Assistant Professor Penn State Health Milton S. Hershey Medical Center, United States
Introduction: Germ cell tumors are a very common form of testicular cancer for young men. On average, 1/3 of patients have metastasis on presentation, however, are clinically stable and have more common sites of metastasis including liver, bones, and lungs. Here we present a young adult with metastatic testicular cancer with extensive tumor burden at initial diagnosis requiring ICU admission for concern of deterioration prior to chemotherapy.
Description: A 30 yo man with a history of congenital bicuspid aortic valve, GERD, and hypertension presented to an outside hospital for lower abdominal pain and flank pain over the past two weeks. On presentation he had an elevated lactate, AKI, anemia, and was pale, tachycardic, with concern for a rigid abdomen. CT A/P showed a large retroperitoneal mass obliterating 3cm of the IVC, loculated fluid collections, and enlarged right scrotum. Pulmonary metastasis, compression on the heart and left atrial thrombus vs mass were also noted. He was transferred here for further oncologic care. Lab work showed a UA 10.3, Cr 2.6, AFP 20,000, hCG 17,000, and LDH 700. Rasburicase was initiated for TLS and the abdominal mass biopsy showed a yolk sac tumor. Due to the tumor burden, initiation of chemo was imperative, but with the extent of LA invasion there was concern for decompensation. Patient did proceed with chemo and tolerated it well.
Discussion: Oncologic emergencies at the time of diagnosis are normally appreciated in leukemia and lymphoma patients due to electrolyte abnormalities, bulky lymphadenopathy, risk of airway compromise, and bleeding. However, other malignancies can cause great tumor burden or thrombi with varying degrees of impact on clinical stability. For this patient, there was concern he had a left atrial thrombus however this was later deemed intra-atrial tumor. Thoracic metastases are common in germ cell tumors however are more often pulmonary. His cancer was atypical as well as yolk sac tumors are uncommon for a man over the age of 2. Ultimately he was high risk due to TLS, IVC obliteration, and LA flow obstruction. There was great concern about decompensation due to preload dependence and risk of free wall rupture during chemo initiation. Had the left atrium responded poorly, there would not have been any surgical options to salvage his condition.
