Benign Neck Metastasis of a Testicular Germ Cell Tumor

Germ cell tumors (GCTs) are relatively rare neoplasms considered to be curable malignancies since the introduction of cisplatin. The presence of neck metastasis has been reported, with fewer reports of metastatic mature teratoma. In this study, 3 cases of “benign neck” metastasis in patients with GCT between 1998 and 2010 were reviewed retrospectively. In all 3 cases the presenting clinical sign was a left lower neck mass, leading to the diagnosis of the primary site in the testis. All had surgical salvage following chemotherapy, with benign lesions or mature teratoma in histopathology of the neck mass. Chemotherapy was followed by salvage lower-half neck dissection showing benign features in the neck specimen, even though malignancy was proven histologically in other areas. Only 1 patient had a postoperative chyle leak, which resolved spontaneously after several days. Neck dissection is recommended in those patients because malignancy cannot be excluded.Key words: Germ cell tumor, Metastasis, Neck, TeratomaTeratoma comes from the Greek words terato, meaning “a monster,” and onkoma, meaning “swelling or mass.” Both teratomas and germ cell tumors (GCTs) arise from postmeiotic germ cells and may occur in both gonadal and extragonadal locations. GCTs are relatively rare neoplasms that account for 0.8% of all cancers in males, and they comprise 95% of testicular neoplasms.¹ GCTs are the most common malignancy among men ages 15 to 44 years, with a peak incidence between the age of 25 and 35 years.^2,3 GCTs have been considered to be curable malignancies, even in the advanced stage, since the introduction of cisplatin,⁴ and a dramatic improvement has been shown by using a treatment protocol of neoadjuvant cisplatin-based chemotherapy followed by surgical resection of residual tumor mass, with a complete response rate of 70% to 80%.⁵Testicular teratomas may present in both prepubertal and adult males. The prognosis differs greatly between these two groups. In children, teratomas most often occur before the age of 4 years, and they have a benign behavior in this age group. In adults, teratomas are usually part of mixed GCTs and have the potential to metastasize. The presence of neck metastasis in patients with testicular GCT is a rare but known phenomenon and has been reported to be present in up to 5% of cases.^6,7 Metastatic disease from the testis first involves the retroperitoneal lymph nodes, and then the tumor spreads via the thoracic duct to its emptying site near the junction of the left internal jugular and subclavian veins. Hence, the left supraclavicular region is one of the possible places where testicular teratomas can metastasize.^8,9 Because testicular carcinoma is the most common malignancy in men ages 20 to 30 years, a left supraclavicular mass in this age group should raise suspicion for a concomitant testicular mass.Our literature search has shown few reports of mature teratomas in patients who had been treated for GCT with neoadjuvant chemotherapy and surgical resection.^10–13 We present here our experience with 3 patients who were treated with neoadjuvant chemotherapy and surgical resection of highly malignant lesion, followed by surgical resection of a metastasis in the left lower neck, with benign histology.