Accepted Manuscript

Title: Germ cell tumor causing pleural effusion: A diagnostic

dilemma

Author: Surabhi Jaggi Reetu Kundu Sanjeev Binji Uma

Handa Varinder Saini

PII: S0019-5707(17)30184-1
DOI: http://dx.doi.org/doi:10.1016/j.ijtb.2017.08.025
Reference: IJTB 230

To appear in:

Received date: 12-6-2017

Accepted date: 1-8-2017

Please cite this article as: Surabhi JaggiReetu KunduSanjeev BinjiUma HandaVarinder
Saini Germ cell tumor causing pleural effusion: A diagnostic dilemma (2017),
http://dx.doi.org/10.1016/j.ijtb.2017.08.025.

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 Title page

TITLE: Germ cell tumor causing pleural effusion: A diagnostic dilemma

AUTHOR NAMES AND AFFILIATIONS:

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Surabhi Jaggia, Reetu Kundub*, Sanjeev Binjia , Uma Handac, Varinder Sainid

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a
Junior Resident, Department of Pulmonary Medicine, Government Medical College and

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Hospital, Sector 32 A, Chandigarh, 160030, India

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b
Assistant Professor, Department of Pathology, Government Medical College and Hospital,

Sector 32 A, Chandigarh, 160030, India

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Professor, Department of Pathology, Government Medical College and Hospital, Sector 32
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A, Chandigarh, 160030, India

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Professor, Department of Pulmonary Medicine, Government Medical College and Hospital,
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Sector 32 A, Chandigarh, 160030, India

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*Corresponding author: Reetu Kundu, Assistant Professor, Department of Pathology,

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Government Medical College and Hospital, Sector 32 A, Chandigarh, 160030, India.

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Telephone number: 9855573077

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Email id: reetukundu@gmail.com

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ABSTRACT

Straw coloured pleural fluid with raised adenosine deaminase (ADA) levels in young healthy

adults usually raises suspicion of tuberculosis, sometimes leading to laxity in carrying

thorough physical examination and missing out some important clues with potential

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disastrous consequences. A 35-year-old male was diagnosed to have left pleural effusion and

anti-tubercular treatment was started on the basis of straw coloured, lymphocyte-predominant

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pleural fluid with significantly raised ADA levels. When there was no improvement after 1

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month of treatment he was investigated further and found to have a mediastinal mass along

with hydro-pneumothorax. Fine needle aspiration cytology (FNAC) of the mass was done

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twice at different centers with different reports followed by biopsy from the mass to settle the

diagnosis. Histopathological examination revealed yolk sac tumor. Testicular ultrasound

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showed a mass with ill defined hypoechoic areas and lobulated margins in left testis, which

was missed on clinical examination. Serum lactate dehydrogenase (LDH) and alpha
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fetoprotein (AFP) levels were found to be elevated. Beta-human chorionic gonadotropin (β-
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hCG) was normal. The final diagnosis of nonseminomatous germ cell tumor with mediastinal
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metastasis was made. The present case underlines the importance of good clinical
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examination, an art which is diminishing with availability of sophisticated investigations and

a thin line of difference between potentially curable and fatal diagnosis, especially in young
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population, where malignancy is overlooked as a differential diagnosis. Furthermore, despite

all its advantages, too much reliance on FNAC may be responsible for misdiagnosis in certain

cases.

KEY WORDS

alpha-fetoprotein; beta-human chorionic gonadotropin; pleural effusion; testicular cancer;

fine needle aspiration cytology

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INTRODUCTION

Straw coloured pleural fluid with increased adenosine deaminase (ADA) levels in countries

endemic for tuberculosis like India in otherwise healthy younger population is usually

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considered to be of tubercular origin and this may lead to missing out looking for leads

pointing to certain uncommon causes for the same. Testicular cancers account for only 1% of

all cancers in males.1 However, these are the commonest solid tumors in males between 15

and 35 years of age.2 Testicular cancers frequently metastasize to the mediastinum. Prompt

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diagnosis should be made in such cases as they have high cure rates.

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CASE REPORT

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We present a case of 35-year-old male who presented with chief complaints of fever for two

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months, shortness of breath for one month and dry cough for four days. Patient was

investigated outside and diagnosed to have left sided pleural effusion (Figure 1). Straw

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colored pleural fluid was aspirated which was lymphocyte-predominant with ADA levels of

75 IU/L, which was a significant increase. Diagnosis of left tubercular pleural effusion was
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made and anti-tubercular treatment (ATT) was started (HRZE) according to body weight.

