eMedicine Specialties > Urology > Cancer, Testicle
Testicular Choriocarcinoma: Differential Diagnoses & Workup
Updated: May 21, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Other Problems to Be Considered
Chronic epididymitis
Non–germ cell testicular tumor, Leydig
Syphilitic gumma
Workup
Laboratory Studies
- Alpha-fetoprotein (AFP) is secreted by yolk sac elements; elevated levels of AFP are consistent with NSGCT. Choriocarcinoma could be a component of such a tumor, but AFP is within the reference range in pure choriocarcinoma. AFP has a serum half-life of between 5 and 7 days.
- Human chorionic gonadotropin (hCG) is a glycoprotein with the same alpha unit as thyroid-stimulating hormone (TSH), follicle-stimulating hormone (FSH), and luteinizing hormone (LH). Therefore, the beta subunit must be assayed. Beta-hCG has a 24- to 36-hour half-life and is secreted by syncytiotrophoblast cells within the tumor. Beta-hCG levels are usually markedly elevated in pure choriocarcinoma. Persistently elevation of beta-hCG levels is defined as continued elevation of the tumor marker above the predicted levels based on serum half-life of 24-36 hours.5 This can also be applied to AFP, in which levels above that expected for the zero order kinetics of a 5- to 7-day expected half-life represent persistent elevation. From a clinical perspective, persistent tumor marker elevation represents residual disease. As such, more advanced treatment modalities (eg, chemotherapeutic) may be required.
- Liver enzyme profile to include lactic acid dehydrogenase (LDH): Elevated levels of LDH may indicate bulky or advanced disease; however, the sensitivity and specificity are limited compared with beta-hCG and AFP. Rising levels after treatment may indicate relapse. Elevation of the remaining liver function tests may correlate with metastatic liver disease.
- Placental alkaline phosphatase (PLAP): PLAP is elevated in some patients with seminoma and advanced disease; however, smoking and several other tumors also cause elevations; therefore, this marker not commonly used.
Imaging Studies
- Scrotal ultrasonography
- Any male with a palpable testicular mass should undergo scrotal ultrasonography. Other indications for ultrasonography may include acute scrotal pain, hydrocele, or other nonspecific scrotal pain, swelling, or mass.
- Choriocarcinoma is associated with hemorrhage and necrosis and may appear more cystic, inhomogeneous, and calcified than a seminoma.6
- Abdominal CT scanning of the abdomen and pelvis with intravenous and oral contrast
- In all other forms of testis GCT, CT scanning can be used to most commonly identify metastatic disease to the retroperitoneal lymph nodes, and it understages approximately 15%-20% of patients thought to have stage I.
- In patients with pure choriocarcinoma, metastatic disease via hematogenous routes may skip the retroperitoneal lymphatics.
- CT scanning of the brain
- Choriocarcinoma is associated with brain metastases. In a review of 242 patients with metastatic germ cell testis cancer undergoing treatment with a multi-agent chemotherapy protocol, Vugrin et al (1979) found 38 cases of brain metastases.7 Among patients with pure embryonal carcinomas, 13% had brain metastases, compared to 83% of patients with pure choriocarcinomas. Furthermore, choriocarcinomas tended to have multiple brain metastatic sites with cerebellar involvement.
- In almost all cases, pulmonary metastases preceded or coincided with brain metastases.
- Chest radiography/chest CT scanning: Chest CT scan is indicated only for an abnormal finding on chest radiography; however, choriocarcinoma has a high metastatic rate, and CT scanning of the chest is usually indicated.
- Bone scan
- In an autopsy study by Bredael et al (1982), GCTs had bony metastases at autopsy, including seminoma (56%), mixed choriocarcinoma (35%), teratocarcinoma (30%), and embryonal carcinoma (24%); however, 0 of 6 cases of pure choriocarcinoma metastasized to the bone.8
- In pure choriocarcinoma, a bone scan can probably be omitted in the absence of bone pain.
Histologic Findings
Gross findings include a small hemorrhagic nodule with some grayish-white viable tumor at the periphery. Histology shows that choriocarcinoma contains both syncytiotrophoblastic cells and cytotrophoblastic cells in intimate association (see Image 1).
Testicular choriocarcinoma has multinucleated syncytiotrophoblastic cells that drape over smaller cytotrophoblastic cells, which together appear to form a border along a blood-filled villouslike space (upper right). Used with permission from Ernstoff MS, Heaney JA, and Peschel RE, eds. Testicular and Penile Cancer. Malden, Mass: Blackwell Science, Inc; 1998:20.
Syncytiotrophoblastic cells are responsible for beta-HCG production.
Staging
American Joint Committee on Cancer and the International Union Against Cancer
Testicular cancer staging system9
- Primary tumor (T)
- pTx - Primary tumor cannot be assessed.
