Prognostic Differences Between Surveillance and Active Treatment After Initial Orchiectomy in Patients With Stage I Mixed Germ Cell Tumors of the Testis: A Propensity Score Matching Analysis.

INTRODUCTION: The prognosis and optimal treatment approach for stage I mixed germ cell cancers of the testis are not well-established. This study aimed to assess contemporary treatment rates and their correlation with the cancer-specific mortality (CSM) and other-cause mortality (OCM) in patients with stage I testicular mixed germ cell tumors (TMGCT) who underwent orchiectomy, comparing surveillance with active treatment, including chemotherapy (CHT) and retroperitoneal lymph node dissection (RPLND). METHODS: Retrospective analysis of clinical data from stage I TMGCT patients who underwent orchiectomy was conducted using the Surveillance, Epidemiology, and End Results database from 2004 to 2019. The annual percentage change (APC) in the use of surveillance, postoperative CHT, and RPLND was examined. Propensity score matching (PSM) and cumulative incidence, analyses were employed to compare differences in CSM and OCM between surveillance and active treatment, as well as between CHT and RPLND. Multivariate competing-risks regression models were utilized to investigate independent factors affecting CSM and OCM among stage I TMGCT patients. RESULTS: The study included 5743 individuals with stage I TMGCT that underwent surveillance (61.6%), CHT(27.2%), or RPLND (11.2%). Among them, 82 deaths were attributed to TMGCT, and 82 deaths resulted from other causes. Surveillance rates increased over time (APC: 0.635%, P = 0.008), as did CHT rates (APC: 0.863%, P < 0.001), while RPLND rates declined (APC: -0.96%, P < 0.001). After PSM, multivariate competing-risks regression analysis showed that, active treatment, compared to surveillance, was not an independent factor for CSM and OCM. In contrast, when compared to CHT, RPLND was an independent factor associated with lower CSM (hazard ratio = 0.247, 95% confidence interval: 0.08-0.761; P = 0.015), but not OCM (hazard ratio = 0.946, 95% confidence interval: 0.377-2.37; P = 0.91). CONCLUSIONS: Surveillance and CHT rates have increased over time for patients with stage I TMGCT following initial orchiectomy, while RPLND utilization has decreased. There was no significant difference in CSM between surveillance and active treatment groups, but RPLND demonstrated significantly lower CSM than CHT in active treatment. Our findings suggest that the usage of RPLND in patients with stage I TMGCT should be reconsidered.

Testicular Mixed Teratoma and Yolk Sac Tumor, Prepubertal Type: A Case Report with Summary of Prior Published Cases.

BACKGROUND: Testicular mixed germ cell tumor is common in the post-pubertal age, less so in prepuberty. There are only 3 reports of prepubertal mixed teratoma and yolk sac tumor. Two of these cases had immature teratoma component and were in the neonatal age group. The third case in a toddler had a mature teratoma component. CASE REPORT: An 18-month-old boy presented with a testicular mass. Serum AFP was elevated (2200 ng/ml). The orchidectomy specimen contained a yolk-sac tumor and a small epidermoid cyst, indicating a mature teratomatous component. CONCLUSION: We report a testicular mixed teratoma and yolk sac tumor, prepubertal type along with summary of prior published cases. There is only one report describing this combination of mature teratoma with yolk sac tumor in the prepubertal testis.

Staged operations for a hypervascular mixed germ cell tumor with growing teratoma syndrome: a case report.

INTRODUCTION: A mixed germ cell tumor with a teratoma component can become enlarged following chemotherapy, and such an event is diagnosed as growing teratoma syndrome. Removing large, hypervascular tumors including a tumor encased by developed vasculatures from the pineal region is challenging during a single operation. CASE REPORT: A 15-year-old male underwent chemotherapy for mixed germ cell tumors according to the KSPNO G082 protocol. This case of a mixed germ cell tumor with growing teratoma syndrome was recognized very early during chemotherapy. The tumor was completely removed during the staged operations. First, the anteriorly located tumor on the third ventricle was removed via the transcallosal interforniceal approach, and 1 month later, the occipital transtentorial approach was used for the pineal tumor with decreased vascularity. CONCLUSION: Performing staged operations could be recommended for large hypervascular pineal tumors, which can be safely removed during the second operation once vascularity has decreased.

