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Duodenal ulcer bleeding led to the first diagnosis of testicular cancer
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  1. Thanita Thongtan1,
  2. Anasua Deb1,
  3. Lukman Tijani2 and
  4. Vaness Costilla3
  1. 1Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
  2. 2Haematology Oncology, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
  3. 3Gastroenterology, University Medical Center, Lubbock, Texas, USA
  1. Correspondence to Dr Anasua Deb; anasua.deb{at}gmail.com

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Description

Worldwide, testicular cancer contributes to 1%–2% of all cancers in men1 and is also the most common malignancy in young adult men.2 Review of the Surveillance, Epidemiology, and End Results programme database from 1975 to 2015 revealed that in the USA, the incidence of testicular cancer has been increasing.3 Germ cell tumour (GCT) is the most common type, accounting for 95% of testicular cancer cases.4 Seminomas account for 60.2% of GCT and have a varied initial presentation.5 Gastrointestinal (GI) presentation of GCT is unusual as they rarely metastasise to the GI tract.6 Less than 5% of all testicular GCT metastasise to the GI tract, whereas the incidence of GI metastasis for seminomas is less than 1%.7 Upper GI tumour bleeding that leads to the first diagnosis of cancer accounts for 2.4% of all acute upper GI bleeding cases.8 We report a case of a male patient who presented with acute upper GI bleeding caused by a duodenal lesion invaded by retroperitoneal metastasis from a testicular GCT.

A 31-year-old man with chronic low back pain who had been taking naproxen for a long time presented with melena and generalised weakness for 2 weeks and a 20-pound weight loss in 1 month. The haemoglobin level was 50 g/L, and the abdominal examination was unremarkable. Esophagogastroduodenoscopy revealed a non-bleeding cratered duodenal ulcer with pigmented material measuring 20 mm in the second portion of the duodenum (figure 1). To rule out duodenal perforation, contrast-enhanced CT was performed, which revealed a 5.8×5 cm midline retroperitoneal soft tissue mass that displaced the third portion of the duodenum anteriorly (figure 2). Both the duodenal ulcer biopsy and the retroperitoneal mass biopsy revealed embryonal carcinoma (figure 3A). Testicular carcinoma was suspected as the primary source even though the patient had no testicular complaints. Both testicles were soft and normal in size. At the base of the right testicle, there was mild irregular notching. A testicular ultrasound showed that both testes were normal in size and that the right testis had multiple hypodense lesions (figure 4, arrow). The patient underwent right inguinal orchiectomy for diagnosis of staging. The pathological findings of the right testicle were confirmed to be seminoma (figure 3B). The patient was diagnosed with stage IIC right testicular GCT (cT2N3M0S1) and was treated with four cycles of bleomycin, etoposide and cisplatin chemotherapy. The patient is in remission at a 2-year follow-up.

Figure 1

Endoscopic view of a non-bleeding cratered duodenal ulcer with pigmented material in the second portion of the duodenum.

Figure 2

Contrast-enhanced CT revealed a midline retroperitoneal soft tissue mass that displaced the third portion of the duodenum anteriorly (arrow).

Figure 3

(A) Duodenal ulcer biopsy and the retroperitoneal mass biopsy revealed large highly pleomorphic tumour cells of embryonal carcinoma. (B) Right testicle excisional biopsy revealed seminoma.) Right testicle excisional biopsy revealed seminoma.

Figure 4

Right testicular ultrasound multiple hypodense lesions (arrow) despite normal size.

Learning points

  • Patients with testicular cancer may present with gastrointestinal bleeding if the retroperitoneal lymph node metastasis is large enough to extend to the gastrointestinal tract.

  • Clinicians should consider a testicular examination in young male patients who present with gastrointestinal bleeding despite no testicular complaint.

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References

Footnotes

  • Contributors TT was involved in drafting and revising the manuscript and in obtaining patient consent. AD was involved in drafting and revising the manuscript. LT was involved in patient care. LT and VC were involved in supervising and revising the manuscript. All authors have approved the final draft submitted.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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