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CASE REPORT  
Year : 2012  |  Volume : 55  |  Issue : 3  |  Page : 406-408
Cutaneous metastasis of testicular choriocarcinoma, diagnosed by fine-needle aspiration cytology: A rare case report and review of the literature


1 Transplant Research Center, Department of Pathology, Shiraz University of Medical Sciences, Shiraz, Iran
2 Department of Pathology, Shiraz University of Medical Sciences, Shiraz, Iran

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Date of Web Publication29-Sep-2012
 

   Abstract 

Skin metastasis of testicular choriocarcinoma is very rare. Until now about nine cases have been reported in the English literature; however, only one of them has been diagnosed by fine-needle aspiration (FNA) cytology. Herein, we report our experience with FNA cytology diagnosis of a metastatic testicular choriocarcinoma to the skin of chin. The combination of highly atypical mononuclear cells (cytotrophoblasts) and multinucleated malignant cells (syncytiotrophoblasts) are characteristic of metastatic tumor in a known case of choriocarcinoma of testis.

Keywords: Choriocarcinoma, fine needle aspiration, skin nodule

How to cite this article:
Geramizadeh B, Rad H. Cutaneous metastasis of testicular choriocarcinoma, diagnosed by fine-needle aspiration cytology: A rare case report and review of the literature. Indian J Pathol Microbiol 2012;55:406-8

How to cite this URL:
Geramizadeh B, Rad H. Cutaneous metastasis of testicular choriocarcinoma, diagnosed by fine-needle aspiration cytology: A rare case report and review of the literature. Indian J Pathol Microbiol [serial online] 2012 [cited 2014 Apr 23];55:406-8. Available from: http://www.ijpmonline.org/text.asp?2012/55/3/406/101760



   Introduction Top


Choriocarcinoma is a highly malignant tumor with common metastasis to the lung and brain. [1] Skin metastasis of choriocarcinoma is very rare and about 15 cases have been reported in the English literature so far. [2] These cases have been from different sites such as testis, endometrium, retroperitoneum, and ovary. [1],[3] Testicular choriocarcinoma with skin metastasis is exceptional. The diagnosis of metastatic choriocarcinoma by fine-needle aspiration (FNA) has rarely been reported in locations such as breast, vagina or brain but only one of skin metastasis has been reported to be diagnosed by FNA. [4],[5],[6],[7] Diagnosis of metastatic tumors to skin by FNA cytology is very rapid and accurate, especially in the patients with known malignancy. [4],[7] In this case report we present a patient with testicular choriocarcinoma and a metastatic skin nodule which was diagnosed by FNA cytology.


   Case Report Top


A 26-year-old male referred to the hospital for right testicular enlargement, which after imaging studies turned out to be testicular tumor. With this impression right orchiectomy was done for him. Abdominal and chest computed tomography (CT) scan were normal with no evidence of metastasis.

Beta-human chorionic gonadatropin (HCG) at the time of diagnosis was >150000 IU/ ml (normal <5 IU/ml), but after resection it begins to decrease (5000/2700/1400/500).

Pathologic studies of the testicular tumor showed pure choriocarcinoma. After surgery, chemotherapy was started (bleomycin, cisplatin, etoposide, and dexamethazone). During his first hospital stay for chemotherapy, a small cutaneous nodule was detected in the right side of his chin [Figure 1].
Figure 1: Skin nodule on the chin

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FNA cytology of the nodule was performed yielded scanty material and the smears stained by Papanucolau (Pap) and Wright methods. Cytology smears showed rich cellularity composed of many tight clusters [Figure 2]a and rare isolated large mononuclear cells with severe atypia, hyperchromatic nuclei, one or multiple distinct nucleoli and plenty of basophilic cytoplasm [Figure 2]b. Some of these large cells showed prominent macronucleoli [Figure 2]c. Some multinucleated large atypical cells were also present.
Figure 2: (a) Many tight clusters of atypical cells (Wright, ×30). (b) Isolated highly atypical cells with large nucleoli in bloody background (Wright, ×400). (c) Highly atypical cells with prominent nucleoli, binucleation and hyperchromasia (Wright, ×250)

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With the diagnosis of subcutaneous metastatic choriocarcinoma, the nodule was excised which confirmed the cytological diagnosis [Figure 3].
Figure 3: Tissue biopsy of the resected mass shows typical choriocarcinoma with extensive necrosis (Hematoxylin and eosin, ×250)

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Now after a month the patient is well and still continuing the chemotherapeutic regimen.


   Discussion Top


Skin is an uncommon site for metastatic tumors and overall incidence of cutaneous metastasis of different tumor types is about 1.4-4.4%. [8]

The most frequent tumors with skin metastasis are breast, colon, and melanoma in women and lung, colon and melanoma in men. The most common sites of skin metastasis are chest and abdomen followed by head and neck. [8]

Metastatic testicular choriocarcinoma to the skin has been very rarely reported and to the best of our knowledge about nine cases of metastatic choriocarcinoma with skin metastasis has been reported in the English literature so far [Table 1]. [2],[7],[9],[10],[11],[12],[13],[14],[15],[16],[17] Until now only a case has been reported to be diagnosed by FNA cytology. [7]
Table 1: Clinical Characteristics of the reported patients with skin metastasis of testicular choriocarcinoma

