A case of relapsed testicular cancer initially isolated to the spleen.

Testis cancer is the most common malignancy in men 15 to 35 years of age. Patients are staged with beta-human chorionic gonadotropin and alpha-fetoprotein (AFP), computed tomography (CT) scans of the chest, abdomen, and pelvis, and a history and physical examination. After orchiectomy, options for clinical stage I disease include surveillance, retroperitoneal lymph node dissection, or primary chemotherapy. Because testis cancer metastasizes in a very predictable pattern (nodal spread initially to the retroperitoneum, hematologic spread to the lungs, and only later to liver, bone, or central nervous system), surveillance is a rationale option. A 37-year-old man underwent a left orchiectomy in November 2004 after he noted a testicular mass on self-examination. Pathology revealed a germ cell tumor comprised of embryonal carcinoma, seminoma, and teratoma with lymphovascular space invasion. The patient opted for surveillance. In July 2005, he had a slight increase in his AFP (15 ng/mL) and a solitary 1.5 cm splenic lesion (Fig. 1) when compared with his prior CT scan from May 2005. A fine-needle aspirate of the splenic lesion revealed a nonseminomatous germ cell tumor. Further work-up included normal serum human chorionic gonadotropin and chest x-ray. One month later, a CT of the chest was obtained (before initiation of chemotherapy), and it revealed a 1.4 cm right upper lung nodule that was not seen in scans from 2004 or on the chest x-ray 1 month prior. From August through October 2005, he received 3 cycles of bleomycin, etoposide, and cisplatin. Before treatment, his AFP had risen significantly to 245, but after the final cycle, his AFP normalized. Repeat CT scan showed persistence of the splenic lesion (1.4 cm from 2.5 cm). Splenectomy was performed, and pathology revealed pure teratoma. A repeat chest CT was also done at this time and showed a persistent, though smaller, 1.1 cm right upper lobe nodule. In light of the teratoma found in the spleen, he was scheduled for a right upper lobe wedge resection, and the resection also revealed teratoma. Follow-up CT scans remain normal, as do serum tumor markers. Splenic involvement in the absence of other sites of metastasis is extremely uncommon. To our knowledge, this is the only case reported in which the patient did not initially have other sites of disease, although he did develop a solitary pulmonary metastasis 1 month later. Four cases in the literature have been reported with splenic metastases in the presence of other metastatic sites. One patient presented with a seizure and had a solitary brain lesion, a splenic lesion, and a new testicular primary nonseminomatous germ cell tumor. The other 3 cases had synchronous disease in other sites of the abdomen or pelvis (retroperitoneal involvement and renal involvement). All 4 patients received systemic chemotherapy. After chemotherapy, only the first patient underwent a splenectomy, and pathology revealed metastatic teratoma. Two patients died shortly after their initial treatment, and the fourth patient is presumed alive. This demonstrates the need for a multidisciplinary approach in patients with metastatic testicular neoplasms, including those with unusual sites such as the spleen.