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\title{Metastatic seminoma presenting in kidney and cervical lymph node after a
25-year interval}



\author[1]{azar naimi}%
\author[1]{haniyeh sohrabi}%
\affil[1]{Isfahan University of Medical Sciences}%


\vspace{-1em}



  
  \date{May 24, 2024}


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\textbf{Metastatic seminoma presenting in kidney and cervical lymph node
after a 25-year interval}

\textbf{Keywords:} Seminoma, Germ cell tumor, Testicular tumor, Distant
metastasis

\textbf{Abstract:} Seminoma comprises approximately 50\% of testicular
germ cell tumors. retroperitoneal lymph nodes being the most common
initial metastatic site but Renal metastases are infrequent and the
majority of renal tumors represent primary neoplasm. In this study, we
present a 48-year-old male with metastases of seminoma to the cervical
lymph node and kidney after a 25-year of interval.

\textbf{Introduction:}

Germ cell tumors are the most common type of testicular cancer. The most
typical symptom of testicular cancer is a painless lesion in the testis.
Less frequent symptoms include gynecomastia and testicular pain. Males
between the ages of 15 and 35 are most frequently affected by testicular
malignancies, which make up 1\% of all cancer cases in men. Seminomas
and nonseminomas are the two types of testicular germ cell cancers. More
than half of diagnoses for germ cell cancers are
seminoma.\textsuperscript{1-4}

Although only a small percentage of seminoma patients have distant
metastases at diagnosis, Lung, bone, liver, and retroperitoneal lymph
nodes are among the organs where seminomas frequently
metastasize.\textsuperscript{1, 5, 6} The majority of kidney
malignancies are primary neoplasms. Secondary kidney tumors are
relatively uncommon in clinical practice. \textsuperscript{7, 8}

In this study, we report the clinic-pathological, radiological, and
immunohistochemical findings of a case of seminoma metastasis to the
kidney and cervical lymph node after 25 years of interval.

\textbf{Case presentation:}

A 48-year-old man who had previously experienced a seminoma 25 years
earlier, came to our attention with a left kidney mass and some masses
in the right side of the neck and base of the skull. Before the
pathologic examination was completed, the patient and his family did not
inform the healthcare professionals about his history of seminoma also
there were no records regarding the stage or treatment of seminoma.
unfortunately, the patient passed away one month after receiving a
diagnosis of metastatic seminoma.

After undergoing multidetector computed tomography (MDCT) and magnetic
resonance imaging (MRI), the patient showed some mass-like lesions at
the base of the skull and in the right cervical region that also
included lymph nodes. Prior to a pathologic examination, radiologic
findings pointed to several potential diagnoses, such as lymphoma or
kidney-originated tumors that had metastasis to the base of the skull
and neck.

Radiologic findings include:

Temporal bone M.D.C.T scan showed Soft tissue density in the middle ear
cavity and mastoid antrum in the Rt side, tissue mass lesion in the base
of the skull in the Rt side at the foramen jugular region with the
destruction of the adjacent bony structure also retention cyst in the
sphenoid sinus.

Brain M.D.C.T scan showed a heterogeneous mass lesion in Rt Petrus
apical portion reaching the level of the nasopharynx and Post-surgical
changes at Rt mastoidectomy, soft-tissue edema, and emphysema in Rt
temporal region.

Brain MRI with multiplanar images in different pulse sequences was
performed. Diffuse signal changes can be seen in the right side of the
skull base, including the petrous apex, right side of the clivus, and C1
vertebra, with intermediate signal intensity on T1W and T2W sequences.
Diffusion restriction and enhancement are also seen, extending to the
ipsilateral jugular foramen and carotid canal as well as invading the
Dorellos canal abducens nerve.

Histologic and immunohistologic findings include:

Seminomas have a nest-like or sheet-like growth pattern, distinct cell
membranes, big polygonal nuclei, pale to clear eosinophilic cytoplasm,
and nest-like or sheet-like shape in the histological inspection.
Lymphocytes could make up the septa. In some metastatic situations, the
histological morphology is a little out of the ordinary. Additionally,
germ cell characteristics of primary and metastatic seminoma tumors,
such as the positivity of the tumor markers OCT3/4, CD117, and PLAP, are
similar. \textsuperscript{9}

The neoplastic proliferation of malignant tumoral cells is visible as
diffuse patterns in the left kidney mass core needle biopsy (Fig.1).
These cells range in size from medium to big, with a high N/C ratio,
eosinophilic cytoplasm, and hyperchromic nuclei that are rounded. There
are mitotic figures and necrotic tissues. Vimentin, PLAP, CD117, and
CD10 IHC staining are all positive in tumor cells (Fig.2).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Fig1.} Renal core needle biopsy. Renal tissue completely
replaced by tumoral cells, composed of neoplastic germ cells with clear
cytoplasm and large nuclei. Hematoxillin \& Eosin staining A) *100 B)
*400\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\textbf{Fig2.} Immunohistochemistry for PLAP antibody shows positive
cytoplasmic staining in tumoral cells.

A mass biopsy of the right skull base reveals a broad pattern of medium
to large cell neoplastic growth. These cells exhibit pleomorphism, a
high mitotic rate, a high N/C ratio, and crashing. IHC staining is Ki67
positive in about 60\%, OCT focally positive, CK dot-like positive, CD10
and PALP positive.

