Cutaneous metastasis from testicular germ cell tumour
A 50-year-old male presented to us in August 2004 with a history of left-sided testicular swelling. On examination, there was a hard 10 × 8 cm left-sided testicular lump with a scar of a previous testicular biopsy on the skin of the left side of the scrotum. Baseline levels of serum lactate dehydrogenase (LDH), alfa fetoprotein (AFP) and beta subunit of human chorionic gonadotropin (beta-HCG) were within normal limits. Chest X-ray was normal and ultrasonography of the abdomen revealed para-aortic lymphadenopathy. He underwent a left high inguinal orchidectomy and left hemiscrotectomy. The histopathology was non-seminomatous malignant mixed germ cell tumor consistent with embryonal carcinoma (97%) with element of teratocarcinoma (3%). Following this, he completed four cycles of adjuvant chemotherapy with Cisplatin (20 mg/m2/day: Days 1-5) and Etoposide (100 mg/m2/day: Days 1-5). Bleomycin was not given due to the previous history of smoking. Subsequent evaluation showed residual para-aortic lymphadenopathy, for which the patient was advised surgery. However, he defaulted treatment and was lost to follow-up.\nSix years later, he presented in November 2010 with a 2-month history of an ulceroproliferative growth over the shin of the right lower limb. On examination, there was an ulceroproliferative growth 3 cm in diameter with satellite lesions over the shin []. Biopsy of this lesion revealed a metastatic malignant germ cell tumor. Further evaluation showed normal levels of tumor markers (LDH, AFP and beta-HCG), with no evidence of intraabdominal or intrathoracic disease. He received three cycles of salvage second-line chemotherapy with Vinblastine (0.11 mg/kg on Days 1 and 2) Ifosfamide (1200 mg/m2/day on Days 1-5) and Cisplatin (20 mg/m2/day on Days 1-5). There was reduction in size of the lesion and he underwent wide local excision of the tumor and skin grafting []. The surgical biopsy was reported as metastatic malignant germ cell tumor. Because the tumor was close to the deep resection margin, he received adjuvant local external radiotherapy to the tumor bed (66 Gy in 33 fractions). He was asymptomatic and was subsequently on regular three-monthly follow-up till May 2012, when he presented with hoarseness of voice. Computed tomography (CT) of the thorax showed a large 4 × 5 cm mediastinal nodal mass with multiple lung metastases. CT-guided biopsy of the mediastinal nodal mass was showed a malignant germ cell tumor with yolk sac component (Pan Cytokeratin and AFP positive on immunohistochemistry) and tumor markers (LDH, AFP and beta-HCG) were within normal limits. He has completed six cycles of salvage third-line chemotherapy with Carboplatin (AUC 5, on Day 1), Paclitaxel (175 mg/m2 on Day 1) and Gemcitabine (1000 mg/m2 on Days 1 and 8), and the repeat CT of the thorax showed minimal decrease in the size of mediastinal lymphadenopathy and lung nodules. He is currently on best supportive care.