An Unusual Presentation of Testicular Metastasis in a Patient With Esophageal Adenocarcinoma: 1670

Esophageal adenocarcinoma is the eighth most common cancer and sixth leading cause of cancer mortality worldwide. Incidence of Esophageal adenocarcinoma (EAC) is dramatically increasing over the past few decades and is now the most common form of esophageal cancer in United States. 54 year old male with no significant medical history presented to primary care clinic with complaints of poor appetite, early satiety, heartburn and 40lb weight loss. He denied any Alcohol and Smoking use. Physical examination and basic labs were unremarkable. Upper GI series showed irregular marginated mass with narrowing and ulceration of distal esophagus. Follow up EGD and Endoscopic ultrasound showed mass extending from 36 cm to 42 cm with portion of tumor invading pericardium. TNM staging was determined as T4aN0Mx. Biopsies obtained from esophageal mass was consistent with invasive poorly differentiated adenocarcinoma. Decision was made to start neoadjuvant chemotherapy with carboplatin and paclitaxel followed by esophagectomy. Interval follow up PET scan after chemotherapy showed improvement in diffuse circumferential mural thickening of esophagus showing favorable response to therapy. Later, he presented to oncology clinic as he started to experience testicular pain and was noted to have right testicular mass and also left sided skull mass. CT head showed 2.9 x3.2 cm mass in the left parietal skull area and Right scrotal ultrasound showed 1.5x1.6x1.8 cm mass in right testicle. The patient underwent craniotomy resection followed by right radical orchiectomy. Biopsies of skull mass and right testicle showed metastatic poorly differentiated esophageal adenocarcinoma positive for CK7, CAM 5.2, MOC 31 and EMA. All markers for mesothelioma of tunica vaginalis, germ cell tumor of testes, adenocarcinoma of rete testis, prostate adenocarcinoma were negative and they were excluded. Pathologist coreviewed the esophageal mass biopsy along with skull mass and testicular mass and it was found that they had many features in common confirming our diagnosis of Testicular metastasis. Testicular cancer most commonly metastasizes to liver, lungs, bone, and adrenal glands via hematogenous route. Only one case of testicular metastasis from esophageal cancer has been reported so far. The exact pathogenesis of metastatic spread to testes remains unknown. High degree of suspicion is indicated when the patient presents with testicular mass in the setting of esophageal cancer.