Metastatic Choriocarcinoma in a 17-year Old Boy

A 17-year old boy presented with acute haemoptysis and chest pain. He had a 3 month history of vision disorders and B symptoms. Furthermore he had a 2 week history of headache and paresthesia of his right arm. Physical examination showed a hard erythematous mass on his left shoulder ([Fig. 2A]). Moreover he had a hardened enlarged left testicle (20 ml) with an partly cystic mass of 3 cm in diameter on ultrasound examination ([Fig. 1E]).

Fig. 1 Imaging studies. (A) Lung (CT); (B) Brain (MRI); (C) Abdomen (MRI); (D) Thyroid gland (sonography); (E) left Testicle (sonography).

Fig. 2 Skin metastasis of the choriocarcinoma (A) at the time of diagnosis (B) after 2 cycles of PEI.

The patient told us that his left testicle felt like this since at least 5 years. He thought that his left testicle was normal, but his right one too small. He never spoke about this to anyone and no physical examination of his genitalia was performed during that time period. Staging after hospital admission revealed a serum beta-human chorionic gonadotropin (ß-HCG)-level with 192.575 mIU/ml (normal range, <2). Imaging studies disclosed multiple metastatic lesions: a mediastinal tumour of 6 cm in size, multiple lung metastasis (at least 200) of various size (0.1–2 cm), mass caudal of the pancreas-tail (5.8 cm), two nodules in the left thyroid gland. In addition 4 metastatic brain lesions explained his neurological disorders ([Fig. 1A–D]). Pathology of the removed left testicle revealed a mature teratoma. The diagnosed histology of mature teratoma of the testicle underlines the boys’ observation that the testicle with the tumor did not change for the last 5 years.

The patient immediately started with chemotherapy for high risk germ cell tumours including 2 cycles of PEI: (Cisplatin, Etoposid and Ifosfamid) in standard dosage and 3 cycles of dose intensified PEI with autologous stem cell rescue. Concerning his risk for intracranial haemorrhage due to his vulnerable brain metastasis (Shinoda et al., J. Neurooncol. 2004; 66: 225–240) he received an extensive antiemetic regimen. Fortunately no episode of retching or vomiting has occurred so far. He is still under treatment, the metastasis are shrinking and the serum ß-HCG-level is constantly decreasing but still elevated (<100 mIU/ml). Local therapy needs to be given.

Choriocarcinoma has a marked tendency to metastasise. In adults the most common sites are lymph nodes and lung (60–95%). Liver and brain metastases are seen only (up to 10%) in far advanced stages. Metastasis in the thyroid gland and the skin are extremely rare (Sofikerim et al., Inter U Nephrol 2005; 37: 759–762) (Erdogan et al., Thyroid 1994; 3: 301–303) and are associated with a very poor outcome. Concerning literature 5 out of 7 patients with metastatic choriocarcinoma to the skin died within 3 months after diagnosis (Shimizu et al., Am J Dermatopathol 1996; 18: 633–636). An earlier detection of the testicular teratoma would have had possibly a tremendous impact on the prognosis in this patient (Harms et al. Klin Padiatr 2006; 218: 296–302).

This case should illustrate that a thorough medical history together with a systematic physical examination is of utmost importance. It is also important to know that skin metastasis are rare in childhood cancers, but if they occur choriocarcinoma should always be considered.

Conflict of interest: The authors have no conflict of interest to disclose.