Wnt suppressor and stem cell regulator TCF7L1 is a sensitive immunohistochemical marker to differentiate testicular seminoma from non-seminomatous germ cell tumor.

The accurate classification and proper identification of testicular germ cell tumors is imperative for treatment selection and clinical prognosis. Although such distinction can often be achieved by microscopic morphology alone, ancillary tests may at times be needed. T-cell factor 7 L1 (TCF7L1, also known as TCF3), a component of the Wnt signaling pathway, plays important roles in embryonic stem cell self-renewal and lineage specification. Here we examined the immunohistochemical expression and diagnostic utility of TCF7L1 in testicular germ cell tumors. Fifty cases of testicular germ cell tumors were collected, including 23 seminomas, 6 embryonal carcinomas, 1 teratoma, 1 choriocarcinoma, and 19 mixed germ cell tumors. The components of the mixed germ cell tumors were seminoma (n = 3), embryonal carcinoma (n = 18), yolk sac tumor (n = 9), teratoma (n = 15), and choriocarcinoma (n = 4). On immunohistochemistry of TCF7L1, only nuclear staining was considered positive. Staining was graded as negative (<5% of tumor cells stained), minimal (5-25% positive), focal (26-50%), and diffuse (>50%). All non-seminomatous components (n = 54) exhibited distinct nuclear expression of TCF7L1 (54/54; 100%). In contrast, no TCF7L1 expression was detected in the majority of seminomatous tumor component (24/26; 92%). Two seminomas (2/26; 8%) exhibited minimal weak nuclear staining (5% and 10%, respectively) for TCF7L1. In conclusion, TCF7L1, highly expressed in non-seminomatous testicular germ cell tumors, might be used as a marker for diagnosis of testicular germ cell tumors, two therapeutically different entities, for better patient management.

[Diagnosis and treatment of testicular mixed germ cell tumors: A report of 27 cases].

OBJECTIVE: To investigate the clinical features, diagnosis, treatment and prognosis of testicular mixed germ cell tumors (TMGCT). METHODS: This retrospective study included 27 cases (2 children and 25 adults) of TMGCT confirmed surgically and pathologically in our hospital from December 2007 to December 2012. The patients' ranged in the age of onset from 7 months to 63 years, averaging at 29.5 years. We analyzed the clinical data and reviewed the related literature. RESULTS: At pathological examination, the TMGCTs displayed a variety of subtypes, including 13 cases of yolk sac tumor (48.1%), 13 cases of seminoma (48.1%), 18 cases of embryonal carcinoma (66.7%), 4 cases of choriocarcinoma (14.8%) and 17 cases of teratoma (63.0%). Of the total number of cases, 15 (55.6%) contained two different germ cell histological elements, 11 (40.7%) contained three, and 1 (3.7%) contained four; 18 cases (66.7%) were in stage Ⅰ, 6 (22.2%) in stage Ⅱ, and 3 (11.1%) in stage Ⅲ. All the patients underwent radical orchiectomy and, in addition, retroperitoneal lymph node dissection (RPLND) + BEP chemotherapy was administered for 3 cases of stage Ⅱ and 1 case of stage Ⅲ. Three cases of stage Ⅱ and 2 cases of stage Ⅲ refused RPLND and 1 case of stage Ⅲ refused chemotherapy. A 27－49-month (mean 30 months) follow-up was completed for 21 of the patients, during which retroperitoneal metastasis was found in 3 cases of stage Ⅰ and 2 cases of stage Ⅱ, who again received RPLND+BEP and experienced no more recurrence. One case of stage Ⅲ refused both RPLND and chemotherapy and died at 12 months. CONCLUSIONS: TMGCT is a rare carcinoma with atypical clinical features, mostly comprising two or three different germ cell histological elements. Comprehensive treatment of RPLND combined with BEP chemotherapy may achieve a high survival rate and reduce recurrence for most of the patients with TMGCT of stage Ⅱ or above.

