Images in Clinical Urology

Mesenteric Lymphadenopathy in Testicular

Germ Cell Tumor
Hooman Djaladat, Kamran Movassaghi, Hamed Ahmadi, Craig R. Nichols, and
Siamak Daneshmand
In approximately 25% of patients with testicular germ cell tumor (GCT), the cancer metastasizes to lymph nodes and
distant organs. The initial lymphatic drainage site of GCTs is the retroperitoneum. GCTs rarely involve mesenteric
lymph nodes. In this study, we report a case of a 32-year-old male patient with GCT and associated mesenteric
lymphadenopathy. UROLOGY 83: e7ee8, 2014.
2014 Elsevier Inc.

Figure 1. (A) Prechemotherapy computed tomographic scan

showing lesions in the retroperitoneal, intraperitoneal, and
mesenteric region. (B) Postchemotherapy computed tomo-
Figure 2. (A) Intraoperative photo showing mesenteric
graphic scan illustrating significant residual disease. A,
lymph node dissection with skeletonized vessels. (B)
aorta; LRA, left renal artery; LRV, left renal vein; RRA, right
Dissected specimens all consistent with mature cystic
renal artery; RRV, right renal vein.
teratoma.

Financial Disclosure: The authors declare that they have no relevant financial interests.

From the Institute of Urology, University of Southern California, Los Angeles, CA;
and the Virginia Mason Medical Center, Seattle, WA
Reprint requests: Siamak Daneshmand, M.D., Institute of Urology, University of
Southern California, 1441 Eastlake Avenue, USC/Norris Comprehensive Cancer
Center, Suite 7416, USC Institute of Urology, Los Angeles, CA 90089. E-mail:
siadaneshmand@yahoo.com
Submitted: August 21, 2013, accepted (with revisions): November 4, 2013
ª 2014 Elsevier Inc.
All Rights Reserved
A
32-year-old man presented with worsening back
pain and hypertension. Massive retroperito-
neal and intraperitoneal masses with extension
into the renal hilum and root of mesentery were seen
in the computed tomographic scan Figure 1A. Tumor
markers were elevated (lactate dehydrogenase-790 IU/L,
0090-4295/14/$36.00 e7
http://dx.doi.org/10.1016/j.urology.2013.11.003
a-fetoprotein-2467 ng/mL, human chorionic
gonadotropin-3979 U/mL). Scrotal ultrasound revealed a
hypoechoic nodule in the right testis. Pathology from
orchiectomy showed pure seminoma. The patient was
diagnosed with stage III non-seminomatous germ cell
tumor (based on elevated AFP) and received chemo-
therapy (3 cycles of bleomycin, etoposide, and plat-
inum). Despite normalization of markers, computed
tomography as shown in Figure 1B illustrated disease
progression consistent with growing teratoma syndrome.
Surgical resection of pelvic, retroperitoneal, and
mesenteric masses was performed with special attention
to bowel vasculature. Pathology revealed mature
teratoma. Fourteen months after surgery, the patient is
alive with minimal residual but stable peripancreatic
cystic masses. Mesenteric lymphadenopathy (LAD) in
patients with GCT has rarely been reported.1 Given the
bulky retroperitoneal disease, mesenteric LAD can be
explained by lymphatic backflow from the retro-
peritoneum2 or disruption of lymphatic drainage
e8
pathways due to chemotherapy.3 Retroperitoneal histol-
ogy might have implications on the management of
mesenteric LAD.4 If histology reveals necrosis/fibrosis,
surveillance can be considered. In cases of teratoma,
most can be enucleated (Fig. 2), whereas others with
more desmoplastic reaction can be biopsied at the time
of retroperitoneal lymph node dissection (RPLND).
References
1. Chen SF. Germ cell tumor of the testiseclinicopathologic analysis of
114 cases. Chin J Oncol. 1985;7:277-279.
2. Park JM, Charnsangavej C, Wallace S, et al. Pathways of nodal
metastasis from pelvic tumors: CT demonstration. Radiographics.
1994;14:1309-1321.
3. Pano B, Sebastia C, Nicolau C, et al. Pathways of lymphatic spread in
male urogenital pelvic malignancies. RadioGraphics. 2011;31:
135-160.
4. Steyerberg EW, Keizer HJ, Messemer JE, et al. Residual pulmonary
masses after chemotherapy for metastatic nonseminomatous germ cell
tumor. Prediction of histology. ReHIT Study Group. Cancer. 1997;
79:345-355.
UROLOGY 83 (3), 2014