Saudi Journal of Kidney Diseases and Transplantation

CASE REPORT
Year
: 2012  |  Volume : 23  |  Issue : 6  |  Page : 1238--1240

Mixed germ-cell testicular tumor in a liver transplant recipient


Mehdi Salehipour1, Farzad Kakaei2, Saman Nikeghbalian3, Kourosh Kazemi3, Sara Pakbaz4, Seyed Ali Malekhosseini3,  
1 Department of Urology, Shiraz University of Medical Sciences, Namazi Hospital, Shiraz, Iran
2 Department of Surgery and Transplantation, Tabriz University of Medical Sciences, Imam Reza Hospital, Tabriz, Iran
3 Department of Surgery and Transplantation, Shiraz University of Medical Sciences, Namazi Hospital, Shiraz, Iran
4 Department of Pathology, Shiraz University of Medical Sciences, Namazi Hospital, Shiraz, Iran

Correspondence Address:
Farzad Kakaei
Visceral Transplant Surgeon, Department of Surgery and Transplantation, Tabriz University of Medical Sciences, Imam Reza Hospital, Tabriz
Iran

Abstract

The development of malignancies after solid organ transplants is a well-known complication. Cancer is associated with significant consequences for the organ transplant patient. It is expected that cancer will surpass cardiovascular complications as the leading cause of death in transplant patients within the next few years. We report on a 36-year-old male patient who developed mixed germ-cell testicular tumor seven years after liver transplantation for alcoholic cirrhosis. He was treated with orchiectomy, retroperitoneal lymph node dissection and post-operative chemotherapy.



How to cite this article:
Salehipour M, Kakaei F, Nikeghbalian S, Kazemi K, Pakbaz S, Malekhosseini SA. Mixed germ-cell testicular tumor in a liver transplant recipient.Saudi J Kidney Dis Transpl 2012;23:1238-1240


How to cite this URL:
Salehipour M, Kakaei F, Nikeghbalian S, Kazemi K, Pakbaz S, Malekhosseini SA. Mixed germ-cell testicular tumor in a liver transplant recipient. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2022 May 24 ];23:1238-1240
Available from: https://www.sjkdt.org/text.asp?2012/23/6/1238/103566


Full Text

 Introduction



The development of malignancies after solid organ transplants is a well-known complication. Cancer is associated with significant consequences for the organ transplant patient. It is expected that cancer will surpass cardiovascular complications as the leading cause of death in transplant patients within the next several years. We report a liver transplant recipient who developed mixed germ-cell testicular tumor seven years after undergoing transplantation.

 Case Report



A 36-year-old man with end-stage liver disease caused by alcohol consumption underwent a successful cadaveric liver transplantation. Seven years after the transplantation, he presented with a painless left testicular enlargement of four months duration. Following transplantation, the patient was on treatment with tacrolimus, mycophenolate mofetil (MMF, Cellcept) and prednisolone as immunosuppressive drugs.

On physical examination, the left testis was larger than the right, without tenderness, redness or other inflammatory signs. There were no other remarkable physical findings. Complete blood count, liver and renal function tests, urinalysis, urine culture as well as urine stain for acid-fast bacilli were normal. Serum α-fetoprotein (AFP), β-human chorionic gonadotropin (β-hCG) and lactate dehydrogenase, (LDH) were in the normal range (AFP = 1.3 IU/mL, β-hCG = 0.01 mIU/mL, LDH = 370 U/L). Scrotal ultrasonography revealed a mixed echogenic mass in the left testis with a thin rim of normal testicular parenchyma in the periphery, suggesting an inflammatory disease.