Equine placental mixed germ cell tumor with metastasis to the foal.

The placenta from an embryo transfer-recipient mare and live foal was examined. The placenta was effaced by multifocal masses, which ranged from less than 1 cm to 14 cm in diameter. The foal represented at 52 days for lethargy, ataxia, and urine dribbling; due to a poor prognosis, the foal was euthanized. At necropsy, the liver was effaced by multifocal, pale, irregular nodules. The lumbar vertebrae and other skeletal sites had multifocal lytic lesions. The placenta had 4 populations of neoplastic cells, including a spindle cell population, tall columnar and transitional epithelial cell populations, and an undifferentiated polygonal cell population. The foal's liver had similar populations and patterns of cells as those in the placenta. The lesion in the placenta and the masses in the foal were diagnosed as a mixed germ cell tumor and metastatic mixed germ cell tumor, respectively.

Spontaneous rupture­induced life­threatening mediastinal mixed germ cell tumor: A case report and therapeutic considerations.

Spontaneous rupture and hemorrhage of mediastinal germ cell tumors is a rare occurrence. In the current report, the case of a 20-year-old male patient who was admitted with chest tightness and dyspnea is presented. An urgent chest CT scan revealed a large tumor in the right anterior mediastinum, measuring ~12 cm in diameter, with associated intratumoral hemorrhage. An emergency thoracotomy was performed to excise the lesion, which revealed that the bleeding was caused by a ruptured tumor. Postoperative pathological findings revealed a mediastinal mixed germ cell tumor consisting of four pathological types: Embryonal carcinoma, seminoma, yolk sac tumor and immature teratoma. Postoperatively, the patient showed marked improvement in the symptoms of dyspnea. However, the follow-up outcome was poor, and the patient succumbed 2 months after surgery. To the best of our knowledge, there are no reports of rupture and hemorrhage involving >4 mixed germ cell tumors. In the present report, the experience of the treatment of the patient is summarized, and literature was reviewed to improve clinicians' awareness of the disease.

Cytodiagnostic Dilemma in a Lung Mass as the First Presentation of Testicular Mixed Germ Cell Tumor Metastasis.

Testicular mixed germ cell tumors (TMGCTs) are rare malignant tumors comprising of two or more types of germ cell tumors. Their onset may be undetectable and the patient may first present with symptoms of metastasis. We hereby report a case of a young male who presented with respiratory discomfort and had no symptoms of primary testicular tumor. CT-guided FNAC lung revealed mainly necrotic, keratinous debris with a focus of chondromyxoid stroma. Differential diagnoses of components of teratoma, squamous cell carcinoma and inclusion cyst was considered. FNAC was reported out for the possible presence of teratoma components. Retrospectively, physical examination and subsequent USG revealed testicular tumor. The case led to a diagnostic dilemma as the patient presented with no prior history suggestive of metastasis from testicular mixed germ cell tumor. The aim of the current case report is to alert the pathologists and clinicians about this uncommon clinical presentation and diagnostic relevance of FNA. It highlights that FNA lung revealing keratinous material should always be searched for the possibility of teratoma component.

Primary lung chordoma: a case report.

