Recurrent Testicular Cancer Presenting with Small Bowel Obstruction: Late Relapse after 13 Years.

Introduction Testicular cancers account for <1% of solid tumors in males. The majority (95%) of testicular cancers are germ cell tumors (GCTS), and they are histologically subclassified into seminomas and non-seminomas. 70% of seminoma patients present with localized stage I disease between the ages of 24 and 34. The estimated 5-year survival rate and 15-years cancer-specific survival of 95% and 99%, respectively. The overall crude relapse rate is 15.2–19.3%, with most relapses occurring in the first two years. We present a case of relapsed metastatic mixed GCTS after 13 years of surgical resection of stage I seminoma. Case Description A 45-year-old male patient with a remote history of localized left testicular cancer was treated with unilateral orchiectomy in 2008. He presented to the ER with a complaint of severe abdominal pain associated with nausea and vomiting. He reported loss of appetite and intentional weight loss of about 15 lbs. over the past six weeks. Computed tomography (CT) of the abdomen and pelvis with contrast showed 14.9 ×11 x 11.3cm heterogeneous hypodense retroperitoneal mass circumscribes the abdominal aorta and inferior vena cava (IVC). Small bowel obstruction is not excluded.The patient underwent upper GI endoscopy revealing severe extrinsic stenosis in the third portion of the duodenum. CT-guided biopsy of the retroperitoneal mass results was consistent with poorly differentiated adenocarcinoma. Immunotoxins demonstrated strong stains with CD117, CD30, and CDX2, consistent with mixed germ cell tumors; 85% seminoma, 5% embryonal carcinoma, 5% yolk sac tumor, and 5% teratoma. Tumor markers testing showed an alpha-feto protein level of 2905ng/ml (normal level 10-20ng/ml), Human chorionic gonadotropin serum level of 1062 mIU/mL (normal level 0-3 mIU/mL), and lactic dehydrogenase level of 1554 IU/L (normal level 313-618 IU/L). Discussion Our patient presented with relapsed mixed germ cell tumor after 13 years of successful surgical resection and surveillance for unilateral seminoma. Recurrence was in the form of large retroperitoneal mass, most probably arising from micro-metastases to the paraaortic nodes, causing mechanical compression. Similar cases that presented recurrence after a long duration of surveillance have been reported. However, very few cases of recurrent testicular cancer presenting with intestinal obstruction have been reported where a primary testicular cancer initially presented with GI metastases causing mechanical obstruction. Conclusion We describe an unusual case of large metastatic retroperitoneal mass originating from a mixed germ cell tumor in a patient who presented with small bowel obstruction after a very long surveillance period. More extended period of surveillance beyond 2-6 years after surgical resection of localized testicular cancer patients may be warranted.