Based on the results of the tests, the patient received antibiotics for three weeks without any benefit. Thus, a decision was made for left testicular exploration. The left testis was explored via a left inguinal incision and frozen section was sent to rule out malignancy. Because the frozen section was suggestive of malignancy, a left radical orchiectomy was done. Histopathological evaluation of the excised sample revealed a mixed germ-cell tumor (seminoma 50%, yolk sac tumor 30% and immature teratoma 20%) without involvement of the spermatic cord [Figure 1] and [Figure 2]. Post-orchiectomy, an abdominal-pelvic spiral computerized tomography (CT) scan showed no evidence of retroperitoneal lymphadenopathy. The patient was scheduled for modified retroperitoneal lymph node dissection (RPLND). After left modified RPLND, histopathologic evaluation of the resected lymph nodes showed tumor involvement in one of the 20 resected lymph nodes in the para-aortic area.{Figure 1}{Figure 2}

 Discussion



Use of newer immunosuppressive drugs has reduced the incidence of acute rejection, and has extended the life expectancy of allograft recipients. Consequently, post-transplant malignancy has become an important cause of morbidity and mortality. The etiology of post-transplant malignancy is believed to be multi-factorial, and involves impaired immune response to neoplastic cells as well as depressed anti-viral immune activity. [1]

In liver transplant recipients, post-transplant lymphoproliferative disorders (PTLD) are more common that skin cancer; 57% of all tumors in liver transplant recipients are PTLD. [1],[2],[3],[4] This difference is because a larger percentage of liver transplant recipients are children and, additionally, the use of immunosuppressive drugs is more intense after liver transplantation. [1]

Testicular cancer is the most common malignancy in young men aged 15-35 years, and comprises 1% of all neoplasms in males. There are two main histological subtypes: seminoma and non-seminoma. About 60% of testicular cancers have more than one histologic pattern (mixed tumors). [5] Non-seminomas have a high potential for metastases, the majority of which are lymphatic. Left-sided tumors metastasize to the left para-aortic and the inter-aortocaval lymph nodes. Right-sided tumors metastasize to the inter-aortocaval and pre-aortic and paracaval lymph nodes. [5] The tumor markers AFP and β-HCG are elevated in 70-80% of affected patients. AFP may be produced by pure embryonal carcinoma, terato carcinoma or yolk sac tumors, but not by pure chorio-carcinoma or pure seminoma.[5]

There are some non-malignant causes of persistently elevated levels of both AFP and HCG. Liver dysfunction, caused by drugs, viral hepatitis and alcohol abuse, may all lead to elevated AFP levels. These tumor markers were normal in our patient.

After radical orchiectomy, seminomas are usually treated by radiation and/or chemotherapy, depending on the stage of the disease. RPLND is indicated in patients with non-seminoma for staging and treatment of early stage disease and for post-chemotherapy residual masses. For patients with minimal retroperitoneal disease (stage N1) who had complete resection, careful follow-up is recommended. For patients with more extensive disease (stage N2), two cycles of adjuvant chemotherapy are recommended after RPLND, and almost always prevent relapse. [5],[6] Our patient had stage N2 and, hence, he received two cycles of post-operative chemotherapy.

After documentation of malignancy in transplant recipients, immunosuppressive drugs should be modified. There are two immunosuppressive drugs that have demonstrated antineoplastic effects in several studies; MMF and sirolimus (SRL). SRL has been used in liver transplant recipients treated for hepatocellular malignancy. [1] We changed the patient's immunosuppressive drugs from tacrolimus (4 mg/ day) and MMF (2000 mg/day) to SRL (2 mg/ day) and MMF (2500 mg/day), and decreased the dose of prednisolone from 10 mg/day to 5 mg/day. During the 24 months follow-up, AFP and β-hCG remained normal and there was no other evidence of tumor recurrence by serial abdominal ultrasonography or computerized tomography scan.

In conclusion, malignancy is a very important cause of mortality in transplant recipients. Once malignancy is suspected, diagnostic investigation and staging should be done rapidly. Treatment involves modification of immunosuppressive drugs, resection of localized disease followed by chemotherapy and close follow-up.

References

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4Penn I. Post transplantation de novo tumors in liver allograft recipients. Liver Transplant Surg 1996;2:52.
5Richie JP, Steele GS. Neoplasms of the testis. In Campbell-Walsh Urology. 9 th ed. Philadelphia: Saunders; 2007. p. 893-935.
6Jewett MA, Pandya RR. Retroperitoneal lymphadenectomy. In Glenn's Urologic Surgery. 6 th ed. Philadelphia: LWW; 2004. p. 505-12.