- p0 - No evidence of primary tumor
- pTis - Intratubular germ cell neoplasia
- pT1 - Tumor limited to the testis and epididymis, no vascular/lymphatic invasion, may invade the tunica albuginea, no invasion of the tunica vaginalis
- pT2 - Tumor limited to the testis and epididymis, vascular/lymphatic invasion or tumor extending through the tunica albuginea with involvement of the tunica vaginalis, invades beyond the tunica albuginea or into the epididymis
- pT3 - Tumor invades the spermatic cord with or without vascular/lymphatic invasion.
- pT4 - Tumor invades the scrotum with or without vascular/lymphatic invasion, invades the scrotum
- Regional lymph nodes (N)
- Clinical
- Nx - Nodes not assessed
- N0 - No regional lymph node metastasis
- N1 - Lymph node mass or multiple lymph node masses less than or equal to 2 cm in greatest dimension
- N2 - Lymph node mass or multiple lymph node masses greater than 2 cm but less than or equal to 5 cm in greatest dimension
- N3 - Lymph node mass greater than 5 cm in greatest dimension
- Pathologic
- pN0 - No evidence of tumor in lymph nodes
- pN1 - Lymph node mass less than or equal to 2 cm in greatest dimension, 5 or fewer nodes positive
- pN2 - Lymph node mass greater than 2 cm but less than 5 cm in greatest dimension, more than 5 nodes positive, evidence of extranodal extension of tumor
- pN3 - Lymph node mass greater than 5 cm in greatest dimension
- Clinical
- Distant metastases (M)
- M0 - No evidence of distant metastases
- M1a - Nonregional nodal or pulmonary metastases
- M2b - Nonpulmonary visceral metastases
Table 1. Serum Tumor Markers (S)Open table in new window
[ CLOSE WINDOW ]Table
S LDH HCG (mIU/mL) AFP (ng/mL) Sx Not assessed Not assessed Not assessed S0 £ N* and Normal and Normal S1 <1.5 x N and <5000 and <1000 S2 1.5-10 x N or 5000-50,000 or 1000-10,000 S3 >10 x N or >50,000 or >10,000 S LDH HCG (mIU/mL) AFP (ng/mL) Sx Not assessed Not assessed Not assessed S0 £ N* and Normal and Normal S1 <1.5 x N and <5000 and <1000 S2 1.5-10 x N or 5000-50,000 or 1000-10,000 S3 >10 x N or >50,000 or >10,000
*N=upper limit of reference range for the LDH assay Table 2. Stage GroupingOpen table in new window
[ CLOSE WINDOW ]Table
Stage grouping T N M S Stage 0 pTis N0 M0 S0 Stage I T1-T4 N0 M0 Sx Stage IA T1 N0 M0 S0 Stage IB T2-4 N0 M0 S0 Stage IS Any T N0 M0 S1-S3 Stage II Any T Any N M0 Sx Stage IIA Any T N1 M0 S0-S1 Stage IIB Any T N2 M0 S0-S1 Stage IIC Any T N3 M0 S0-S1 Stage III Any T Any N M1 Sx Stage IIIA Any T Any N M1a S0-S1 Stage IIIB Any T Any N M0-M1a S2 Stage IIIC Any T Any N M0-M1a S3 … Any T Any N M1b Any S Stage grouping T N M S Stage 0 pTis N0 M0 S0 Stage I T1-T4 N0 M0 Sx Stage IA T1 N0 M0 S0 Stage IB T2-4 N0 M0 S0 Stage IS Any T N0 M0 S1-S3 Stage II Any T Any N M0 Sx Stage IIA Any T N1 M0 S0-S1 Stage IIB Any T N2 M0 S0-S1 Stage IIC Any T N3 M0 S0-S1 Stage III Any T Any N M1 Sx Stage IIIA Any T Any N M1a S0-S1 Stage IIIB Any T Any N M0-M1a S2 Stage IIIC Any T Any N M0-M1a S3 … Any T Any N M1b Any S
- Additional staging systems are well discussed by Prow (1998).10
More on Testicular Choriocarcinoma |
| Overview: Testicular Choriocarcinoma |
 Differential Diagnoses & Workup: Testicular Choriocarcinoma |
| Treatment & Medication: Testicular Choriocarcinoma |
| Follow-up: Testicular Choriocarcinoma |
| Multimedia: Testicular Choriocarcinoma |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
Mostofi FK, Sesterhenn IA. Anatomy and pathology of testis cancer. In: Comprehensive Textbook of Genitourinary Oncology. Baltimore, Md: Williams and Wilkins; 1996.
Ramon y Cajal S, Pinango L, Barat A. Metastatic pure choriocarcinoma of the testis in an elderly man. J Urol. Mar 1987;137(3):516-9. [Medline].
Berney DM, Warren AY, Verma M, Kudahetti S, Robson JM, Williams MW, et al. Malignant germ cell tumours in the elderly: a histopathological review of 50 cases in men aged 60 years or over. Mod Pathol. Jan 2008;21(1):54-9. [Medline].
Batata MA, Whitmore WF Jr, Chu FC. Cryptorchidism and testicular cancer. J Urol. Sep 1980;124(3):382-7. [Medline].
Klein EA. Tumor markers in testis cancer. Urol Clin North Am. Feb 1993;20(1):67-73. [Medline].
