Case Author(s): Xia Wang, M.D, Heather Tauschek, M.D. and Jerold Wallis, M.D. , 10/28/05 . Rating: #D., #Q.

Diagnosis: Pulmonary and Mediastinal Metastases from Testicular Cancer

Brief history:

46 year old male with shortness of breath.

Images:

Coronal PET image. View MIP cine in AVI format.

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View second image(pt). Axial PET/CT

View third image(pt). Axial PET/CT

View fourth image(fl). Chest X-ray

Full history/Diagnosis is available below

Diagnosis: Pulmonary and Mediastinal Metastases from Testicular Cancer

Full history:

A 46 year-old male developed shortness of breath and was found to have multiple lung masses. The biopsy revealed pulmonary embryonocarcinoma. He was found to have an enlarged left testicle. PET/CT was requested to for initial staging.

Radiopharmaceutical:

14.6 mCi F-18 Fluorodeoxyglucose i.v.

Findings:

PET/CT: In the chest, there are multiple FDG-avid lymphadenopathy within right hilar, right paratracheal, and precarinal regions. There are multiple large FDG-avid pleural based masses in both lungs. There is large mass at the right lung base which shows intense FDG uptake peripherally with central photopenia likely relating to necrosis. In the left testicle, there is a solid mass with increased FDG uptake peripherally and central necrosis.

CXR: There are multiple pleural based masses in both lungs and enlarged lymph nodes in the mediastinum.

Discussion:

Germ cell tumors (GCTs) are a morphologically distinct group of neoplasms with varied clinical presentation. Ninety-five percent of tumors arising in the testes are GCTs. GCTs are classified on the basis of their histologic features into seminomas and nonseminomas(1).

Tumor markers alpha-fetoprotein (AFP), beta-HCG, and lactate dehydrogenase (LDH) are vital in the evaluation and management of patients with GCTs. They are used for determining diagnosis, staging, prognosis, and response to therapy(1).

GCTs are seen predominantly in whites and rarely in African Americans. GCT is the most common solid tumor in men aged 15-35 years. Risk of developing GCT in the cryptorchid testis is higher than in the normally descended testis(1).

Pattern of metastases is as follows: The right testicular tumors usually metastasize to nodes between the aorta and the inferior vena cava (interaortocaval nodes); left testicular tumors usually metastasize to the pre-aortic and para-aortic nodes (1). Left supraclavicular adenopathy and pulmonary nodules may occur with or without retroperitoneal disease. Metastasis rarely occurs in the liver, bone or brain.

FDG-PET has been reported to have the potential to evaluate the residual GCT or suspected recurrent GCT to reliably distinguish between the viable tumor and fibrosis/necrosis. A negative FDG-PET following the chemotherapy of testicular cancer suggests eradication of malignant disease, but increased activity may represent either viable or inflammatory tissue. Important limitations have been noted including the low level of uptake of FDG PET in differentiated teratoma and the false-positives immediately following chemotherapy(2,3). PET scanning is particularly useful where the tumour markers are rising and CT is negative.

Reference:

1. Carver BS, Sheinfeld J. Germ cell tumors of the testis. Ann Surg Oncol. 2005 Nov;12(11):871-80. Epub 2005 Sep 26.

2. Nuutinen JM, Leskinen S, Elomaa I, Minn H, Varpula M, Solin O, Soderstrom KO, Joensuu H, Salminen E. Detection of residual tumours in postchemotherapy testicular cancer by FDG-PET. Eur J Cancer. 1997 Jul;33(8):1234-41

3. Huddart RA. Use of FDG-PET in Testicular Tumours. Clinical Oncology (2003) 15:123-127

Followup:

Patient underwent left radical orchidectomy. Pathology showed non-seminomatous malignant germ cell neoplasm with embryonal carcinoma, choriocarcinoma and teratoma components.

Major teaching point(s):

FDG PET is a good modality for staging and post-therapy evaluation of GCT and particularly useful where the tumor markers are rising and CT is negative.

ACR Codes and Keywords:

References and General Discussion of PET Tumor Imaging Studies (Anatomic field:Genitourinary System, Category:Neoplasm, Neoplastic-like condition)

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Case number: pt144

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