BACKGROUND: Chordoma, a rare malignant tumor arising from notochordal tissue, usually occurs along the spinal axis. Only a few published reports of primary lung chordomas exist. Herein, we present a case of primary lung chordoma and discuss important considerations for diagnosing rare chordomas. CASE PRESENTATION: We report a case of primary lung chordoma in a 39-year-old male with a history of testicular mixed germ-cell tumor of yolk sac and teratoma. Computed tomography revealed slow-growing solid lesions in the left lower lobe. We performed wedge resection for suspected germ-cell tumor lung metastasis. Histologically, large round or oval cells with eosinophilic cytoplasm were surrounded by large cells with granular, lightly eosinophilic cytoplasm. Tumor cells were physaliphorous. Immunohistochemistry was positive for brachyury, S-100 protein, epithelial membrane antigen, vimentin, and cytokeratin AE1/AE3, suggesting pulmonary chordoma. Re-examination of the testicular mixed germ-cell tumor revealed no notochordal elements. Although some areas were positive for brachyury staining, hematoxylin and eosin (HE) staining did not show morphological features typical of chordoma. Complementary fluorescence in situ hybridization (FISH) of the lung tumor confirmed the absence of isochromosome 12p and 12p amplification. Thus, a final diagnosis of primary lung chordoma was established. CONCLUSIONS: In patients with a history of testicular mixed germ cell tumors, comparison of histomorphology using HE and Brachyury staining of lung and testicular tumors, and analyzing isochromosome 12p and 12p amplification in lung tumors using FISH is pivotal for the diagnosis of rare lung chordomas.

Endoscopic Endonasal Transsphenoidal Surgery for Intrasellar Mixed Germ Cell Tumors.

A mixed germ cell tumor (MGCT) in the neurohypophysis is very rare, with only a few reported cases1-4 but none with surgical videos. In this report, the endoscopic endonasal transsphenoidal approach for MGCT in the neurohypophysis is presented (Video 1). A 12-year-old girl with ocular pain, fatigue, and nausea presented with gradual onset of quadrant hemianopsia and left oculomotor palsy. Magnetic resonance imaging showed an enhanced mass in the sella turcica with multiple components involving the pituitary gland and stalk. Her endocrinological examination showed decreased levels of pituitary hormones and simultaneously elevated serum levels of alpha-fetoprotein and beta-human chorionic gonadotropin. After pituitary hormone replacement, endoscopic endonasal transsphenoidal surgery was planned. The tumor was strongly adherent to the surrounding structures, and gross total resection was achieved. The histological diagnosis was MGCT with a teratoma component. Postoperatively, her vision and oculomotor palsy improved swiftly, and adjuvant chemotherapy and radiotherapy were administered. In this case, 3-dimensional computer graphics were created from the preoperative computed tomography and magnetic resonance imaging studies. Preoperative simulation with the 3-dimensional computer graphic images and intraoperative verification with indocyanine green images facilitated our understanding of the surrounding anatomy, including the tumor components, pituitary gland, and internal carotid arteries.5 After removal of the tumor, multilayer fascial closure was performed for skull base reconstruction.6 MGCT in the neurohypophysis can be strongly adherent to the surrounding structures, requiring careful dissection and resection under endoscopy. At the last follow-up (8 months after surgery), the tumor was successfully controlled, and the patient had no neurological symptoms with pituitary hormone replacement therapy.

Isolated retroperitoneal mixed germ cell tumor presenting as acute abdomen - case report.

Extragonadal germ cell tumors are an uncommon clinical entity. Their prevalence varies between 1 and 5% of all germ cell tumors. Approximately 85-90% of cases have metastatic changes at the time of diagnosis. In our article we would like to present a case of an 18-year-old patient who was admitted to the hospital due to acute abdominal symptoms. A day earlier, the patient suffered blunt abdominal trauma during workout. Post-traumatic changes, which were described after admission in computed tomography, intraoperatively proved to be masses of extraperitoneal tumor.

Renal vein thrombosis due to metastatic germ cell tumor, report of a case with a very rare clinical scenario.

BACKGROUND: Renal metastasis is a rare manifestation of germ cell tumors. Extension of malignant lesions into the renal vein can complicate the scenario. CASE: This report presents a 35-year-old man with primary stage IS NSGCT. Fourteen months after radical orchiectomy he presented with metastasis in the lung, kidney, and para-aortic lymph nodes. He received multiple lines of salvage treatments including chemotherapy and surgery. Intraoperative exploration during radical nephrectomy and retroperitoneal lymphadenectomy revealed intra-renal vein involvement with a prominent teratomatous component. CONCLUSION: Defining the exact extent of malignant lesions, especially endovascular lesions, is very important to clarify how advanced the malignant lesions are. The surgeons must be aware of the risk factors that predict vascular involvement, and therefore, providing intraoperative access to vascular surgery procedures when needed.