Horstman WG. Scrotal imaging. Urol Clin North Am. Aug 1997;24(3):653-71. [Medline].
Vugrin D, Cvitkovic E, Posner J. Neurological complications of malignant germ cell tumors of testis: biology of brain metastases (I). Cancer. Dec 1979;44(6):2349-53. [Medline].
Bredael JJ, Vugrin D, Whitmore WF Jr. Autopsy findings in 154 patients with germ cell tumors of the testis. Cancer. Aug 1 1982;50(3):548-51. [Medline].
Beahrs O, Henson D, Hutter R. Handbook for staging of cancer. In: The Manual of Staging Cancer. 4th ed. Philadelphia, Pa: JB Lippincott; 1993:195-7.
Prow DM. Germ cell tumors: staging, prognosis, and outcome. Semin Urol Oncol. May 1998;16(2):82-93. [Medline].
Logothetis CJSamuels MLSelig DEOgden SDexeus FSwanson DJohnson Dvon Eschenbach A. Cyclic chemotherapy with cyclophosphamide, doxorubicin, and cisplatin plus vinblastine and bleomycin in advanced germinal tumors. Results with 100 patients. American Journal of Medicine. 2/1986;81:219-28. [Medline].
Tatokoro M, Kawakami S, Sakura M, Kobayashi T, Kihara K, Akamatsu H. Successful management of life-threatening choriocarcinoma syndrome with rupture of pulmonary metastatic foci causing hemorrhagic shock. Int J Urol. Mar 2008;15(3):263-4. [Medline].
Bodiwala D, Summerton DJ, Terry TR. Testicular prostheses: development and modern usage. Ann Royal Coll Surg Engl. 2007;89:349-53. [Medline]. [Full Text].
Mead GM. Chemotherapeutic Management of Metastatic Germ Cell Testis Cancer. Risk-Adapted Therapy/Poor Risk Patients. In: Vogelzang et al, eds. Comprehensive Textbook of Genitourinary Oncology. 2nd ed. Philadelphia, Pa: Lippincott Williams & Williams; 2000:1024-31.
Requena L, Sanchez M, Aguilar A. Choriocarcinoma of the testis metastatic to the skin. J Dermatol Surg Oncol. May 1991;17(5):466-70. [Medline].
Saxman SB, Loehrer PJ. Chemotherapeutic Management of Metastatic Germ Cell Testicular Cancer. Overview of Initial Therapy for Metastatic Seminoma and Nonseminoma. In: Vogelzang et al, eds. Comprehensive Textbook of Genitourinary Oncology. 2000. 2nd ed. Philadelphia, Pa: Lippincott Williams & Williams; 1010-7.
Batata MA, Chu FC, Hilaris BS. Therapy and prognosis of testicular carcinomas in relation to TNM classification. Int J Radiat Oncol Biol Phys. Aug 1982;8(8):1287-93. [Medline].
Lepidini G, Biancari F, D'Andrea V. Severe thrombosis after chemotherapy for metastatic choriocarcinoma of the testis maintaining complete remission for a long period. Scand J Urol Nephrol. Apr 1997;31(2):221-2. [Medline].
Bosl GJ, Geller N, Cirrincione C. Interrelationships of histopathology and other clinical variables in patients with germ cell tumors of the testis. Cancer. Jun 1 1983;51(11):2121-5. [Medline].
Azzopardi JG, Mostofi FK, Theiss EA. Lesions of the testes observed in certain patients with widespread choriocarcinoma and related tumors. Am J Pathol. 1961;38:207-225.
Fleming ID, Cooper JS, Henson DE, et al. AJCC Cancer Staging Manual. 5th ed. New York, NY: Lippincott-Raven; 1997.
Kodama M, Murakami M, Kodama T. Chronological transition of the age-adjusted incidence rates (AAIRs) of 20 major neoplasias from early 1960s to mid-1980s. Anticancer Res. Jan-Feb 1999;19(1B):779-87. [Medline].
Looijenga LH, Oosterhuis JW. Pathogenesis of testicular germ cell tumours. Rev Reprod. May 1999;4(2):90-100. [Medline].
Parkin DM, Muir CS. Cancer Incidence in Five Continents. Comparability and quality of data. IARC Sci Publ. 1992;45-173. [Medline].
Richie JP. Neoplasms of the Testis. In: Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders Co; 1998.
Ro JY, Dexeus FH, el-Naggar A. Testicular germ cell tumors. Clinically relevant pathologic findings. Pathol Annu. 1991;26 Pt 2:59-87. [Medline].
Swerdlow AJ. Epidemiology of testicular cancer. In: Principles and Practice of Genitourinary Oncology. Philadelphia, Pa: Lippincott-Raven Publishers; 1997.
Ulbright TM. Germ cell neoplasms of the testis. Am J Surg Pathol. Nov 1993;17(11):1075-91. [Medline].
Keywords
testicular choriocarcinoma, trophoblastic malignant teratoma, trophoblastic neoplasia, testicular seminoma, nonseminomatous germ cell tumors, NSGCT, germ cell tumors, GCT
