergency department with melena of 3 weeks duration. He denied hematemesis, abdominal pain, changes in bowel habits or vomiting.
Clinical findings: on physical exam, the
patient was normotensive, afebrile and has normal heart rate. He
had significant pallor. The abdominal exam was benign and the rectal exam
Left testicular swelling was noted, which had become hard on palpation
with negative transillumination test.
Diagnostic assessment: laboratory studies showed anemia with Hb of 8.7g/dL. Esophagogastroduodenoscopy was done urgently and showed a gastritis. No active bleeding was seen. A scrotal ultrasound was performed, revealing a left testis measuring 6x5.2x6 cm with a heterogeneous echo texture and multiple nodular lesions suspicious for neoplasm. The patient's β-human chorionic gonadotrophin level was elevated at 805588IU/mL. Lactate dehydrogenase level was also elevated at 699 U/L, and serum α-fetoprotein level was normal at 2.8 ng/ml. The following day, the patient developed serious abdominal pain with bilious vomiting. An urgent computerized tomography was done and showed a small bowel intussusception due to an umbilicated lesion measuring 4x3cm, with multiple liver, lung and left kidney nodules.
Therapeutic intervention: the patient
underwent left orchiectomy with intestinal resection, removing the umbilicated
lesion and biopsy of the liver nodule. Histologic studies of the left testis,
intestinal and hepatic specimens removed revealed choriocarcinoma.
Follow-up and outcomes: the multidisciplinary team decision was an aggressive chemotherapy, but unfortunately, the patient died few days after.
Testicular cancers, though rare (1%), represent the most common neoplasm
among young men. It is more common in white males than black males .
Dominated by par germ cell tumors that can be seminomas or non-seminomas.
Testicular choriocarcinomas are highly aggressive due to their rapid proliferation,
excessive vascularity and neovascularization leading to usual tumor necrosis
. Most testicular tumors present as a painless mass, but can be painful if bleeding
or infarction occurs. However, they can be discovered through atypical symptoms
related to metastasis and organs involved .
Gastrointestinal metastases were found in 27% of testicular cancer
cases in a postmortem study .
In a necropsy series of 990 patients with testicular tumors, Dixon and Moore
identified 7 cases of pure choriocarcinoma, 5 of which were associated with
metastases to the gastrointestinal tract. However, few of these metastases
were clinically apparent . The gastrointestinal involvement is commonly associated with non- seminomatoustumors
. Metastases to the gastrointestinal tract occur by either direct tumor extension
from affected lymph nodes or hematogenous spread. The sites of GI involvement
include the duodenum, jejunum, ileum, stomach, esophagus, colon and the
pancreas. The duodenum is the most common site of involvement because of
its anatomic proximity to the retroperitoneal nodes, where the lymphatic
drainage of the testis occurs .
But clinically apparent gastrointestinal involvement was seen in < 5%
of cases, and presents as abdominal pain (46%), melena (44%), hematemesis
(24%), vomiting or abdominal mass . Clinical digestive symptoms are mostly related to intestinal obstruction,
pancreatic involvement, or mucosal ulcerations. The symptoms of anemia
secondary to GI blood loss can appear. The blood loss can be occult
or massive. Johnson et al.  found a hemorrhagic complication in 7 of 16 patients with choriocarcinoma.
Of these 7 patients, 4 died of massive GI hemorrhage. Choriocarcinoma
generally has rapid proliferation, excessive vascularit and a tendency
to outgrow its
blood supply. Choriocarcinomas with these characteristics, therefore,
have a tendency to ulceration, necrosis and then bleeding. Necrosis
resulting from chemotherapy is another frequent cause of GI bleeding, which
can be fatal
In patients with testicular cancer, especially those with disseminated choriocarcinoma, gastrointestinal involvementshould be considered if symptoms of gastrointestinal bleeding develop . The patients with gastrointestinal presentation of their germ cell malignancy most often belong to a poor-prognosis group, due to large-volume disease elsewhere, independent of histology. They are today treated with extremely intensive chemotherapy . Platinum-based chemotherapeutic regimens have high success rates in the treatment of metastatic germ cell tumors . But the outcome of the patients with gastrointestinal involvement is quite poor and source of failure after chemotherapy. Therefore, early intervention with surgical resection of the involved segment of bowel is necessary when gastrointestinal complications develop .
Although there have been reports in the literature of germ cell tumors
metastasizing to the gastrointestinal tract, they have generally been in
the setting of known primary testicular cancer or metastatic disease. The
specification of our case is the diagnostic of testicular choriocarcinoma,
which wach until then ignored, a small intestine metastasis revealed by
melena and complicated by acute intussusception.
Testicular germ cell tumors are a malignancy of the young. Young
men presenting with evidence of gastrointestinal bleed with suggestions
of underlying malignancy may not offer information on testicular swelling,
even if present. A review of systems that includes scrotal/testicular swelling
should be conducted and a genital examination done if appropriate. An early
recognition of germ cell malignancy localized in the upper GI tract and
adequate multimodality treatment can have a profound effect on the patient
management. However, these patients belong to a poor prognosis group with
an overall unfavorable outcome, even with today´s
The authors declare no competing interests.
All the authors contributed to the conduct of this work. All the authors have read and agreed to the final manuscript.
We extend our appreciation and gratitude to the medical staff of gastroenterology department for furnishing the data for this research.
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