Testicular Mixed Germ Cell Tumor Presenting with Upper Gastrointestinal Bleeding: A Case Report.

Testicular mixed germ cell tumors (TMGCTs) are aggressive neoplasms that often have metastases at the time of diagnosis, primarily in the lungs, bones, and brain. Gastrointestinal metastases are rare, occurring in less than 5% of cases, while duodenal involvement is extremely rare, with only few reported cases. Furthermore, gastrointestinal bleeding is an atypical initial presentation of metastatic TMGCTs. Herein, we present a very rare case of upper gastrointestinal bleeding caused by a duodenal metastasis of a TMGCT in a 24-year-old man. The patient was admitted to our hospital due to abdominal pain and melena with a hemoglobin level of 52 g/L. He had no history of testicular swelling, or any other symptoms or signs of a testicular tumor. Upper gastrointestinal endoscopy revealed a duodenal tumor mass with irregular bleeding, and abdominal ultrasound and computed tomography showed a duodenal mass that infiltrate retroperitoneum. Emergency surgery was performed, and the histopathological findings of the resected specimen were consistent with TMGCT metastasis. Subsequently, a testicular tumor was confirmed and surgically removed; however, multiple metastatic deposits were observed in the lungs. Due to the patient's poor general condition, chemotherapy was not performed. The patient died 3 months after the initial diagnosis. This case suggests that, although duodenal metastatic TMGCTs are rare, they should be considered in the differential diagnosis of gastrointestinal bleeding in young male patients.

A rare case of life-threatening mixed germ cell tumor infiltrating the heart: A case report.

INTRODUCTION AND IMPORTANCE: Extragonadal germ cell tumors at the mediastinum are rare and comprise of 3-4 % of all germ cell tumors. Mixed GCTs can remain asymptomatic for long periods and often present with complications. We present a case of a young male patient with a mediastinal tumor infiltrating the heart and obstructing the right ventricular outflow tract, causing cardiogenic shock. CASE PRESENTATION: A 16-year-old male came with chief complain of shortness of breath and underwent an echocardiogram which revealed a mass in the right atrium and right ventricle. On CT scan, a solid mass in the mediastinum, expanding and infiltrating the right atrium was found. Our patient underwent surgical treatment. Histopathology results were consistent with mixed germ cell tumor comprised of seminoma, yolk sac, and mature teratoma at the right atrial and mediastinum. CLINICAL DISCUSSION: The pathogenesis of extragonadal GCTs has been linked to abnormal and/or incomplete migration of the primordial germ cells from the endoderm yolk sac to gonads. Mediastinum GCT can become clinically problematic through its growth patterns, especially its expansive profile, which can cause compression on surrounding mediastinal structures, including major vessels, which in turn diminish blood flow. Overall survival improvement is strongly linked with surgical resection of the tumor, which achieve removal of tumor tissue resistant to chemotherapy and provides sample for histological examination, which helps assessment of pathological response to chemotherapy and planning of further management. CONCLUSION: The mediastinum is a site of different neoplasia, including germ cell tumors. Despite its low incidence, the diagnosis of a mediastinal mixed germ cell tumor should be considered in young patients with a mediastinal mass. This tumor is aggressive and often infiltrates surrounding structures and metastasis. Physicians must be aware of the difficulties and complications associated with the diagnosis.

Primary Intracranial Germ Cell Tumors: A Study with an Integrated Clinicopathological Approach.

