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

      case-report
      1 , , 2 , 3
      ,
      Cureus
      Cureus
      choriocarcinoma syndrome, testicular germ cell tumor, paraneoplastic hyperthyroidism

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          Abstract

          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.

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          Most cited references20

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          ESMO Consensus Conference on testicular germ cell cancer: diagnosis, treatment and follow-up

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            Severe Complications in Testicular Germ Cell Tumors: The Choriocarcinoma Syndrome

            Testicular germ cell tumors (TGCTs) represent the most common solid tumor in young men and is a model of curable cancer. The effectiveness of cisplatin-based chemotherapy secures more than 95% of patients' 5-years survival rate. However, some high-risk patients with a very advanced disease develop choriocarcinoma syndrome (CS) connected with acute respiratory failure with poor prognosis and high mortality rate shortly after beginning systemic chemotherapy. CS was first described as a syndrome with hemorrhage from metastatic sites in patients with TGCTs with significantly high choriogonadotropin level. Acute hemorrhage to lung metastases is typical, but hemorrhage can occur from any metastatic site. Patognomic of choriocarcinoma cells is an invasion of small blood vessels within CS. The incidence of CS in patients with TGCTs are not well-defined and can vary across the world. To date, there are a few case reports and small retrospective series reporting a connection between systemic chemotherapy and the development of CS in metastatic TGCTs. CS is known to be triggered by massive tumor cell lysis as a result of chemotherapy and cytokine release, aggravated with alveolar hemorrhage. This can lead to a consecutive superinfection, furthered with neutropenia after chemotherapy, acute respiratory distress syndrome, rising to systemic inflammatory response, resulting in multiorgan failure and death. A reasonably effective approach in patients with extensive disease could be a shortened course of chemotherapy as well as a reduction of dosage in induction chemotherapy before full-dose chemotherapeutical regimen; however, current data regarding optimal treatment approach are limited. Patients' referral to tertiary centers and the administration of induction chemotherapy in an intensive care unit setting could further improve the treatment outcome.
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              Metastases from testicular carcinoma. Study of 78 autopsied cases.

              The necropsy records of 78 patients with histologically proved germ cell tumors of the testis, who died as a direct result of their malignant disease, were reviewed to determine the usual modes of spread, distribution of metastasis, the histologic characteristics of the metastatic foci as compared with the morphology of the primary tumor and the specific cause of death. The sites of metastases in order of decreasing frequency for all cases were lung, retroperitoneal lymph nodes, liver, mediastinal lymph nodes, brain, kidney, gastrointestinal tract, bones, adrenals, peritoneum and spleen. The absence of metastases solely in the anterior mediastinum without involvement of other mediastinal nodes (middle/posterior) strongly supports the premise for a primary extragonadal origin whenever the anterior mediastinum alone is involved with malignant disease having the histologic appearance of a primary germ cell tumor. The histologic features of the metastatic lesions were usually similar in nature to those of the primary tumor except for seminoma in which the metastatic lesions proved to be of a different histologic pattern in almost one third of the patients dying from the disease. It should be axiomatic that whenever a patient with seminoma fails to respond appropriately to radiotherapy that his treatment be immediately discontinued and that appropriate biopsies be obtained to substantiate the histologic pattern present.
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                Author and article information

                Journal
                Cureus
                Cureus
                2168-8184
                Cureus
                Cureus (Palo Alto (CA) )
                2168-8184
                4 April 2021
                April 2021
                : 13
                : 4
                : e14286
                Affiliations
                [1 ] Internal Medicine, Roger Williams Medical Center/Boston University, Providence, USA
                [2 ] Department of Medicine, Roger Williams Medical Center, Providence, USA
                [3 ] Division of Hematology and Oncology, University of California Irvine, Irvine, USA
                Author notes
                Article
                10.7759/cureus.14286
                8096621
                33968500
                5dfbaae7-d03c-4302-aec4-cdf50d461693
                Copyright © 2021, Tannous et al.

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 1 April 2021
                Categories
                Pathology
                Urology
                Oncology

                choriocarcinoma syndrome,testicular germ cell tumor,paraneoplastic hyperthyroidism

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