Patient presented to our centre after one month of taking ATT with no clinical improvement.
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On examination there were decreased breath sounds on left side and trachea was shifted to
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right side. Pleural fluid aspiration was done which showed thick hemorrhagic fluid,
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cytological examination of which showed blood only. Intercostal chest tube drainage was
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done and hemorrhagic fluid was drained. CECT chest was subsequently done and it showed

left loculated hydro-pneumothorax with left posterior mediastinal mass in contact with aorta
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(Figure 2). FNAC done from the mass was suggestive of adenocarcinoma (Figure 3, 4).

Tumor was staged as TxNxM1. Patient was planned for chemotherapy. Meanwhile patient’s

condition deteriorated and he went to another higher centre where repeat FNAC of mass was

done which was suggestive of squamous cell carcinoma. Patient was accordingly started on

carboplatin and etoposide. Due to variation in the two reports, biopsy was subsequently done

from the mass and histopathological examination revealed yolk sac tumor (Figure 5).

Thereafter, testicular ultrasound was done which showed ill defined hypoechoic areas with

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lobulated margins in the left testis which was missed on clinical examination. Serum LDH

and AFP were then ordered and found to be raised. Beta-hCG was normal (Table 1). Whole

body scintigraphy was done which showed no evidence of bony metastasis. MRI brain was

also normal. Hence, diagnosis of nonseminomatous germ cell tumor with mediastinal

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metastasis was made. Patient underwent orchidectomy whose histopathological examination

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further confirmed the diagnosis and he was treated with bleomycin, etoposide and cisplatin.

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Patient also underwent surgical removal of the mediastinal tumor after three cycles of

chemotherapy. There was subsequent decrease in serum LDH and AFP levels. Patient

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subsequently recovered completely from the disease (Figure 6). On follow up after three

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years, patient is healthy and alive with no evidence of recurrence of disease.

DISCUSSION
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Testicular cancer has three main types: germ cell tumors, non–germ cell tumors, and

extragonadal tumors. Germ cell tumors, which are the most common, are classified as either
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seminoma or nonseminoma, based on histology. Of the three main types of testicular cancer,
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nonseminomatous germ cell tumors (NSGCTs) are second only to seminomas in terms of
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frequency.3 Testicular cancer usually manifests as a painless swelling/ enlargement of the

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testis and only about 10% of patients complain of new onset pain in the testicle. Nearly a

quarter of patients with metastatic disease experience symptoms like low back pain caused by
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tumoral metastasis to the retroperitoneal lymph nodes.4 The serum markers α-fetoprotein, ß-

human chorionic gonadotropin, and lactate dehydrogenase can be useful for diagnosis,

treatment and surveillance.4,5 Radical orchidectomy is the primary treatment for most patients

presenting with a suspicious testicular mass. Orchidectomy is both diagnostic and

therapeutic. Given that the testis can act as a sanctuary site for tumor cells from

chemotherapeutic agents, orchidectomy should be performed even in the case of metastases

suitable for biopsy.4,6 Patients with metastatic NSGCTs are usually treated using a

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multimodal approach consisting of systemic chemotherapy followed by consideration of post

chemotherapy retroperitoneal lymph node dissection.4,7 As testicular cancers are curable even

in the presence of metastatic disease, the correct diagnosis and staging is a critical component

for therapeutic decision making and prognosis. Yolk sac tumor exhibits diverse cytologic

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patterns which include papillary, cohesive clusters, acinar formations and scattered cells with

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vacuolated cytoplasm and conspicuous nucleoli.8 At times, coarse clumped chromatin and

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irregular nuclear membranes are observed.9 Schiller- Düval bodies, a characteristic feature on

histopathology is occasionally seen on FNAC.10 Aforementioned cytologic features can lead

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to a mistaken diagnosis of adenocarcinoma/ squamous cell carcinoma on FNAC as happened

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in this case. Therefore, high degree of suspicion is required in such cases for correct

diagnosis. Anterior mediastinal involvement is seen in primary mediastinal germ cell tumors
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which is expected in view of their proposed thymic origin whereas posterior mediastinal

involvement occurs in case of metastases from germ cell tumors,11 as seen in the index case.
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The current case underlines the importance of good clinical examination, an art which is
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diminishing with availability of sophisticated investigations. It also signifies that despite all
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its advantages, FNAC might not be the best tool in certain situations to clinch the correct
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diagnosis. The case highlights the thin line of difference between a potentially curable and a

fatal diagnosis and the important role played by the pathologist in this regard. Testicular
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cancers are curable even in the presence of metastatic disease. Thus, high degree of suspicion

is required in these cases. Malignancy should always be kept in differential diagnosis even in

younger population with undiagnosed pleural effusion.

