Japanese Journal of Clinical Oncology 30:239-240 (2000)
© 2000 Foundation for Promotion of Cancer Research
Spermatic Cord Metastases from Gastric Cancer with Elevation of Serum hCG-ß: A Case Report
Tomonori Ota1,
Mitsuru Shinohara1,
Masahiko Tanaka1,
Yoji Date1,
Hironao Itakura1,
Akio Munakata1,
Kenji Kinoshita1,
Tsunekazu Hishima2,
Morio Koike2 and
Masatsugu Kitamura3,+
Departments of 1Urology and 2Pathology, Tokyo Metropolitan Komagome Hospital, Tokyo and 3Department of Surgery, Tokyo Metropolitan Bokuto Hospital, Tokyo, Japan
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ABSTRACT
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Spermatic cord metastases from gastric cancer are rare. We here
document a case involving a gastric cancer that mimicked primary
testicular tumor because of elevation of the serum human chorionic
gonadotropin-beta (hCG-ß). The possibility of metastasis
or recurrence of prior malignancies should therefore be considered
when the clinical features described here are encountered, although
elevation of hCG-ß is rare with tumors other than
those in testis.
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INTRODUCTION
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Metastatic tumors of the spermatic cord are rare. Elevation
of the serum level of human chorionic gonadotropin-ß
(hCG-ß) is generally indicative of a testicular tumor.
However, we have encountered a case of spermatic cord metastases
from a gastric cancer featuring an increase in serum hCG-ß.
We here document our findings and the literature for such cases.
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CASE REPORT
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A 51-year-old male underwent surgery for a Borrmann III type
stomach cancer. Histologically, poorly differentiated adenocarcinoma,
featuring variant signet ring cell, mucinous elements and lymph
node metastasis was revealed. UFT was administrated for post-operative
adjuvant therapy. After 9 years, facial edema, increase of body
weight and swelling of the left scrotum without pain or fever
appeared. Computed tomography revealed right hydronephrosis,
ascites and a mass lesion in the right pelvic cavity associated
with peritoneal dissemination of prior gastric cancer. Although
left hydrocele testis was also observed, an intrascrotal solid
tumor remained after aspiration. Serum LDH was within the normal
range, but hCG-ß and CA19-9 were elevated (9.48 ng/ml
and 6411.2 U/ml, respectively). A particularly high value for
hCG-ß was also found in hydrocele fluid (83.2 ng/ml).
Since the elevation of CA19-9 implied recurrence of gastric
cancer, but a primary testicular tumor was also suspected because
of intrascrotal tumor unrelated to the pelvic mass and the elevation
of hCG-ß, we performed left high orchiectomy. Grossly
the surgical specimen was a spermatic cord tumor. The tumor
had invaded the epididymis and parietal tunica vaginalis. Testis
was clearly separated from the tumor (Fig.
1). Hematoxylin and
eosin staining and PAS staining revealed it to be an invasive
mucinous adenocarcinoma (Fig.
2), with histochemically demonstrable
hCG-ß positive foci (Fig.
3A). The prior gastric cancer
tissue also had hCG-ß positive foci (Fig.
3B). These
indicated recurrence of gastric cancer in the pelvic cavity
and the left spermatic cord. Chemotherapy with 5-FU and methotrexate
was transiently effective, but the patient died 1 year later.
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Figure 1. A 2.5 x 1.5 x 1.5 cm solid tumor on the spermatic cord. The spermatic cord tumor had invaded the epididymis and parietal tunica vaginalis. Testis was clearly separated from the tumor.
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Figure 2. Hematoxylin and eosin staining of the spermatic cord tumor revealing adenocarcinoma features with scirrhoid invasion and ductal formations (x200).
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Figure 3. (A) Histochemical staining revealed hCG-ß-positive foci in the spermatic cord tumor (x320). (B) hCG-ß-positive foci were also observed in the prior gastric cancer tissue featuring signet ring cell and mucinous elements (x400).
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DISCUSSION
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The major primary sites for metastatic spermatic cord tumors
are considered to be the colon, stomach and pancreas (
1). Kanno
et al., however, reported that the most frequent primary site
was the stomach (70.4%) in Japan (
1). In the present case, the
diagnosis of recurrence of the prior gastric cancer was relatively
simple on the basis of the mass lesion in the pelvic cavity
and the elevation of serum CA19-9. However, the scrotal tumor
with elevation of serum hCG-ß pointed to a primary
testicular tumor.
It is well known that serum 
-fetoprotein (AFP), hCG-ß and LDH are elevated with testicular tumors. These biomarkers are useful not only for diagnosis but also for the evaluation of the efficacy of treatments. Elevation can also occur in some situations, including tumor destruction, iatrogenic hypogonadism and hepatic dysfunction, but an increase in hCG-ß is rare with tumors other than those in the testis. Gastric cancer is one of the few exceptions that is relatively frequently associated with increased blood levels of hCG (2). Thus 10.5–23.5% of patients have been found to demonstrate immunoreactive hCG (2,3), although this is not used as a marker for gastric cancer at present. It is reported that 50.8% of gastric cancers are immunoreactive for hCG-ß with no significant difference between early and advanced lesions (4). Retrospectively, we examined the binding of antibody to hCG-ß in the prior gastric cancer tissue in the present case and also detected hCG-ß-positive foci (Fig. 3B).
Only one case of primary leiomyosarcoma of the spermatic cord has been reported to be positive for hCG-ß (5) and, to our knowledge, this is the first description of a metastatic tumor at this site with elevation of hCG-ß. As demonstrated here, the possibility of metastasis or recurrence of prior malignancies should also be considered when a palpable tumor is identified in the scrotum, even when a rise in serum hCG-ß is apparent.
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Acknowledgement
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We thank Dr Malcolm A. Moore for his kind advice during the
preparation of the manuscript.
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FOOTNOTES
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+ For reprints and all correspondence: Tomonori Ota, Department
of Urology, Tokyo Metropolitan Komagome Hospital, 3–18–22
Hon-Komagome, Bunkyo-ku, Tokyo 113-8677, Japan. E-mail: tota-k@komagome-hospital.bunkyo.tokyo.jp
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REFERENCES
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1 Kanno K, Ohwada S, Nakamura S, Ohya T, Iino Y, Morishita Y, et al. Epididymis metastasis from colon carcinoma: a case report and a review of the Japanese literature.
Jpn J Clin Oncol 1994;
24:340–4.
[Abstract/Free Full Text]
2 Braunstein GD, Vaitukaitis JL, Carbone PP, Ross GT. Ectopic production of human chorionic gonadotrophin by neoplasms. Ann Intern Med 1973;78:39–45.
3 Rosen SW, Weintraub BD, Arronson SA. Nonradom ectopic protein production by malignant cells: direct evidence in vitro. J Clin Endocrinol Metab 1980;50:834–41.[Abstract/Free Full Text]
4 Fukayama M, Hayashi Y, Koike M. Human chorionic gonadotropin in gastric cancer. An immunohistochemical study suggesting independent regulation of subunits. Virchows Arch A 1987;411:205–12.[Web of Science]
5 Seidl C, Lippert C, Grouls V, Jellinghous W. Leiomyosarcoma of the spermatic cord with paraneoplastic beta-hCG production. Pathologie 1998;19:146–50.
Received November 25, 1999; accepted February 23, 2000.
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