\textbf{Discussion:}

Males between the ages of 15 and 35 most frequently develop testicular
tumors, which have an improving rate of complete recovery. Seminoma
usually spreads metastatically along the lymphatic drainage routes to
the retroperitoneal lymph nodes; however, involvement of the kidney,
adrenal gland, psoas muscle, stomach, seminal vesicle, bladder,
prostate, and pericardium is rarely present
(\textless{}1\%).\textsuperscript{10}

For testis tumors, metastases during the first two years are considered
as early, whereas those after five years are categorized as late. The
majority of metastases occur within the first two
years.\textsuperscript{11} We present a case of very late seminoma
metastases that occurred after 25 years.

In a research conducted by the husband and colleagues on 650 patients
with testicular malignancies who underwent CT, only 6 patients showed
kidney metastases, of which 2 were seminomas. This study demonstrates
the uncommon frequency of renal seminoma metastases.\textsuperscript{10}

Castel\selectlanguage{ngerman}án et al describe a case of a 24-year-old man who underwent a left
radical orchiectomy as a result of classic seminoma, left renal
metastases from seminoma were also discovered in this
instance.\textsuperscript{8} Despite this, the renal metastasis in our
patient occurred 25 years after the initial seminoma presentation.

Malignant tumors are the most frequent cause of neck masses in adults,
and neck involvement may frequently be the first or only clinical
symptom \textsuperscript{12} and Neck metastases from uterine, ovarian,
prostate, and testicular malignancies have been described seldom.
Supraclavicular metastases can develop in men as their prostate and
testicular cancers progress. \textsuperscript{13}

Considering that 4.5-15\% of seminoma patients may experience neck
metastases during the course of the disease, the neoplastic diffusion to
the cervical lymph node is not an unusual presentation of the
disease.\textsuperscript{14, 15}

A 59-year-old man who presented with a left indolent neck swelling that
had developed gradually over 6 months is the focus of a case study by
Corazzi and colleagues. The clinical history of the patient revealed a
left testicular seminoma that had undergone surgery and adjuvant
treatment 20 years ago. \textsuperscript{12}

To the best of our knowledge, no other examples of seminoma metastases
to the kidney, cervical, and base of the skull occurring simultaneously
after a 25-year interval have been documented in the literature.

\textbf{Conclusion:}

Late neck lymph node and renal metastasis is rare occurrence in the
natural history of testicular cancers. In cases of positive clinical
data, cancers of remote sites should always be considered especially in
the differential diagnosis of neck adenopathies with unknown etiology,
even many years after the primary treatment.

\textbf{Authorship List:}

Each author participated sufficiently in the work to take responsibility
for appropriate portions of the content. All authors read and approved
the final manuscript.

\textbf{Acknowledgments:}

Written consent was obtained from the patient for publication of study.
We wish to thank in particular the patient for his collaboration.

\textbf{Conflict of Interest Statement:}

The authors declare that they have no competing interests.

\textbf{References:}

1. Siegel, R.L., et al., \emph{Cancer Statistics, 2021.} CA Cancer J
Clin, 2021. \textbf{71} (1): p. 7-33.

2. Chen, W., et al., \emph{Cancer statistics in China, 2015.} CA Cancer
J Clin, 2016. \textbf{66} (2): p. 115-32.

3. Bosl, G.J. and R.J. Motzer, \emph{Testicular germ-cell cancer.} N
Engl J Med, 1997. \textbf{337} (4): p. 242-53.

4. Goldberg, H., et al., \emph{Germ Cell Testicular Tumors-Contemporary
Diagnosis, Staging and Management of Localized and Advanced
disease.}Urology, 2019. \textbf{125} : p. 8-19.

5. Bokemeyer, C., et al., \emph{Metastatic seminoma treated with either
single agent carboplatin or cisplatin-based combination chemotherapy: a
pooled analysis of two randomised trials.} Br J Cancer, 2004.\textbf{91}
(4): p. 683-7.

6. Schmoll, H.J., et al., \emph{Testicular seminoma: ESMO clinical
recommendations for diagnosis, treatment and follow-up.} Ann Oncol,
2009. \textbf{20 Suppl 4} : p. 83-8.

7. Tomita, M., et al., \emph{Isolated Renal Metastasis from
Non-Small-Cell Lung Cancer: Report of 2 Cases.} Case Rep Surg,
2015.\textbf{2015} : p. 357481.

8. Castelán-Maldonado, E.E., et al., \emph{{[}Renal metastasis of
classic seminoma{]}.} Cir Cir, 2013. \textbf{81} (2): p. 153-7.

9. Marko, J., et al., \emph{Testicular Seminoma and Its Mimics: From the
Radiologic Pathology Archives.} Radiographics, 2017. \textbf{37} (4): p.
1085-1098.

10. Husband, J.E. and E.A. Bellamy, \emph{Unusual thoracoabdominal sites
of metastases in testicular tumors.} AJR Am J Roentgenol,
1985.\textbf{145} (6): p. 1165-71.

11. Lipphardt, M.E. and P. Albers, \emph{Late relapse of testicular
cancer.} World J Urol, 2004. \textbf{22} (1): p. 47-54.

12. Corazzi, V., et al., \emph{Late relapse in the neck: considerations
from a case of seminoma and review of the literature.} Acta
Otorhinolaryngol Ital, 2020. \textbf{40} (4): p. 313-315.

13. López, F., et al., \emph{Cervical lymph node metastases from remote
primary tumor sites.} Head Neck, 2016. \textbf{38 Suppl 1} (Suppl 1): p.
E2374-85.

14. Büttner, H., et al., \emph{{[}Metastases of germ cell tumors to the
ENT area--a rare differential diagnosis of lymph node metastases in
unknown primary tumor{]}.} Laryngorhinootologie, 1996. \textbf{75} (10):
p. 616-8.

15. See, W.A., et al., \emph{Incidence and management of testicular
carcinoma metastatic to the neck.} J Urol, 1996. \textbf{155} (2): p.
590-2.

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