A rare cause of GI bleeding

Clinical History

A 28-year-old male presented to the ER with complaints of active melenas, abdominal pain and weight loss. Physical examination revealed abdominal tenderness and a pulsatile periumbilical mass. Laboratory work-up showed decresead haemoglobin (7,5 g/dL).Imagiologic studies namely chest CT, CT of the abdomen and pelvis and others were performed.

Imaging Findings

A 28-year-old male consulted an emengency room with complaints of active upper GI bleeding and melenas , abdominal pain, malaise, and weight loss. Physical examination revealed paleness, abdominal tenderness and a pulsatile periumbilical mass. Laboratory work-up in the ER showed decresead haemoglobin (7,5 g/dL), shligt leucocitosys and positive CRP. Chest X-ray was normal. Computed tomography was performed and demonstrated an heterogeneous mass and some lymphadenopathies along the inter-aorto-cava region, encasing an intestinal segment (Pictures 1-4) During hospital stay serum betahCG, alfa-phetoprotein and LDH levels were determined and found to be elevated (35 U/L, 50 ng/ml and 728 U/l respectively). Testicular ultrasonography was then performed and a 15 mm left testicular hypoecohoic nodule was detected. Left inguinal orchiectomy was performed. The patient received 2 courses of chemotherapy with cisplatin, etoposide and bleomycin. After this therapy, the retroperitoneal mass in the aortic region significantly decrease in size and melenas completely resolved. Although clinical complete remission was achieved and serum LDH level was normalized, the serum hCGbeta level remained low level positive.

Discussion

Testicular cancer is an abnormal, rapid, and invasive growth of cancerous (malignant) cells in the testicles (male sex glands adjacent to the penis). Although the exact cause of testicular cancer is unknown, several factors seem to increase risk. These include a past medical history of undescended testicle(s), abnormal testicular development, Klinefelter's syndrome (a sex chromosome disorder that may be characterized by low levels of male hormones, sterility, development of breasts, and small testes), or previous testicular cancer. They include exposure to certain chemicals and infection with the human immunodeficiency virus (HIV). A family history of testicular cancer may increase risk. Between 6,000 and 8,000 men will be diagnosed with testicular cancers each year. Although testicular cancer accounts for 1% of all cancers in men, it is the most common form of cancer in young men 15 to 40 years old. It may also occur in young boys, but only about 3% of all testicular cancer is found in this group. White American men have about five times the risk of African-American men and more than twice the risk of Asian-American men. The risk for testicular cancer has doubled among white Americans in the past 40 years but has remained the same for African-Americans. The reasons for these differences are not known. Testicular cancers may be classified as follows: Seminomas account for about 30-40% of all testicular tumors. These are usually is found in men in their 30s and 40s. The condition is usually localized to the testes, although in about 25% of cases it has spread to lymph nodes. Non-seminomas account for 60% of all testicular tumors; subcategories of these tumors are listed below. Non-seminoma tumors often contain more than one of the following cell types: Embryonal carcinoma (about 20% of testicular cancers) occurs in 20-30 year olds and is highly malignant. It grows rapidly and spreads to the lung and liver. Yolk sac tumor (about 60% of all testicular cancers in young boys). Teratomata (about 7% of testicular cancers in adult men and 40% in young boys). Choriocarcinoma (rare). A physical examination typically reveals a firm, non-tender testicular mass that does not "trans-illuminate" (light from a flashlight held to the scrotum does not pass through the mass). Other tests include: Scrotal ultrasound usually reveals a well defined hypoechoic lesion, although imaging presentation is very unspecific. Blood tests for tumor markers: alpha-fetoprotein (AFP), human chorionic gonadotrophin (beta HCG), and lactic dehydrogenase (LDH). Approximately 85% of non-seminomas will have elevations of either AFP or beta HCG. Seminomas will have elevations only in beta HCG or LDH. These tests can also be used to monitor the response to treatment. A chest X-ray is done to look for potential metastasis (spreading of cancer) to the lungs. An abdominal and pelvis CT scan is usully done to look for potential metastasis, typically presenting as bulky retroperitoneal adenopathy Tissue biopsy is usually by surgical removal of the testicle. After the testicle is removed, the tissue is examined.

Differential Diagnosis List

Final Diagnosis

Testicular seminoma with extensive retroperitoneal lymphadenopathy invading the duodenum.

URL:	https://www.eurorad.org/case/5813
DOI:	10.1594/EURORAD/CASE.5813
ISSN:	1563-4086