Background and Objective: Primary intracranial germ cell tumors (ICGCTs) are rare and are histologically classified as germinomas and non-germinomatous with distinctive prognostic and therapeutic implications. ICGCTs, essentially due to the inherent difficulty of surgical access, pose different challenges and management connotations than their extracranial counterparts. This is a retrospective analysis of histologically verified ICGCTs, which was undertaken to evaluate various clinicopathological features and their implications on patient management. Materials and Methods: Eighty-eight histologically diagnosed cases (over 14 years) of ICGCT at our institute formed the study cohort and were classified into germinoma and non-germinomatous germ cell tumors (NGGCTs). Additionally, germinomas were further subdivided on the basis of 1) tumor marker (TM) levels, as germinoma with normal TM, mildly elevated TM, and markedly elevated TM and 2) radiology features, as germinomas with typical radiology and atypical radiological features. Results: ICGCT with age ≤6 years (P = 0.049), elevated TM (P = 0.047), and NGGCT histology (P < 0.001) showed significantly worse outcomes. Furthermore, germinomas with markedly elevated TM and certain atypical radiological features showed prognosis akin to NGGCT. Conclusions: Analysis of our largest single cancer center Indian patient cohort of ICGCT shows that inclusion of age ≤6 years, raised TM, and certain radiological features may assist clinicians in overcoming the limitations of surgical sampling, with better prognostication of histologically diagnosed germinomas.

Metastatic Testicular Mixed Germ Cell Tumor Presenting as Posterior Scrotal Pain in the Emergency Department: A Case Report.

Testicular neoplasms, or testicular cancer, are not typically seen in the emergency department (ED) since their presentation involves a painless hard mass that emerges slowly over time. Uncommon presentation of testicular neoplasm to the ED with acute onset of scrotal pain may present challenges as an incomplete physical examination without supplemental imaging and laboratory workup may overlook the diagnosis of testicular neoplasm. As a result, a delay in proper treatment may occur. Early recognition of testicular neoplasm can decrease morbidity and mortality and improve overall patient survival. Here, we present a case of a 32-year-old male who presented in the ED with an acute onset of testicular pain localized on the posterior right side of the scrotum. Despite the unusual presentation, a complete physical examination, including a complete genitourinary system exam, was performed. During the physical examination, a high index of suspicion for testicular neoplasm was present. Necessary imaging and laboratory workup were ordered. Based on the findings, testicular neoplasm was highly suspected. Thus, surgical intervention was pursued to remove the suspicious mass and pathology revealed a mixed germ cell tumor. Further imaging and laboratory workup showed metastasis into other organ systems, and medical management was chosen to treat the metastatic neoplasm systemically.

Cytological spectrum of testicular malignancies with histopathological correlation: A retrospective analysis.

BACKGROUND: Testicular malignancy is the most common solid organ cancer occurring in young men. The most common testicular malignancy is germ cell tumor. Extragonadal malignancies such as lymphomas are rare. Testicular fine-needle aspiration cytology (FNAC) in cancer is a bit controversial amidst fear of tumor seeding along the needle tract. Nevertheless, its largely safe, cost-effective technique providing a quick and fairly reliable diagnosis. METHODS: A retrospective analysis of testicular malignancies on FNAC over a period of 9 years with cyto-histological correlation wherever possible was carried out. FNAC slides and cell blocks with immunocytochemistry wherever done were retrieved. RESULTS: A total of 74 cases were obtained. The age ranged from 1 year to 65 years. Infiltration by leukemia was the most common malignancy detected in pediatric population, while germ cell tumors were common amongst young adults and middle-aged men. In elderly, metastatic carcinoma, infiltration by lymphoma were identified. On FNAC, 38 cases were of leukemic infiltration, 27 of germ cell tumors (subtyped as mixed germ cell tumors-15 cases, seminoma-11 cases, and yolk sac tumor-1 case) with two cases each of non-Hodgkin lymphoma, Leydig cell tumor, metastatic adenocarcinoma, and one case each of metastatic small cell carcinoma, rhabdomyosarcoma, and malignant neoplasm. Histological correlation was available in 15/74 cases. Only 3 cases were discordant. Seeding of tumor along the needle tract was not seen. CONCLUSION: The current study deciphers the cytological spectrum of testicular malignancies on FNAC and highlights its importance as a reliable modality for a prompt diagnosis of testicular tumors guiding patient management.

Intraperitoneal seeding of a testicular mixed germ cell tumor following spontaneous intraperitoneal mass rupture with associated anti-NMDA paraneoplastic encephalitis.

