University of California Riverside School of Medicine Rialto, CA, United States
Priyanka Yaramada, MD1, Harold Paredes, MD2 1University of California Riverside School of Medicine, Corona, CA; 2University of California Riverside School of Medicine, Rialto, CA
Introduction: Extragonadal germ cell tumors (GCTs) are classified as seminomas and nonseminomatous GCTs.
Nonseminomatous GCTs include yolk sac tumors, embryonal carcinoma, choriocarcinoma and mixed germ cell tumors. Choriocarcinoma is an aggressive malignancy with high metastatic potential and least common type of GCT, that mainly affects young males. It has a predilection for highly vascularized extra-gonadal organs, with common sites of metastasis involving lung, liver and brain. Gynecomastia and elevated serum beta-human chorionic gonadotropin (hCG) are characteristic. We describe an unusual case of metastatic choriocarcinoma of the pancreas arising from a regressed testicular germ cell tumor that clinically mimicked a primary pancreatic tumor.
Case Description/Methods: A 43 y/o male with previous history of testicular cancer, who was treated with orchiectomy and chemotherapy at age 12, presented with unintentional weight loss, icterus and fatigue. Labs on admission demonstrated normal white count, Hb 9.8. Total bilirubin (TB) of 2.4, alanine phosphatase (ALT), 42, aspartate phosphatase (AST), 45, alkaline phosphatase (ALP) 280 and normal lipase. Beta-hCG, 105526 and AFP, 1.9.CT abdomen/pelvis w contrast showed complex pancreatic head mass measuring ~13 cm and innumerable liver lesions (image 1). EGD/EUS demonstrated compression of 2nd portion of the duodenum (image 2). The echoendoscope was not able to traverse this area. There was an 11 cm x 10 cm heterogeneous mass with areas of cystic degeneration arising from the head of the pancreas (image 3). Fine needle biopsy x3 was performed. Pathology revealed metastatic nonseminomatous GCT, mostly consistent with choriocarcinoma. Liver mass biopsy was done as well, pathology confirmed metastatic poorly differentiated nonseminomatous carcinoma of testicular origin. His TB rapidly spiked to 22, due to intrahepatic cholestasis. Chemotherapy was initiated, with improvement of TB to 15. Unfortunately, his clinical status deteriorated rapidly despite chemotherapy and passed away.
Discussion: Choriocarcinoma is germ cell tumor which presents with normal alpha-fetoprotein and high beta-hCG levels, differentiating from other GCTs. Involvement of pancreas is quite rare. Only few case reports are available so far per literature review. EUS is a well established diagnostic tool, in detection of pancreatic lesions, FNB has further helped in the accurate diagnosis. We report this case of pancreatic choriocarcinoma due to its extreme rarity and the diagnostic dilemma.
Figure: Image 1: Contrasted cross sectional imaging (coronal view) showing ~13 cm pancreatic mass and multiple liver lesions. Image 2: Endoscopy demonstrating inflammatory changes and luminal obliteration of 2nd portion of the duodenum, due to extrinsic compression of the pancreatic mass. Image 3: Endoscopic ultrasound revealing large pancreatic head mass with cystic degeneration.
Priyanka Yaramada indicated no relevant financial relationships.
Harold Paredes indicated no relevant financial relationships.
Priyanka Yaramada, MD1, Harold Paredes, MD2. P0101 - Metastatic Choriocarcinoma Masquerading as Pancreatic Cancer: A Rare Entity, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.