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Cytologic smears of choriocarcinoma either primary or metastatic are reported to show both cytotrophoblasts and syncytiotrophoblasts. [9],[10] In our case, FNA of the subcutaneous nodule was performed and showed good cellularity with many tight clusters composed of mononuclear cells with large hyperchromatic nuclei and several distinct nucleoli. Rare multinucleated cells were present in the smears

The diagnosis of metastatic choriocarcinoma was made according to the patient's history and also confirmed by histology. However, it would be difficult to diagnose without known primary malignancy and if the smears were composed of predominantly mononuclear cytotrophoblasts. [4],[10] In this situation, any high grade malignant tumor from the more common cancers such as lung and breast could not be excluded without ancillary studies. [4]

There are reports of FNA cytology diagnosis of metastatic germ cell tumors to different sites other than skin such as brain, and mediastinum, but according to previous reports and our experience cytological findings of choriocarcinoma is characteristic i.e., presence of mononucleated cells and multinucleated giant cells corresponding to cytotrophoblasts and syncytiotrophoblasts, respectively, can be diagnostic especially with a positive history. [4] FNA cytology can be very helpful with rapid results for the diagnosis of metastatic skin choriocarcinoma. [7]

Our case is the second report of skin metastasis of choriocarcinoma which was diagnosed by FNA cytology.

 
   References Top

1.Chama CM, Nggada HA, Nuhu A. Cutaneous metastasis of gestational choriocarcinoma. Int J Gynecol Obstet 2002;77:249-50.  Back to cited text no. 1
[PUBMED]    
2.Gleizal A, Torossian JM, Wan DC, Béziat JL. Testicular choriocarcinoma presenting as cutaneous nasal metastasis: Case report and review of the literature. Br J Oral Maxillofac Surg 2008;46:416-8.  Back to cited text no. 2
    
3.Wesche WA, Khare VK, Chesney TM, Jenkins JJ. Non-hematopoietic cutaneous metastasis in children and adolescents: Thirty years experience at St. Jude Children's Research Hospital. J Cutan Pathol 2007;27:485-92.  Back to cited text no. 3
    
4.Choi HJ, Park IA. Fine needle aspiration of metastatic choriocarcinoma presenting as a breast lamp. A case report. Acta Cytol 2004;48:91-4.  Back to cited text no. 4
[PUBMED]    
5.Samantaray S, Rout N, Kakkar S, Pattanayak L. Choriocarcinoma presenting as a vaginal nodule: a rare presentation diagnosed by fine needle aspiration cytology. Acta Cytol 2009;53:364-5.  Back to cited text no. 5
[PUBMED]    
6.Arabi H, Shah M, Saleh H. Aspiration biopsy cytomorphology of primary pulmonary germ cell tumor metastatic to the brain. Diagn Cytopathol 2009;37:715-9.  Back to cited text no. 6
[PUBMED]    
7.Bhatia K, Vaid AK, Rawal S, Patole KD. Pure choriocarcinoma of testis with rare gingival and skin metastasis. Singapore Med J 2007;48:e77- 80.  Back to cited text no. 7
[PUBMED]    
8.Reyes CV, Jensen JA, Eng AM. Fine needle aspiration cytology of cutaneous metastasis. Acta Cytol 1993;37:142-8.  Back to cited text no. 8
[PUBMED]    
9.Winter CC, Trepashko DW. Rare solitary metastasis to subcutaneous tissue from choriocarcinoma of testis. Urology 1989;33:320-1.  Back to cited text no. 9
[PUBMED]    
10.Requena L, Sánchez M, Aguilar A, Sánchez Yus E. Choriocarcinoma of testis metastatic to the skin. J Dermatol Surg Oncol 1991;17:466-70.  Back to cited text no. 10
    
11.Chhieng DC, Jennings TA, Slominski A, Mihm MC Jr. Choriocarcinoma presenting as a cutaneous metastasis. J Cutan Pathol 1995;22:374-7.  Back to cited text no. 11
[PUBMED]    
12.Shimizu S, Nagata Y, Han-yaku H. Metastatic testicular choriocarcinoma of the skin. Report and review of the literature. Am J Dermatopathol 1996;18:633-6.  Back to cited text no. 12
[PUBMED]    
13.Tinkle LL, Graham BS, Spillane TJ, Barr RJ. Testicular choriocarcinoma metastatic to the skin: an additional case and literature review. Cutis 2001;67:117-20.  Back to cited text no. 13
[PUBMED]    
14.Sofikerim M, Doðan I, Ekici S, Bayraktar N, Ozen H. Testicular choriocarcinoma metastatic to the skin. Int Urol Nephrol 2005;37:759-62.  Back to cited text no. 14
    
15.Müller CS, Tilgen W, Pföhler C, Graf N. Cutaneous and systemic metastasis of a testicular choriocarcinoma. Am J Dermatopathol 2010;32:521-2.  Back to cited text no. 15
    
16.Geramizadeh B, Daneshbood Y, Karimi M. Cytology of brain metastasis of yolk sac tumor. Acta Cytol 2005;49:110-1.  Back to cited text no. 16
    
17.Naniwadekar MR, Desai SR, Kshirsagar NS, Angarkar NN, Dombale VD, Jagtap SV. Pure choriocarcinoma of ovary diagnosed by fine needle aspiration cytology. Indian J Pathol Microbiol 2009;52:417-20.  Back to cited text no. 17
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Correspondence Address:
Bita Geramizadeh
Department of Pathology, Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, PO BOX: 71345-1864
Iran
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DOI: 10.4103/0377-4929.101760

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