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Year : 2017  |  Volume : 32  |  Issue : 2  |  Page : 153-154  

Primary germ cell tumor of testes with extensive lymph nodal and splenic metastases masquerading lymphoma on 18-F-FDG PET/CT


1 Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Department of Nuclear Medicine, Eastern Diagnostics, Kolkata, India
3 Department of Pathology, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication16-Mar-2017

Correspondence Address:
Dr. Shamim Ahmed Shamim
Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.202243

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   Abstract 

Germ cell tumors (GCT) account for the 95% of the malignancies associated with testes. They are the most common solid malignancies affecting the males in the age group of 15–35 years. It is known to be bilateral in 3% of cases. We herein present FDG PET-CT findings of a case with biopsy proven GCT with multiple lymph nodal and splenic metastases mimicking lymphomatous neoplasm.

Keywords: Germ cell tumor, FDG PET-CT, lymphomaatous neoplasm, splenic metastases


How to cite this article:
Tripathy S, Mukherjee A, Bal C, Tripathi M, Mallick S, Shamim SA. Primary germ cell tumor of testes with extensive lymph nodal and splenic metastases masquerading lymphoma on 18-F-FDG PET/CT. Indian J Nucl Med 2017;32:153-4

How to cite this URL:
Tripathy S, Mukherjee A, Bal C, Tripathi M, Mallick S, Shamim SA. Primary germ cell tumor of testes with extensive lymph nodal and splenic metastases masquerading lymphoma on 18-F-FDG PET/CT. Indian J Nucl Med [serial online] 2017 [cited 2019 Nov 17];32:153-4. Available from: http://www.ijnm.in/text.asp?2017/32/2/153/202243

A 40-year-old male presented with chief complaints of back pain, intermittent fever, dyspnea, pain abdomen, flank pain, and swelling of neck for 3 months. On physical examination, there were painful palpable cervical lymph nodes and splenomegaly. For further evaluation, the patient was referred for FDG PET-CT. 18F-FDG PET/CT revealed multiple hypermetabolic lymph nodes involving both sides of diaphragm with multiple hypermetabolic hypodense lesions involving spleen [Figure 1]a-[Figure 1]d. Along with that, heterogenous FDG uptake and calcification noted in enlarged left testis [Figure 1]e, [Figure 1]f. Based on the FDG PET-CT findings, provisional diagnosis of lymphoproliferative disorder with secondary testicular involvement was made [Figure 1]g MIP image. So for further confirmation, biopsy from the left supraclavicular lymph node was performed, which revealed predominantly fibrocollagenous tissue with chronic inflammatory infiltrate. Tumor cells showed hyperchromatic nuclei with prominent nucleoli and moderate amount of clear cytoplasm [Figure 2]a. Tumor cells are immunopositive for SALL4 [Figure 2]b and CD117 [Figure 2]c, whereas negative for pancytokeratin [Figure 2]d, CD20 [Figure 2]e and CD3 [Figure 2]f, which suggested seminomatous germ cell tumor.
Figure 1: (a-d) 18F-FDG PET/CT revealed multiple hypermetabolic lymph nodes involving both sides of diaphragm with multiple hypermetabolic hypodense lesions involving spleen. (e,f) Along with that heterogenous FDG uptake and calcification noted in enlarged left testis.

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Figure 2: Microphotograph shows atypical calls with scant cytoplasm and hyper chromatic nuclei and mild nuclear pleomorphism. Few lymphoid cells are present in the background. [H and E ×200] Immunohistochemistry shows positive for (b) SAL4 [×200], (c) CD117 [×200], whereas it negative for (d) Cytokeratin [×200], (e) CD20, and (f) CD3 [×200]

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The testes have shown to demonstrate normal physiological 18F-FDG uptake, which is moderate in intensity and symmetrical in pattern, and the level of uptake declines with advancing age.[1] There are currently no standard interpretative criteria to evaluate 18F-FDG testicular uptake. The interpretation generally relies on visual analysis, and the presence of focal or asymmetrical uptake on PET would be regarded as pathological. Secondary involvement of the testes as an extranodal site is rare and occurs in 1% of all NHL and more common in males >60 years.[2],[3] Furthermore, there is a paucity of literature, limited to several case reports, evaluating the pattern, prevalence, and clinical significance of abnormal testicular 18F-FDG uptake on PET in patients with lymphoma.[4],[5],[6] So for further confirmation, histopathological evaluation was suggested which was consistent with metastatic seminoma. Seminoma is a malignant germ cell tumor of the testis or, more rarely, of extragonadal locations which originates in the germinal epithelium of the seminiferous tubules. About half of germ cell tumors of the testis are seminomas. Metastatic seminoma is the paradigm of a curable cancer and the cure rate has now attained 95%, with extrapulmonary visceral metastases being the main identified prognostic factor.[7],[8] So, we hereby discussed FDG PET-CT findings of seminoma involving left testis with extensive lymph nodal, splenic, and liver metastasis masquerading lymphoma. This case further illustrates the fact that heterogeneous uptake in testes should be interpreted with caution and should be confirmed with histopathological diagnosis.

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Conflicts of interest

There are no conflicts of interest

 
   References Top

1.
Kosuda S, Fisher S, Kison PV, Wahl RL, Grossman HB. Uptake of 2-deoxy-2-[18F] fluoro-D-glucose in the normal testis: retrospective PET study and animal experiment. Ann Nucl Med 1997;11:195-9.  Back to cited text no. 1
    
2.
Moller MB, d'Amore F, Christensen BE. Testicular lymphoma: a population-based study of incidence, clinicopathological correlations and prognosis. The Danish Lymphoma Study Group, LYFO. Eur J Cancer 1994;30:1760-4.  Back to cited text no. 2
    
3.
Verma N, Lazarchick J, Gudena V, Turner J. Chaudhary UB, Testicular lymphoma: an update for clinicians. Am J Med Sci 2008;336:336-41.  Back to cited text no. 3
    
4.
Kuo PH, Cooper DL, Cheng DW. Recurrence of lymphoma presenting as asymmetrically increased testicular activity on FDG-PET/CT. Semin Nucl Med 2006;36:105-7.  Back to cited text no. 4
    
5.
Scalcione LR, Katz DS, Santoro MS, Mahboob S, Badler RL, Yung EY. Primary testicular lymphoma involving the spermatic cord and gonadal vein. Clin Nucl Med 2009;34:222-3.  Back to cited text no. 5
    
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Sidhu P, Lin P, Son H, Rosenfeld D, Lin M. Testicular fluorine-18 fludeoxyglucose uptake on positron emission tomography CT in patients with lymphoma: clinical significance and management impact. Br J Radiol 2014;87- Epub 2014 Oct 21.  Back to cited text no. 6
    
7.
Nallu A, Mannuel HD, Hussain A. Testicular germ cell tumors: biology and clinical update. Curr Opin Oncol 2013;25:266-72.  Back to cited text no. 7
    
8.
Daneshmand S, Albers P, Fosså SD, Heidenreich A, Kollmannsberger C, Krege S, et al. Contemporary management of postchemotherapy testis cancer. Eur Urol 2012;62:867-76.  Back to cited text no. 8
    


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