A 25-year-old male was admitted to the neurological intensive care unit for neurologic deterioration, likely caused by a paraneoplastic syndrome secondary to testicular malignancy. He experienced spontaneous rupture and hemorrhage of his testicular mass arising from an undescended testis while admitted. The tumor was excised, revealing a mixed germ cell tumor. Serum tumor markers began to rise after 4 cycles of chemotherapy. Surveillance scans 32 weeks after mass rupture revealed numerous tumor deposits throughout his peritoneum concerning for teratoma. We review a case of intraperitoneal metastasis of a testicular mixed germ cell tumor following intra-abdominal mass rupture.

Successful surgical management of massive hemoretroperitoneum caused by spontaneous rupture of retroperitoneal lymph node metastases in a patient with advanced mixed germ cell tumor: a COVID-19 pandemic-related surgical challenge.

BACKGROUND: Spontaneous rapture of a germ cell tumor (GCT) metastases causing massive hemoretroperitoneum in a patient without choriocarcinoma component who has not received previous systemic chemotherapy is an exceedingly rare event. In such a devastating case scenario, a high index of clinical suspicion for early diagnosis and appropriate management is crucial. CASE PRESENTATION: We report on a 25-year-old male patient with a 4-month history of orchiectomy for testicular GCT (tGCT), who presented in the emergency department with acute abdomen and hemodynamic instability. Urgent computed tomography scan depicted a retroperitoneal mass measuring approximately 13 × 11.4 × 15 cm and massive intraperitoneal hemorrhage. Hemoperitoneum caused by spontaneous rapture of the metastatic retroperitoneal mass was suspected. COVID-19 pandemic-related deviation from the oncologic surveillance standards combined with COVID-19-related patient's emotional distress and self-neglect had led to loss of opportunity for appropriate adjuvant chemotherapy, obviously leading to the development of this devastating complication. An emergency, surgical exploration was decided. The bleeding mass was adequately exposed following a Cattell-Braasch maneuver and active bleeding was controlled by a challenging resection of approximately 80% of the lymph node mass volume. Pathological evaluation of the specimen revealed teratoma with low volume of yolk sac tumor component and extensive necrosis, findings compatible with the patient's history. Postoperative recovery was uneventful, followed by early start of adjuvant chemotherapy. Two years after the operation the patient is doing well with no evidence of recurrent disease. CONCLUSIONS: Massive hemoperitoneum is a devastating event that exceedingly rarely can complicate the clinical course of patients with advanced tGCT. Emergency surgical intervention is usually necessary however, sound judgement and careful surgical techniques are required for a positive and uneventful outcome. During COVID-19 pandemic, first-line medical personnel push their limits further not only to ensure health care services standards but also, to manage unpredictable, life-threatening cancer-related complications, associated with COVID-19-related deviation from appropriate oncologic surveillance and care.

Exceedingly Rare Bilateral Synchronous Germ Cell Testicular Tumors With Different Histopathological Features.

Bilateral synchronous testicular tumors are a relatively uncommon occurrence, especially when they involve germ cell tumors of different histology. In this context, we present a compelling case report of a male patient who was diagnosed with bilateral synchronous germ cell testicular tumors, with one being a seminoma and the other a non-seminomatous germ cell tumor (NSGCT). The coexistence of two distinct histological types, seminoma and NSGCT, necessitates a comprehensive diagnostic approach to accurately identify and characterize each tumor. This underscores the importance of clinical history, physical examination, imaging techniques, and histopathological analysis to establish an appropriate diagnosis. Careful consideration must be given to factors such as tumor stage, histological subtype, and individual patient characteristics to determine the most suitable treatment strategy. Treatment options may encompass a combination of surgery, chemotherapy, and radiation therapy, tailored to each tumor's specific characteristics and the patient's overall health. By highlighting this unique case, we aim to underscore the significance of meticulous evaluation and accurate diagnosis when confronted with bilateral synchronous testicular tumors of different histology.