CONFLICTS OF INTEREST

The authors have none to declare.

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REFERENCES

1. Office for National Statistics. Cancer statistics registrations: registrations of cancer

diagnosed in 2002 England. Series MB1 no.33. London: Office for National Statistics,

2005.

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2. Devesa SS, Blot WJ, Stone BJ, Miller BA, Tarone RE, Fraumeni JF Jr. Recent cancer

cr
trends in the United States. J Natl Cancer Inst. 1995; 87: 175–182.

us
3. Mostofi FK, Sesterhenn IA. Revised international classification of testicular tumours. In:

Jones WG, Harnden P, Appleyard I, eds. Germ cell tumours III. Vol. 91 of Advances in

an
the biosciences. Oxford, England: Pergamon Press, 1994: 153–158.

4. Siverino RO, Uccello A, Giunta ML, Uccello M, Amadio P, Petrillo G. Non-

M
Seminomatous Germ Cell Tumor Metastasis to the Jaw: An Imaging Case Report. Iran J

Radiol. 2016; 13:e27812.

d
te

5. Kreydin EI, Barrisford GW, Feldman AS, Preston MA. Testicular cancer: what the

radiologist needs to know. AJR Am J Roentgenol. 2013; 200: 1215–1225.

p

6. Greist A, Einhorn LH, Williams SD, Donohue JP, Rowland RG. Pathologic findings at
ce

orchiectomy following chemotherapy for disseminated testicular cancer. J Clin Oncol.

Ac

1984; 2: 1025–1027.

7. Fizazi K, Pagliaro L, Laplanche A, Flechon A, Mardiak J, Georois L, et al. Personalised

chemotherapy based on tumour marker decline in poor prognosis germ-cell tumours

(GETUG13): aphase3, multicentre, randomised trial. Lancet Oncol. 2014; 15: 1442–1450.

8. Gupta R, Mathur SR, Arora VK, Sharma SG. Cytologic features of extragonadal germ

cell tumors: a study of 88 cases with aspiration cytology. Cancer. 2008; 114: 504–511.

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Page 7 of 16
9. Kataria SP, Misra K, Singh G, Kumar S. Cytological findings of an extragonadal yolk sac

tumor presenting at an unusual site. J Cytol. 2015; 32: 62–64.

10. Chhieng DC, Lin O, Moran CA, Eltoum IA, Jhala NC, Jhala DN, et al. Fine needle

aspiration biopsy of nonteratomatous germ cell tumors of the mediastinum. Am J Clin

t
ip
Pathol. 2002; 118: 418–424.

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11. Raghavan D, Barrett A. Mediastinal seminomas. Cancer. 1980; 46: 1187–1191.

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Legends to the figures

Figure 1: Chest radiograph showing left sided pleural effusion

Figure 2: CECT Chest showing mass in the left hemithorax encasing the collapsed left

lung

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Figure 3: Aspirate smear showing tissue fragment and sheet of loosely cohesive tumor

cells (H&E x100)

Figure 4: Photomicrograph showing moderately anaplastic tumor cells with conspicuous

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nucleoli and vacuolated cytoplasm (H&E x400)

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Figure 5: Histopathologic section showing Schiller–Düval body in yolk sac tumor (H

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&E x400)

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Figure 6: Chest radiograph after treatment

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Table 1. Serum tumor markers before and after treatment

Tumor marker Before treatment After treatment Normal Value

Alpha Fetoprotein 5790 20 <7.2
(ng/mL)
Beta-hCG (IU/L) 1.15 0.26 <6.5
Serum LDH (U/L) 2032 350 225-450

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Beta-hCG: Beta-Human Chorionic Gonadotropin, Serum LDH: Serum Lactate
Dehydrogenase

Highlights

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The current case underlines the importance of good clinical examination, an art which is

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diminishing with availability of sophisticated investigations. It also signifies that despite all

its advantages, FNAC might not be the best tool in certain situations to clinch the correct

us
diagnosis. The case highlights the thin line of difference between a potentially curable and a

fatal diagnosis and the important role played by the pathologist in this regard. Testicular

an
cancers are curable even in the presence of metastatic disease. Thus, high degree of suspicion

is required in these cases. Malignancy should always be kept in differential diagnosis even in
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younger population with undiagnosed pleural effusion.
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